Current Research:
cleft palate
"a study into weight gain in infants with cleft palate"
Written By: Diane Beaumont MA, DipHE (professional
studies), RSCN, SRN, SCM Team Leader, Clinical Nurse Specialist Cleft Lip and Palate, The General Infirmary, Leeds
Published: Nursing Children and Young People, (Britain) Volume 20, Number 6
Reviewed By: Libby Solomon
Parents of a child with cleft palate are understandably concerned about the feasibility of feeding their child properly. They worry that the child will fail to put on weight and fail to thrive. This study is reassuring, in that it researches whether early feeding support (given to caregivers by a nurse) decreases the chances of poor weight gain - and found that it did.
Purpose: To study whether early feeding support for children with cleft palate/lip decrease the amount of infants classified as failure-to-thrive.
Methodology: Researchers used weight and height records of children with cleft lips and/or palates and underwent surgery, analyzing their weight gain compared to normal population parameters. Premature or children who had not had surgery were excluded due to possibility of confounding variables. The researchers divided the group into Syndromic and Non-Syndromic, and then further into ICL (Isolated Cleft Lip), ICP (Isolated Cleft Palate), UCLP (Unilateral Cleft Lip and Palate) and BCLP (Bilateral Cleft Lip and Palate).
Results: Researchers found that although some infants with CL/P were classified as failing to thrive, percentage of the CL/P that were failing to thrive was lower after introduction of visiting nurses providing feeding support.
Implications for the SLP: Besides for providing speech therapy within sessions, ensuring that client is receiving continued medical surveillance and guidance can minimize the impact that the CL/P has on the infant's weight gain or lack thereof. Additionally, the SLP can take an active part in the feeding support by providing parents with guidelines, techniques and the merits of various feeding methods.
"A Preoperative Appliance for a Newborn with Cleft Palate"
Authors: Banu Karayazgan, D.D.S., M.S., Yumushan Gunay, D.D.S., M.S., Bahadir Gurbuzer, D.D.S., M.S., Mustafa Erkan, D.D.S., M.S., Arzu Atay, D.D.S., M.S. Cleft-Palate Craniofacial Journal, January 2009
Reviewed by: Breindel Antokol
Link: http://www.deepdyve.com/lp/allen-press/a-preoperative-appliance-for-a-newborn-with-cleft-palate-m0Da0J3olR
Purpose: The purpose of the study was to see if using a modified maxillary obturator, (which is kind of like a bite plate and acts like a natural velopharyngeal extension on babies with cleft) made of softer material will produce more comfortable and effective swallows than the conventional obturator.
Methodology:A 3 day old male baby who was diagnosed with a soft palate defect was referred to the department of Maxillofacial Prosthetic Service at the Military Training Hospital and requested a soft palate obturator to make it possible for the baby to be nursed until surgery was performed. The child had difficulty eating and a
nasogastric tube was inserted for feeding. A preoperative appliance was then created for the baby using a modified maxillary obturator for the area that covered the defect.
Results: At first the child demonstrated gagging and nausa reflexes but after a few hours
the child exhibited excellent adaption and received great nutrition keeping his weight within normal limits; indicating the effectiveness of the use of the modified maxillary obturator.
A REVIEW OF CLEFT PALATE REPAIRS AND VARIATIONS
Agrawal, K. (2009). Cleft palate repair and variations. Indian Journal of Plastic Surgery, 42, 102-109.
Reviewed by: Sarah CurlandLink:http://content.ebscohost.com.libsrv.wku.edu/pdf23_24/pdf/2009/SV2/02Nov09/45003744.pdf?T=P&P=AN&K=45003744&S=R&D=aph&EbscoContent=dGJyMNLr40SeqLE4v%2BbwOLCmr0ueprZSsKi4SLeWxWXS&ContentCustomer=dGJyMPGut1GxprROuePfgeyx44Dt6fIA
There are many ways in which surgeons perform a palatoplasty but the principals and objectives of the surgery are the same. The surgery is performed to close the cleft, improve speech, and prevent a deformation in maxillary growth. The surgery is also performed to fix the soft palate muscles including the levator palati and align the muscles necessary for speech.
Some preoperative considerations include the schedule of palatoplasty and the use of antibiotics. Most surgeons agree 6-12 months is the optimal time to operate, though some surgeons believe 12-18 months is acceptable. Some surgeons will operate as late as 10-12 years. Generally it is agreed that surgery can begin when a baby starts to babble. Most surgeons also believe that a palatoplasty should take place before a repair of the cleft lip. Antibiotic use before operation can reduce the risk of infections such as otitis media, or oropharyngeal or respiratory infection. Antibiotics are also linked to shorter hospitalization and a diminished chance of postoperative fever.
The following are various types of surgical techniques used by surgeons to perform cleft palate repair:
- von langenbeck’s bipedicle flap technique
- veau-wardill-kilner pushback technique
- bardach’s two-flap technique
- furlow double opposing z-plasty
- two-stage palatal repair
- hole in one repair
- raw area free palatoplasty
- alveolar extension palatoplasty (aep)
- primary pharyngeal flap
- intravelarveloplasty
- vomerflap
- buccal myomucosal flap
A Comparison of Procedures:
Bardach two-flap palatoplasty- this procedure was developed based off of the von langenbeck technique. Incisions are made on the cleft and alveolar margins and then are joined anteriorly. The soft palate is repaired as well. It is repaired in a straight line.
The hole in one repair- this procedure is done in developing countries but has become popular in many other countries. The procedure is a one-stage cleft lip and palate repair to facilitate the issue of patients inability to be hospitalized more than once.
Primary pharyngeal flap- this procedure is not favorable to many surgeons. The purpose of the procedure is to help improve speech but it also causes an abnormal anatomy of the cleft.
Cleft palate repair over time has made major improvements largely due to both the team approach and early evaluation and repair. The surgeon and the popularity of the procedure in the specific center it is performed often indicates the type of surgery used and the modifications made to the specific surgery.
"Feeding and Swallowing Dysfunction in Genetic Syndromes"
Cooper-Brown, L., Copeland, S., Dailey, S., Downey, D., Petersen, M.C., Stimson, C., Van Dyke, D.C. (2008). Feeding and swallowing dysfunction in genetic syndromes. Developmental Disabilities Research Reviews, 14, 147-157.
http://search.ebscohost.com.libsrv.wku.edu/login.aspx?direct=true&db=aph&AN=35418859&site=ehost-live
Reviewed by: Marisa Cohen
"Feeding and Swallowing in Genetic Dysfunctions" highlights the difficulties associated with feeding children who present with cleft palate. There is discussion about several feeding modifications and modifications to be made after there is a cleft palate repair.
Infants born with an intact palate are able to produce "negative intraoral pressure as their lips and tongue form a seal around the nipple and the tongue produces rhythmic sucking motions. An intact soft palate elevates to seal off the nasopharynx" (Cooper-Brown, Copeland, Dailey, Downey, Peterson, Stimson & Van Dyke, 2008, p. 149). These motions allow the infant to suck or pull milk into their oral cavity from the breast or bottle. Unlike an infant with an intact palate, one that exhibits a cleft palate will have difficulty creating intraoral pressure to suck milk into their oral cavity " due to the "inability to seal the nasal cavity and nasopharynx from the oral cavity and oropharynx" (Cooper-Brown et al., 2008, p. 149).
Infants with cleft palate present a range in severity of feeding issues. The severity of the cleft palate usually determines the severity of feeding difficulties. Besides difficulty creating suction, infants with cleft palate often times experience nasopharyngeal regurgitation due to liquid entering the nasopharynx from the oral cavity. In addition, infants may also experience excess air ingestion because of lack of separation between the nasal and oral cavities ( Cooper-Brown et al., 2008, p. 149). According to Cooper-Brown et al., "Air ingestion can lead to bloating, choking, gagging, fatigue with feeding, prolonged feeding times and contributes to spitting up and emesis" (2008, p. 149). In addition, "an infant with cleft palate and neurological impairments or syndromes may have oral motor difficulties that further complicate the feeding process (Cooper-Brown et al., 2008, p. 149).
Cooper-Brown et al. discuss feeding modifications for infants with cleft palate. Cooper-Brown et al. state that "infants with a cleft palate with or without cleft lip are likely to feed successfully with a nipple that requires only compression (Haberman Feeder, Pigeon Cleft Palate Nurser) or a cross-cut nipple with a squeezable bottle (Mead-Johnson Cleft Palate Nurser)." However, research studies are inconsistent about which modified feeding approach is the most effective.
Positioning during feeding is also discussed. Cooper-Brown et al. encourage "holding the infant in a more upright position to minimize entry of formula/breast milk into the nasal cavity and eustachian tubes during sucking and swallowing activity. In addition, to release excess air that was possibly ingested during feeding, frequent burping should take place (Cooper-Brown et al., 2008, p.149).
There are also precautions to take during feeding with an infant who had a cleft palate repair. Cooper-Brown et al. state, "Following primary palate repair it is common practice for children to do no sucking or take hard solids to prevent dehiscence of the suture line(s). Cup drinking and soft food diet is recommended during the postoperative period. Length of time after surgery of abstinence from sucking or hard solids is determined by the surgeon with a maximum time likely to be 5 weeks." Feeding assessment and intervention should always be addressed by a specialized healthcare team.
"Feeding Issues and Interventions in Infants and Children with Clefts and Craniofacial Syndromes"
Miller, C.K. (2011). Feeding issues and interventions in infants and children with clefts and craniofacial syndromes. Seminars in speech and language, 32 (2), 115-126. doi: 10.1055/s-0031-1277714. http://web.ebscohost.com.libsrv.wku.edu/ehost/detail?sid=92174264-cf4d-49fd-a066-9bca204ae04a%40sessionmgr15&vid=6&hid=9
Reviewed by: Sara Lagalante
Miller discusses Craniofacial Syndromes with Cleft lip with and without cleft palate, as well other craniofacial abnormalities. She mentioned that other issues such as oral-motor dysfunction, pharyngeal disorders and cranial nerve and neuromotor anomalies may be secondary to CL/CP.
Afterwards she presented oral feeding techniques, specific instructions for breast feeding, specialized feeding equipment, and information on palatal obturators. Highlights from Claire K. Miller’s article can be found in the Feeding: Problem Solving tab under Solutions: Additional Information.
Published: Nursing Children and Young People, (Britain) Volume 20, Number 6
Reviewed By: Libby Solomon
Parents of a child with cleft palate are understandably concerned about the feasibility of feeding their child properly. They worry that the child will fail to put on weight and fail to thrive. This study is reassuring, in that it researches whether early feeding support (given to caregivers by a nurse) decreases the chances of poor weight gain - and found that it did.
Purpose: To study whether early feeding support for children with cleft palate/lip decrease the amount of infants classified as failure-to-thrive.
Methodology: Researchers used weight and height records of children with cleft lips and/or palates and underwent surgery, analyzing their weight gain compared to normal population parameters. Premature or children who had not had surgery were excluded due to possibility of confounding variables. The researchers divided the group into Syndromic and Non-Syndromic, and then further into ICL (Isolated Cleft Lip), ICP (Isolated Cleft Palate), UCLP (Unilateral Cleft Lip and Palate) and BCLP (Bilateral Cleft Lip and Palate).
Results: Researchers found that although some infants with CL/P were classified as failing to thrive, percentage of the CL/P that were failing to thrive was lower after introduction of visiting nurses providing feeding support.
Implications for the SLP: Besides for providing speech therapy within sessions, ensuring that client is receiving continued medical surveillance and guidance can minimize the impact that the CL/P has on the infant's weight gain or lack thereof. Additionally, the SLP can take an active part in the feeding support by providing parents with guidelines, techniques and the merits of various feeding methods.
"A Preoperative Appliance for a Newborn with Cleft Palate"
Authors: Banu Karayazgan, D.D.S., M.S., Yumushan Gunay, D.D.S., M.S., Bahadir Gurbuzer, D.D.S., M.S., Mustafa Erkan, D.D.S., M.S., Arzu Atay, D.D.S., M.S. Cleft-Palate Craniofacial Journal, January 2009
Reviewed by: Breindel Antokol
Link: http://www.deepdyve.com/lp/allen-press/a-preoperative-appliance-for-a-newborn-with-cleft-palate-m0Da0J3olR
Purpose: The purpose of the study was to see if using a modified maxillary obturator, (which is kind of like a bite plate and acts like a natural velopharyngeal extension on babies with cleft) made of softer material will produce more comfortable and effective swallows than the conventional obturator.
Methodology:A 3 day old male baby who was diagnosed with a soft palate defect was referred to the department of Maxillofacial Prosthetic Service at the Military Training Hospital and requested a soft palate obturator to make it possible for the baby to be nursed until surgery was performed. The child had difficulty eating and a
nasogastric tube was inserted for feeding. A preoperative appliance was then created for the baby using a modified maxillary obturator for the area that covered the defect.
Results: At first the child demonstrated gagging and nausa reflexes but after a few hours
the child exhibited excellent adaption and received great nutrition keeping his weight within normal limits; indicating the effectiveness of the use of the modified maxillary obturator.
A REVIEW OF CLEFT PALATE REPAIRS AND VARIATIONS
Agrawal, K. (2009). Cleft palate repair and variations. Indian Journal of Plastic Surgery, 42, 102-109.
Reviewed by: Sarah CurlandLink:http://content.ebscohost.com.libsrv.wku.edu/pdf23_24/pdf/2009/SV2/02Nov09/45003744.pdf?T=P&P=AN&K=45003744&S=R&D=aph&EbscoContent=dGJyMNLr40SeqLE4v%2BbwOLCmr0ueprZSsKi4SLeWxWXS&ContentCustomer=dGJyMPGut1GxprROuePfgeyx44Dt6fIA
There are many ways in which surgeons perform a palatoplasty but the principals and objectives of the surgery are the same. The surgery is performed to close the cleft, improve speech, and prevent a deformation in maxillary growth. The surgery is also performed to fix the soft palate muscles including the levator palati and align the muscles necessary for speech.
Some preoperative considerations include the schedule of palatoplasty and the use of antibiotics. Most surgeons agree 6-12 months is the optimal time to operate, though some surgeons believe 12-18 months is acceptable. Some surgeons will operate as late as 10-12 years. Generally it is agreed that surgery can begin when a baby starts to babble. Most surgeons also believe that a palatoplasty should take place before a repair of the cleft lip. Antibiotic use before operation can reduce the risk of infections such as otitis media, or oropharyngeal or respiratory infection. Antibiotics are also linked to shorter hospitalization and a diminished chance of postoperative fever.
The following are various types of surgical techniques used by surgeons to perform cleft palate repair:
- von langenbeck’s bipedicle flap technique
- veau-wardill-kilner pushback technique
- bardach’s two-flap technique
- furlow double opposing z-plasty
- two-stage palatal repair
- hole in one repair
- raw area free palatoplasty
- alveolar extension palatoplasty (aep)
- primary pharyngeal flap
- intravelarveloplasty
- vomerflap
- buccal myomucosal flap
A Comparison of Procedures:
Bardach two-flap palatoplasty- this procedure was developed based off of the von langenbeck technique. Incisions are made on the cleft and alveolar margins and then are joined anteriorly. The soft palate is repaired as well. It is repaired in a straight line.
The hole in one repair- this procedure is done in developing countries but has become popular in many other countries. The procedure is a one-stage cleft lip and palate repair to facilitate the issue of patients inability to be hospitalized more than once.
Primary pharyngeal flap- this procedure is not favorable to many surgeons. The purpose of the procedure is to help improve speech but it also causes an abnormal anatomy of the cleft.
Cleft palate repair over time has made major improvements largely due to both the team approach and early evaluation and repair. The surgeon and the popularity of the procedure in the specific center it is performed often indicates the type of surgery used and the modifications made to the specific surgery.
"Feeding and Swallowing Dysfunction in Genetic Syndromes"
Cooper-Brown, L., Copeland, S., Dailey, S., Downey, D., Petersen, M.C., Stimson, C., Van Dyke, D.C. (2008). Feeding and swallowing dysfunction in genetic syndromes. Developmental Disabilities Research Reviews, 14, 147-157.
http://search.ebscohost.com.libsrv.wku.edu/login.aspx?direct=true&db=aph&AN=35418859&site=ehost-live
Reviewed by: Marisa Cohen
"Feeding and Swallowing in Genetic Dysfunctions" highlights the difficulties associated with feeding children who present with cleft palate. There is discussion about several feeding modifications and modifications to be made after there is a cleft palate repair.
Infants born with an intact palate are able to produce "negative intraoral pressure as their lips and tongue form a seal around the nipple and the tongue produces rhythmic sucking motions. An intact soft palate elevates to seal off the nasopharynx" (Cooper-Brown, Copeland, Dailey, Downey, Peterson, Stimson & Van Dyke, 2008, p. 149). These motions allow the infant to suck or pull milk into their oral cavity from the breast or bottle. Unlike an infant with an intact palate, one that exhibits a cleft palate will have difficulty creating intraoral pressure to suck milk into their oral cavity " due to the "inability to seal the nasal cavity and nasopharynx from the oral cavity and oropharynx" (Cooper-Brown et al., 2008, p. 149).
Infants with cleft palate present a range in severity of feeding issues. The severity of the cleft palate usually determines the severity of feeding difficulties. Besides difficulty creating suction, infants with cleft palate often times experience nasopharyngeal regurgitation due to liquid entering the nasopharynx from the oral cavity. In addition, infants may also experience excess air ingestion because of lack of separation between the nasal and oral cavities ( Cooper-Brown et al., 2008, p. 149). According to Cooper-Brown et al., "Air ingestion can lead to bloating, choking, gagging, fatigue with feeding, prolonged feeding times and contributes to spitting up and emesis" (2008, p. 149). In addition, "an infant with cleft palate and neurological impairments or syndromes may have oral motor difficulties that further complicate the feeding process (Cooper-Brown et al., 2008, p. 149).
Cooper-Brown et al. discuss feeding modifications for infants with cleft palate. Cooper-Brown et al. state that "infants with a cleft palate with or without cleft lip are likely to feed successfully with a nipple that requires only compression (Haberman Feeder, Pigeon Cleft Palate Nurser) or a cross-cut nipple with a squeezable bottle (Mead-Johnson Cleft Palate Nurser)." However, research studies are inconsistent about which modified feeding approach is the most effective.
Positioning during feeding is also discussed. Cooper-Brown et al. encourage "holding the infant in a more upright position to minimize entry of formula/breast milk into the nasal cavity and eustachian tubes during sucking and swallowing activity. In addition, to release excess air that was possibly ingested during feeding, frequent burping should take place (Cooper-Brown et al., 2008, p.149).
There are also precautions to take during feeding with an infant who had a cleft palate repair. Cooper-Brown et al. state, "Following primary palate repair it is common practice for children to do no sucking or take hard solids to prevent dehiscence of the suture line(s). Cup drinking and soft food diet is recommended during the postoperative period. Length of time after surgery of abstinence from sucking or hard solids is determined by the surgeon with a maximum time likely to be 5 weeks." Feeding assessment and intervention should always be addressed by a specialized healthcare team.
"Feeding Issues and Interventions in Infants and Children with Clefts and Craniofacial Syndromes"
Miller, C.K. (2011). Feeding issues and interventions in infants and children with clefts and craniofacial syndromes. Seminars in speech and language, 32 (2), 115-126. doi: 10.1055/s-0031-1277714. http://web.ebscohost.com.libsrv.wku.edu/ehost/detail?sid=92174264-cf4d-49fd-a066-9bca204ae04a%40sessionmgr15&vid=6&hid=9
Reviewed by: Sara Lagalante
Miller discusses Craniofacial Syndromes with Cleft lip with and without cleft palate, as well other craniofacial abnormalities. She mentioned that other issues such as oral-motor dysfunction, pharyngeal disorders and cranial nerve and neuromotor anomalies may be secondary to CL/CP.
Afterwards she presented oral feeding techniques, specific instructions for breast feeding, specialized feeding equipment, and information on palatal obturators. Highlights from Claire K. Miller’s article can be found in the Feeding: Problem Solving tab under Solutions: Additional Information.