What is Cleft Lip and Cleft Palate?
Although a cleft lip and a cleft palate often appear together, either defect may appear alone.
- Cleft lip and cleft palate are openings or splits in the upper lip, the roof of the mouth (palate) or both.
In embryonic development, the palate closes later than the lip, and the failure to close occurs for different reasons.
- The cleft lip and palate defects result from failure of the maxillary and premaxillary processes to fuse during the 5th to 8th week of intrauterine life.
- The cleft may be a simple notch in the vermilion line, or it may extend up into the floor of the nose.
- The child born with a cleft palate but with an intact lip does not have the external disfigurement that may be so distressing to the new parent; however, the problems are more serious.
- In an 8-week old embryo, there is still no roof to the mouth; the tissues that are to become the palate are two shelves running from the front to the back of the mouth and projecting vertically downward on either side of the tongue.
- The shelves move from a vertical position to a horizontal position; their free edges meet and fuse in the midline.
- Later, bone forms within this tissue to form the hard palate.
- Normally the palate is intact by the 10th week of fetal life.
- Exactly what happens to prevent this closure is not known for sure, leading to a cleft lip and cleft palate.
Statistics and Incidences
Parents and family are naturally eager to see and hold their newborn and must be prepared for the shock of seeing the facial disfigurement.
- Cleft lip occurs in about 1 in 1,000 live births and is more common in males.
- Cleft palate occurs in 1 newborn in 2, 500, more often in females.
- Cleft palate occurs with a cleft lip about 50% of the time, most often with bilateral cleft lip.
The incidence of cleft palate is higher in the close relatives of people with the defect than it is in the general population, and some evidence indicates that environmental and hereditary factors play a part in this defect.
- Hereditary. The mother or the father can pass on genes that cause clefting, either alone or as part of a genetic syndrome that includes a cleft lip or cleft palate as one of its signs.
- Environmental. In some cases, babies inherit a gene that makes them more likely to develop a cleft, and then an environmental trigger actually causes the cleft to occur.
Usually, a split (cleft) in the lip or palate is immediately identifiable at birth.
- Cleft. A split in the lip and roof of the mouth (palate) that can affect one or both sides of the face; a split in the lip that can appear as only a small notch in the lip or can extend from the lip through the upper gum and palate into the bottom of the nose; a split in the roof of the mouth that doesn’t affect the appearance of the face.
- Difficulty with feedings. The newborn easily becomes choked on liquids.
- Difficulty swallowing. The newborn has a hard time in swallowing, with potential for liquids or foods to come out the nose.
- Nasal speaking voice. Due to the split in the palate, the newborn has a nasal speaking voice.
Assessment and Diagnostic Findings
The physical appearance of the newborn confirms the diagnosis of cleft lip; diagnosis of cleft palate is made at birth.
- Inspection. Diagnosis of cleft palate is made at birth with the close inspection of the newborn’s palate; to be certain that a cleft palate is not missed, the examiner must insert a gloved finger into the newborn’s mouth to feel the palate to determine that it is intact.
- Observation. Cleft lip can be diagnosed through observation of the physical appearance of the newborn.
Treatment for a newborn with cleft lip and palate includes:
- Surgery. Cleft lip repair, usually performed by a plastic surgeon, is a major part of the treatment of a newborn with cleft lip, palate, or both; some surgeons favor early repair, before the newborn is discharged from the hospital; other surgeons prefer to wait until the newborn is 1 to 2 months old, weighs about 10 lbs, and is gaining weight steadily.
- Dental speech appliance. If surgery must be delayed beyond the 3rd year, a dental speech appliance may help aid the child develop intelligible speech.
A complete and thorough process of care should be undergone by the newborn with cleft lip and cleft palate.
One primary concern in the nursing care of the newborn with a cleft lip and cleft palate is the emotional care of the newborn’s family.
- Interview. In interviewing the family and collecting data, the nurse must include exploration of the family’s acceptance of the newborn; conduct a thorough interview with the caregiver that includes a question about the methods they found to be most effective in feeding the infant.
- Physical exam. Physical examination of the infant includes temperature, apical pulse, and respirations; listen to breath sounds, observe skin turgor and color, infant’s neurologic status, noting alertness and responsiveness.
- Compromised family coping related to visible physical defect.
- Anxiety of family caregivers related to child’s condition and surgical outcome.
- Deficient knowledge of family caregivers related to care of child before surgery and the surgical procedure.
- Risk for aspiration related to a reduced level of consciousness after surgery.
- Ineffective breathing pattern related to anatomical changes.
- Risk for deficient fluid volume related to NPO status after surgery.
- Acute pain related to surgical procedure.
- Risk of injury to the operative site related to newborn’s desire to suck thumb or fingers and anatomical changes.
Nursing Care Planning and Goals
Goal setting and planning must be modified to adapt to the surgical plans; the major goals include:
- Maintaining adequate nutrition.
- Increasing family coping.
- Reducing the parents’ anxiety and guilt regarding the newborn’s physical defects, and preparing parents for the future repair of the cleft lip and palate.
Nursing interventions for the patient with cleft lip and palate are:
- Maintain adequate nutrition. Breastfeeding may be successful because the breast tissue may mold to close the gap; if the newborn cannot be breastfeed, the mother’s breast milk may be expressed and used instead of formula; a soft nipple with a cross-cut made to promote easy flow of milk may work well.
- Positioning. If the cleft lip is unilateral, the nipple should be aimed at the unaffected side; the infant should be kept in an upright position during feeding.
- Tools for feeding. Lamb’s nipples (extra long nipples) and special cleft palate nipples molded to fit into the open palate area to close the gap may be used; one of the simplest and most effective methods may be the use of an eyedropper or an Asepto syringe with a short piece of rubber tubing on the tip (Breck feeder).
- Promote family coping. Encourage the family to verbalize their feelings regarding the defect and their disappointment; serve as a model for the family caregiver’s attitudes toward the child.
- Reduce family anxiety. Give the family information about cleft repairs; encourage them to ask questions and reassure them that any question is valid.
- Provide family teaching. Explain the usual routine of preoperative, intraoperative, and post operative care; written information is helpful, but be certain the parents understand the information.
Major goals for the care of the infant with cleft lip and cleft palate include:
- Maintained adequate nutrition.
- Increased family coping.
- Reduced parents’ anxiety and guilt regarding the newborn’s physical defects.
Documentation for a patient with cleft lip and palate include the following:
- Assessment findings, including current and the past coping behaviors, emotional response to situation and stressors, support systems available.
- Level of anxiety and precipitating/aggravating factors.
- Description of feelings.
- Awareness and ability to recognize and express feelings.
- Client’s description of response to pain, specifics of pain inventory, acceptable level of pain.
- Plan of care.
- Teaching plan.
- Responses of family members/client to interventions, teaching, and actions performed.
- Attainment or progress toward desired outcomes.
- Modification to plan of care.
- Long term plan and who is responsible for actions.
- Specific referrals made.
Practice Quiz: Cleft Lip and Cleft Palate
1. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
A. Lowered resistance from malnutrition.
B. Ineffective functioning of the Eustachian tubes.
C. Plugging of the Eustachian tubes with food particles.
D. Associated congenital defects of the middle ear.
1. Answer: B. Ineffective functioning of the Eustachian tubes.
- B: Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.
- A: Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques.
- C: Food particles do not pass through the cleft and into the Eustachian tubes.
- D: There is no association between cleft palate and congenital ear deformities.
2. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?
A. Sucking ability.
B. Respiratory status.
D. GI function.
2. Answer: A. Sucking ability.
- A: Because of the defect, the child will be unable to from the mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification.
- B: Respiratory status may be compromised if the child is fed improperly or during the postoperative period.
- C: Locomotion would be a problem for the older infant because of the use of restraints.
- D: GI functioning is not compromised in the child with a cleft lip.
3. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?
C. In an infant seat.
D. On the side.
3. Answer: B. Prone.
- B: Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage.
- A: If the child is placed in the supine position, he or she may aspirate.
- C: Using an infant seat does not facilitate drainage.
- D: Side-lying does not facilitate drainage as well as the prone position.
4. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
A. Elbow restraints.
B. Full arm restraints.
C. Wrist restraints.
D. Mummy restraints.
4. Answer: A. Elbow restraints.
- A: The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints.
- B, C, D: Answers B, C, and D are more restrictive and unnecessary; therefore, they are incorrect.
5. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions?
A. “I will use a nipple with a small hole to prevent choking.”
B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
C. “I will allow the infant time to swallow.”
D. ”I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth.”
5. Answer: B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
- B: An infant with cleft palate would have difficulty in feeding despite stimulation for sucking.
- A, C, D: All these options are correct for an infant with cleft palate.