Cleft lip and palate

Cleft lip and palate are birth defects that affect the upper lip and palate (roof of the mouth). It occurs in one in 600-800 births.

Cleft lip and palate are birth defects that affect the upper lip and palate (roof of the mouth). It occurs in one in 600-800 births.

Clefting can affect appearance, can create difficulties with eating and talking, and makes the patient susceptible to ear infections. Surgery to close the lip and palate is usually effective.

Alternative names

Hare lip

Causes and risk

Normally, the tissues that form the palate and lip fuse together in a complex process during early pregnancy. Clefting occurs when this doesn't happen properly, creating a gap.

We don't know the reasons, though it is thought to be a combination of genetic and other factors.

• Clefts often run in families, and the risk is higher if there is a family history.
• Toxic substances in the environment can affect foetal development. Factors may include maternal illness, diet, and exposure to drugs, alcohol, cigarettes, and substances such as pesticides.
• Clefts are most common in Asians, and least common in black people.
• More boys have a cleft lip, while more girls have cleft palate without a cleft lip.
• A cleft palate can be a symptom of other congenital disorders.

Symptoms

Cleft lip and palate can appear separately or together. A cleft lip may appear as a small dent or scar, or it can be a gap that extends all the way to the nose. Similarly, the cleft in the palate may be partial - a small hole - or it may extend from front to back, through the hard and soft palates. This opening connects the mouth directly to the nasal cavity.

Clefting can happen on one or both sides of the mouth (uni- or bilaterally).

Diagnosis

Because there are obvious visible symptoms, clefting is easy to diagnose in newborns. It can even be spotted before birth, by ultrasound.

Treatment

Surgery is usually done in stages. A cleft lip may be closed up 2-3 months after birth. If the cleft is bilateral, two operations may be required.

Often a cleft palate is temporarily closed with a prosthetic device (an obturator), before surgery is performed at between 9 and 18 months. In the operation, tissue is pulled from either side of the mouth and joined together to create a functional palate.

Further operations may be done as the child grows older, to improve speech, breathing and appearance, and to stabilise and align the jaw.

A tube is frequently inserted into the eardrum to aerate the middle ear.

Prognosis

Most cleft lips and palates are effectively treated with surgery, although some clefts are more severe than others. Certain patients may require ongoing care and surgery.

Complications:

• Breast-feeding. A cleft lip can make it difficult to suck, while a cleft palate may allow milk to enter the nasal cavity. Special nipples and other devices can help, as can feeding in an upright position.
• Speech problems. A cleft lip should not cause major problems. However, a cleft palate can make the voice nasal and incoherent, and may delay speech acquisition. Surgery may correct this. Any child with a cleft lip or palate should see a speech therapist.
• Hearing problems. Children with clefts are at risk of ear infections. The cleft lets fluid and germs into the middle ear, and fluid doesn't drain properly. Inserted tubes help to drain fluid, but children with clefts should have their ears checked regularly, or risk permanent damage.
• Dental problems. A cleft palate may cause cavities, as well as missing, extra, deformed, or displaced teeth. Treatment and surgery can align the teeth and fill gaps. Dental hygiene is important.
• Jaw development. Often, upper jaw growth is slowed. Surgery may be needed to help the jaw to develop, or to position it. If the cleft affects the alveolar ridge (the bony upper gum), a bone graft may be performed.
• Psychological problems. Bonding between mother and baby can be affected. Older children and teenagers may experience teasing and socialisation problems. A child psychologist or social worker may be helpful.

When to call your doctor

A cleft palate should be diagnosed in the course of normal antenatal care, or at the birth of the infant.

How can it be prevented?

While most clefting cannot be prevented, research continues into the possibility of environmental toxins causing the problems. Some research suggests that folic acid might help in prevention.