Children with cleft lip and palate exhibit multiple issues like feeding problems, delayed speech and language skills, misarticulation, dental problems, psychological problems, etc. Hence the testing and treatment of children with cleft lip and palate requires a team of professionals who are expert in the field. The multidisciplinary team includes:

Children with cleft lip and palate exhibit wide range of problems at various point of time in life. Therefore, timely evaluation should be carried out at least once in a year. Sometimes, one problem can lead to another among these children. For ex: Dental problems in children with cleft palate can also lead to speech problems. Therefore, appropriate and timely intervention is must for children with cleft lip and palate.

Guidelines for Treatment for Children with Cleft Lip and Palate

0 to 1 YEARS

 

1- 2 YEARS

2- 5 YEARS

 

5 – 10 YEARS 

 

10-15 YEARS

 

15 -20 YEARS & ABOVE

 

TREATMENT OPTIONS FOR CHILDREN WITH CLEFT LIP AND PALATE

SURGERY

Consultation with plastic surgeon is highly recommended immediately after the infant is born with cleft lip and palate. Information regarding timing of surgery will be provided by the plastic surgeon. Usually, surgery for cleft lip is recommended when the infant is around 3-6 months. The surgery takes around an hour. After the surgery, the child will be monitored under the supervision of doctors for a day. After the child’s condition is stable, the child will be discharged from the hospital. Sometimes, along with cleft lip, nasal problems are also seen which will be corrected during surgery of the cleft lip.

The surgery for the cleft palate will be performed when the child is around 9-16months. The surgery may require approximately two hours. After the surgery the child might have to be monitored in hospital. Once the health condition is stable, the child will be discharged. During this stage, the infant will be given soft or liquid diet following surgery.

When the primary surgery is not helpful, the child might have to undergo a secondary surgery, but this may be not possible in some cases due to lack of muscle tissue or child’s poor health condition. The surgery of cleft lip and palate is done free of cost through Smile train program across some hospitals in India.

One of the important factors that one has to remember is, surgery will only correct the structural problems, but this does not influence the speech and language problems that child might have because of cleft lip and palate. Speech and language training is very much necessary to correct the speech and language problems.

FEEDING THE CHILD WITH CLEFT LIP AND PALATE

Parents of children with cleft lip and palate should get appropriate guidance from the doctor/nurse on feeding the infant.  Like all babies, most infants with clefts are born ready to eat by mouth, but they may need special care during feedings. Due to the size and place of the cleft, the infant may have difficulty for suction and strength to draw milk from the breast or bottle. To overcome the problem, there are special nipples that can be used to help for feeding.

Babies with clefts tend to tire quickly, because they use more energy trying to suck the milk.  Feeding can be difficult and frustrating the first few weeks to the mother, but with training and support, this can be made easier.  The doctor or nurses can examine the feeding posture and can suggest the feeding tips for parents of children with cleft lip and palate. Parents will always have to remember that:

  • Feedings should last no more than 30 minutes, whether breast or bottle feeding.
  • Feedings should be pleasant for both mother and baby, this can help the child to gain weight.
  • The use of special feeding bottles may be required, even if the mother is giving breast milk her baby.

Feeding after Surgery

Parents have to be little cautious over feeding their child after surgery. They do not have to change the feeding procedures immediately after the surgery. The doctors will provide guidelines for the feeding after surgery, what has to be fed and how. Parents will have to strictly follow the guidelines provided to them. They can use special feeding appliances.

Tips for Feeding the child with cleft

Keep your child in a good position for feeding

  • The baby should be kept upright at an angle between 45 and 90 degrees. This will help to prevent milk running out from his nose.
  • The chin needs to be tucked toward the chest. This improves the sucking ability and reduces the amount of swallowed air.

Point the nipple away from the cleft

  • The angle of the nipple should be away from the side of the mouth with the cleft. This will help the child to gag less.
  • The nipple shouldn’t be placed inside the cleft.

Be ready for nasal regurgitation

  • Nasal regurgitation is the food coming back out from the baby’s nose during feeding. When this happens, one should not panic. The feeding should be paused to let child sneeze or cough, and resume feeding.
  • If this happens often, the baby should be held more upright during feedings.
  • The baby’s mouth and nose area should be kept clean. A bulb syringe can be used as if needed. If the area around the nose or lip is crusty, clean it gently with sterile water and a cotton swab.
  • If the problem continues, the issues have to be discussed with the feeding therapist.

Special bottles and nipples

  • A special bottle or nipple made for children with clefts can make feedings easier
  • Ask the nurse, occupational therapist, nutritionist, lactation consultant or speech pathologist on your child’s craniofacial team about such products.

Tips for Feeding Solid Foods

  • Solid foods should be given by spoon, not in a bottle.
  • The child should be kept in upright position in an infant seat or high chair.
  • The food should be offered at small amounts at child’s own pace. Feeding process should not be rushed.
  • The acidic and spicy foods should be avoided.
  • The purees and infant foods should be initiated in the child’s feeding plan as advised by the child’s doctor.

 Stick to a feeding schedule

  • The baby should be on a feeding schedule. Within the first two weeks of life, a newborn may need to feed every two to three hours. Missed feedings might mean the baby is not taking enough volume at feedings.
  • The feeding sessions should be limited to 20 to 30 minutes. Infants with clefts often work hard during feedings and tire easily. If allowed to feed longer, they may burn more calories than they take in from the bottle or breast.

Burp baby often

  • Baby should be burped every 15 minutes during and after feedings. Infants with clefts take in a lot of air when they swallow. This can cause painful gas buildup if they do not burp often.

Keep baby upright after feedings

  • After feeding the baby, before the baby is made to lie down, have a wait period of 30 minutes. This can reduce the chances of food being spit up.
  • Infant seat, baby sling, bouncy seat or car seat can be used to help keep baby upright.
  • The weight of the baby needs to be monitored, to keep record that the baby should be gaining weight as fast as he should, record his weight every week for four to six weeks. Baby should gain about 30 grams per day after 2 weeks of age.

PROSTHODONTIC TREATMENT 

Plastic surgery is one of the main treatment strategies for correction of cleft lip and palate. Sometimes, surgery cannot be done because of certain contraindications like lack of muscle tissues, poor health stability of the child, etc. In such situations; the best option for rehabilitation is through prosthetic management. Prosthodontic treatment involves providing an artificial plate which can be fitted to the teeth. This will be prepared by taking an impression of the palate and a plate which will be provided with the clasps (wires). If speech therapy is provided after prosthesis fitting, it may be showing some improvement in child’s speech. The treatment will be usually carried out by orthodontist and prosthodontist. If the dental alignment is corrected, it will have a positive impact on speech and language development.

ORTHODONTIC TREATMENT

Children with cleft lip and palate may also have associated dental problems like missing teeth, mal-alignment of teeth, malocclusion of upper and lower teeth, etc… This can be treated by an orthodontist. Sometimes the dental problems may lead to speech problems. The correction of dental anomalies positively influences speech.

SPEECH AND LANGUAGE DEVELOPMENT

Surgery alone cannot help to correct the speech and language problems that child might have due to cleft lip and palate. Speech and language therapy is very much required for the child to correct the speech problems. The speech and language problems of the child will be evaluated by the speech language pathologist using different examination protocols and instruments. Once the child’s baseline in speech and language skills are established, they begin the training accordingly so as to tailor the needs of every individual child.

Guidelines for Parents of Children with Cleft Lip and Palate Regarding Speech and Language Training:

  • It is every parent’s responsibility to make sure that the environment is apt for the child to develop speech and language. The children should be provided with adequate speech and language stimulation at home. Parents should always keep in mind that the improvement in speech and language skills of the child will not be noticed immediately after the surgery. The surgery will just correct the structural defects and not the function (movement of the soft palate) of the structure.
  • Speech production and proper articulation (pronunciation) depends on many factors. If the surgery is done prior to one-year, early speech and language intervention will lessen the chances of child developing articulatory problems. The speech and language therapy might not have an immediate outcome, but intensive training and regular follow up will help the child to attain greater accuracy in articulation.
  • The rehabilitation of children with cleft lip and palate is a long and steady process. Parents need be to be patient enough to get all the evaluation and treatment procedures done for the child’s overall development. Co-operation of parents with speech language therapists is very important for better prognosis.

The following guidelines will help the parents of children with cleft lip and palate, to achieve better speech and language skills in child with cleft lip and palate

  • Always keep in mind to talk slowly and with open mouth. This will help the child to follow you and to talk slowly. If the child is making an attempt to talk slowly and with open mouth, appreciate the attempt and reinforce your child. This will improve the clarity of speech and others can understand child’s speech.
  • Make your child sit in front of a mirror and teach individual sounds to your child. Demonstrate the movement of tongue when contacting palatal structures when producing certain speech sounds. If the child is not able to follow you, take an ice-cream stick and, with the help of that, touch the palatal structure with the stick and teach them to produce the sounds correctly.
  • When the child is attempting to produce an oral sound, examine whether there is any air escaping through nose. If there is any nasal air emission present, please contact plastic surgeon. This is one of the main reasons for the speech problems faced by children with cleft lip and palate.
  • Encourage the child to talk. If the child makes a mistake while speaking, correct the errors and provide positive reinforcements to encourage him to talk.
  • The child- parent interaction should be good; Parents should encourage their child tp speak and teach them in a natural environment and through play activities.
  • After the surgery, the child has to be given speech and language therapy immediately. The activities that have been taught by the speech therapist should also be carried out in home.
  • Reinforcement is very crucial
  • To increase the language abilities of the child, encourage the child to speak in simple sentences and encourage him to learn and speak new words daily.
  • If the child is not able to speak the sounds or words correctly, do not discourage the child by beating him or scolding him.
  • To help the child develop adequate oral pressure for production of oral sounds, the child should be taught to control the air stream, to keep up and maintain the air pressure in the mouth. This can be done by teaching some exercises to the tongue, lips, palate and to improve the contact between tongue and palate. Child should be encouraged to indulge in activities like blowing balloon, playing wind instruments, etc. These activities will help the child to understand to regulate the air pressure through the mouth. This will also help the child direct the air stream entirely through the mouth and avoid nasal air emission. These activities may not immediately have an impact on speech, but will surely help the child to understand the importance of air pressure regulation for production of speech.
  • Make the child understand the difference in airflow when producing an oral sound and nasal sound. It is very important for the child to understand the difference between producing an oral sound and nasal sound. Only then, the child can effectively use the same strategy in speech

  • The hearing ability of the child should be tested once in six months.
  • If the child has any hearing problem or nasal defects, then the child has to be examined by an ENT professional.
  • Consultation with orthodontist should be considered if the child is found to have dental problems.
  • Children with cleft lip and palate are found to have speech and language problems. They are advised to undergo systematic speech therapy. Therefore, consultation with speech language pathologist is mandatory.
  • When correcting an articulation (pronunciation) problem, different auditory, visual and tactile cues can be given to the child to teach the correct production of a speech sound.

  • Build up your child’s confidence
  • It is important to get timely testing and treatment from various professionals for child’s overall development.
  • Discuss about your child’s speech problem with his/her teacher and peer group and request them to co-operate and support your child, which will make him more confident.
  • It is important to know the intellectual level of the child. If the child has intellectual disability, speech and language development of the child will be delayed. This further delay the academic performance of the child.
  • Various professionals play a very vital role in the overall development of the children with cleft lip and palate. Therefore, a team of professionals are required in evaluating and treating children with cleft lip and palate.

Early intervention is of prime importance to facilitate typical speech and language development. The rehabilitation plan for each individual will vary depending on the type and severity of the cleft.  A multidisciplinary team approach is mandatory to diagnose and rehabilitate a child with cleft lip and palate.

ARTICLE BY:

Sahana Muralikrishna

MVM College of Allied Health Sciences

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