Cleft lip and Palate

Introduction

The difference between a cleft lip and a cleft palate is that while a cleft lip affects the patient’s lip, a cleft palate the roof of a patient’s mouth or what is medically referred to as a palate. It should be understood that a cleft means a separation or a split. A cleft lip is also a narrow gap within the upper lip’s skin which extends to the base of the nose. Partial clefting is when the clefts only extend through both back and front parts of the palate.

These two conditions are both splits in the mouth structure. The craniofacial anomaly is what physicians call this condition (clefting). When children are born with clefts it means that they do not have sufficient tissue in their respective mouths. There is a possibility of a child being born with both cleft palate and clef t lip. In addition, a child’s oral structure can have either of the above-mentioned conditions. Cleft lip usually is characterized by an opening from the upper towards both or just one nostril.

Clefts are the most common birth defects as statistics indicate there occurrence in 1 to between 700 and 1000 births. However, clefts are generally common in Asia, Latin America or Native America. All hope should not be lost since clefts can be treated. Most children undergo reconstructive surgery when they are twelve to eighteen months not only to correct the defect but also to improve the appearance of the face.

As state earlier, cleft lip is a rather common condition which occurs in approximately 1 in 700 children. Eighty percent of these cases are reported in males. However, many females are associated with the cleft palate. This occurrence varies differently for ethnic and racial lines across the world. On the other hand, a cleft palate occurs in 1 per 2500 births. The cleft condition occurs less frequently in African- American children thus proving the fact that a person’s ethnic link contributes highly to the possibility of having this condition. Research shows that up to thirteen percent of the reported cases occur at the same time with other birth defects.

The isolated cleft palate is used to refer to when a palate occurs alone. Cleft palate accounts for thirty percent of all the reported cases. it should be understood that all the races have the same degree of risk amongst themselves. The isolated cleft lip translates into approximately twenty percent of all clefts.

The purpose of this review article is to get to understand cleft lip and cleft palate condition in terms of the etiology and epidemiology of the disorder, pathogenesis, clinical manifestations, diagnosis, treatment, prognosis, prophylaxis and non-allopathic management of the very disorder.

Etiology and epidemiology of the disorder

The etiology of cleft lip and palate is characterized by the state of failure of the development of the embryo. This results into defects that are closely associated to syndromes that are also in turn related to various abnormalities.

The second factor is the genetic inclination where the growing fetus which is conceived by a parent who has a cleft condition has a risk of between two to four as compared to the other people who are not affected by the condition. The later has a 0.15 risk of acquiring the condition. The environmental aspect also plays a pivotal role in this field.

The environmental factor involves the anti-epileptic drugs taken when the mother is pregnant, introduction of toxic substances through smoking, heavy alcoholic intake, other infections, and general deficiency of folic acid in the body and acute intoxication of the vitamin A content in the body (Luo et al., 2006).

Research shows that the epidemiological studies are affected by chance correlations. Different cultures races and countries across the world represent different frequencies of clefting as a condition. The cleft palate and lip the most widespread hereditary abnormalities and has an approximate degree of prevalence.

The degree ranges in between 1/1000 to 2.69/1000 across the globe. One in every 2500 African Americans are given birth to with clefts. However, the Caucasian has a higher prevalence of these conditions as compared to the African-Americans. In Malawi there generally fairly low prevalence (0.7 per 1000 births) of the conditions as compared to Sudan in the city of Khartoum which has zero point nine per one thousand births. Prevalence in Latin America is lower than in the Caucasian world.

Pathogenesis of cleft lip and or cleft palate

It is worth noting that every human beings during the early stages of growth and development, usually exhibit cleft lip and cleft palate conditions. This is because, between the sixth and eleventh weeks of development, the clefts are usually fused into one that is in the lip and palate.

The occurrence of these facial defects has got nothing to do with any action of the mother during pregnancy. When a child has the cleft lip or cleft palate it means that one or both of these expected splits did not attain fusion.

Types of clefts

As mentioned earlier clefts occur in a variety of ways. These are cleft lip and cleft palate occurring together, cleft palate without a cleft lip and a cleft lip without a cleft palate. When clefts are on one side of the mouth they are referred to as unilateral clefting and bilateral clefting when they occur on both sides of the mouth.

According to Luo et al. (2006), a general understanding is that the number of boys who have cleft lips across the world is more than the number of girls who have the same condition. Another point is that the number of girls who have cleft palate is more than the number of boys who have the same condition.

The ease of diagnosis of clefting is due to the fact that the symptoms of this condition can easily be seen, thanks to technology since the condition can be detected by use of prenatal ultrasound. In the event that there is difficulty in identifying the particular defect before birth then it can be identified later after the baby is born by simply observing and making the necessary correct judgments.

Unilateral cleft lip

As explained earlier, unilateral cleft lip affect a single side. It may appear as a tiny notch in the lip thus a minor occurrence. When the cleft involves the dental ridge, the roof of the child’s mouth and the lip then it qualifies to be a serious thus major condition. Still under this kind of clefting, there are other major categories.

The first category is when it involves either the whole lip or just part of the lip. it may affect the colored border of the lip or even two thirds of the lip’s height. A common observation is when the horizontal lip muscle is divided at the lower part of the lip while the other part of the muscle remains undamaged. There is a possibility of complete division of the muscle resulting in an open gap of the skin. The parts may bulge on both sides of the gap since the muscle of the upper lip is not connected at the cleft. The nose is also affected when a unilateral cleft occurs.

The separated muscle of the cleft lip usually tends to pull with a tension of some sort which is usually asymmetrical. The asymmetrical tension is usually against the nostril which is on the side where the cleft is. The result of this condition is that the lip becomes large and also the nostril will appear horizontal (Luo et al., 2006). The central column of the central cartilage will become short simply because of the pull. The result of this is that the nose will generally be lower than normal.

The second condition is the unilateral cleft lip and the dental ridge. In this condition, the underlying dental ridge and the upper lip are all divided into two parts. There are cases where the cleft can extend from the lip through the floor of the nose in an upward direction. Another possibility is when it only affects the dental ridge and the lip.

A separation in the skin and segments is created because the lip muscle is divided. These very segments may appear to bulge on one of the two sides. The dental ridge can be described as lacking teeth and it is for this reason that they may appear unusually rotated, shaped or crowded. In other cases, the perimeter of the dental ridge appears to be narrower than normal. This condition also affects the nose.

The muscles of the divided lip pull against the nostril. The pull is usually asymmetrical just like in the unilateral cleft lip which involves part or the whole height of the lip. The lips will in turn appear larger than usual in addition to a more horizontal nostril. The central column of the central cartilage will become short simply because of the pull. The result of this is that the nose will generally be lower than normal.

The third condition is the unilateral cleft lip, dental ridge and the roof of the mouth or with additional complications from the palate. In this case the opening of the cleft is positioned both on the dental ridge and the lip. In addition, it extends right through the palate. The extension could be either through the hard or soft palate. The level of correction of the defect and speech therapy is therefore determined by the extend which the cleft goes towards the back of the child’s mouth.

This type of unilateral cleft translates into lacking teeth on that specific cleft side. The teeth may therefore be rotated, erupted or malformed in the palate side in place of the dental ridge. A clear variation of these complications is also expected.

Bilateral cleft lip

As the name suggests, a bilateral cleft lip normally affects two sides. The degree of effect of this kind of cleft can be minor or very extensive. The bilateral cleft lip is one of the major categories. The lip is divided into three parts meaning the lip is affected by two clefts. Through observation one can see two lateral parts together with a central part or segment which has no single muscle but has a colored border.

Landes et al. (2006) assert that the lip can be divided on one side more than the other or better still the lip can be divided equally. This only means that the lip may be symmetrically or asymmetrically divided. The nasal malformation is normally associated with children or rather patients who have bilateral cleft lip. It should also be understood that when a symmetrical cleft only affects the lower part of the lip, it may not necessarily affect the nose.

The bilateral cleft lip and the dental ridge is another category of the bilateral cleft lip. It results when the dental ridge and the lip are separated into three parts. In most cases the lips are wholly divided on the two sides.

It is worth noting that while one side of the lip may have an apparent cleft, the other side may only have an indentation. The central segment tends to grow past the limit of the dental ridge in situations where it is divided completely on both sides. The dental ridge may protrude downward or forward.

When the middle segment protrudes, it is referred to as pro-labium.the dental ridge may not have teeth, or the teeth may be shaped unusually or worse still, they may be adjacent to the cleft. There is also a possibility of the teeth crowding or even rotating into the palate in the mouth.

The third type of bilateral cleft lip is the bilateral cleft lip, roof of the mouth and the dental ridge. As much as this condition is the least common, it happens to be the most severe type when it occurs. This particular condition is similar to the second one as discussed earlier, the only difference being that it affects the palate.

The three parts affected by this condition (dental ridge, roof of the mouth and the lip) are all divided into three parts or rather segments. In most cases the lip is usually divided on the two sides. The dental ridge may or may not be divided completely. One side may exhibit an apparent cleft condition and they may only have an indentation.

In situations where the dental ridge is completely separated, the central part or segment grows past its limits (Landes et al., 2006). Another observation is that the bony segment protrudes forward and even downwards. the middle protrusion id hence referred to as the pro-labium where the prefix “pro” means in front while the suffix “labium” means of the lips thus in front of the lips. The teeth may be shaped unusually or worse still, they may be adjacent to the cleft. There is also a possibility of the teeth crowding or even rotating into the palate in the mouth.

The teeth may therefore be rotated, erupted or malformed in the palate side in place of the dental ridge. There is a possibility of the mouth area being short with a very narrow yet asymmetrical shape of the upper jaw. Food being consumed by the patient can easily pass into the nose since the cleft palate usually transforms into an open space in between the nasal area and the inner mouth. Special precautions of feeding are therefore required in the event of such a condition affecting someone.

The cleft palate involves either the hard or soft areas of the palate. This means that the cleft palate affects only the palate. The cleft lip as compared to cleft palate condition varies with it’s extend of effect. Problems associated with breathing, feeding and speech are all created by a divided palate. The cleft lip and palate conditions as compared to cleft palate only condition has more effect on the development of the nose and the dental formula.

The cleft palate condition has a number of categories which are going to be discussed shortly. The hard cleft palate only affects the hard or rather bonny part of the palate or in other words, the roof of the mouth. On the other hand the soft cleft palate only affects the part of the palate that is soft as the name suggests. This area is usually near the throat that is at the back of the mouth.

The extended middle cleft palate is a rather complicated condition since the cleft finds its way to the soft palate from the hard palate. Additional surgery is definitely required in this particular situation. The surgery will ensure that the soft palate is sufficient for the production of speech as much it will still cause difficulty in feeding and breathing. Most affected children normally need a single surgery so as to close up the palate in order to have normal speech. This translates into ninety percent.

The sub-mucous cleft palate is another kind of cleft palate. This appears to be concealed under palate’s lining. The lining is basically a mucous membrane. It is difficult to determine the kind of cleft because of the visibility reasons unless a careful examination is effected. As the muscles pull perpendicularly to their usual positions, it may be seen in the soft palate.

The location of the hard palate submucous cleft is at the middle of the hard or bonny area. It may sometimes be identified by a feeling of a notch on the roof of the child’s mouth. It is worth noting that sometimes these clefts are associated with a mass of tissue hanging down at the back of the baby’s throat commonly known as cleft uvula. This condition is associated with hearing problems, speech and feeding difficulty. However, not all patients go through such difficulties.

Causes

Abdulreda et al. (2010) stipulates that it has not been established for a fact why people develop clefts but doctors have for a long time based their judgments on the belief that these may be due to genetic and environmental factors. The environmental factors include drugs, illnesses and indulging in uncouth habits such as alcohol drinking and smoking of tobacco by women during pregnancy.

When a parent has cleft conditions then it translates into a higher risk of passing the condition to his or her sibling. Both fathers and mothers are capable of passing these genes associated with clefting to their siblings.

A further or rather deeper look at the causes of clefts reveals that no one really knows the exact causes of the same. People only believe and base their assumptions on inherited characteristics from the parents, the environment in terms of poor early pregnancy health or exposure to the above mentioned toxic substances and genetic syndromes. A syndrome is basically the abnormality of genes.

The abnormalities of genes which make up the chromosomes result into malfunctions that are arranged into a particular pattern (Abdulreda et al., 2010). Therefore cleft palate and cleft lip are both syndromes among the other four hundred syndromes. Statistically, thirty percent of the cleft conditions are related to a particular syndrome. It is for this syndrome that genetic counseling and proper medical evaluation is required by the victims of clefts.

A cleft palate or cleft lip is capable of affecting the facial appearance, feeding problems, ear complication and also speech problems. The problems are related to the appearance of a small notch or a clear cut groove on the roof of the mouth.

Complications

Children with cleft lip or palate are at a higher risk of having ear fluid collections, loss of hearing and speech problems. The cleft palate poses dental problems. These problems are missing teeth, overcrowding, malformation, displacement of the very teeth and cavities. These children are also vulnerable to infections of the ears. This is so because the Eustachian tubes in their ears have a compromised capability of draining fluid properly into the throat from the middle ear.

The accumulation of fluids and pressure build up makes it even easier for infections to occur. To correct the situation, special tubes can be surgically inserted in the ears during the first phase of reconstructive surgery (Douglas et al., 2007).

It should be understood that speech is both expressive and receptive. It is receptive when we comprehend a language that is being spoken to us. It is expressive when we move our tongue, mouth and the oral activity so as to express ourselves. Hearing and speaking are closely related. It is quite difficult for a baby to mimic the sound of a certain speech if it cannot hear. This means that the baby is at risk for receptive acquisition of language in addition to expressive acquisition of language.

It is common knowledge that both the palate and lips are used for pronunciation thus people who are affected by cleft normally require the help of a speech therapist. It is very necessary to support both parents and children affected by these conditions since socializing with affected family and even the child may be greatly interfered by unusual appearance, impaired speech and surgical involvements.

The feeding of the child is also another problem. The cleft lip is closely associated with the inability to suckle and the cleft palate condition may cause accidental sucking of milk through the nasal cavity. This situation can be made manageable by use of special nipples. A child with a cleft palate will be more comfortable when feeding in an upright position because milk will be prevented from coming through its nose by gravity.

Comprehensive information on how to use these specialized nipples can be given where they are purchased. The haberman feeder is used for gravity feeding. Another method is by using a combination of nipples and bottle inserts (Douglas et al., 2007). A controllable flow of milk for the infant can be achieved by a cross cut, a slit in the nipple, a large hole or a protruding nipple and squeezing it in a regular rhythm. This in a way works to reduce the stigma caused when the specialized equipment are used.

Some situations require that the affected child wears a prosthetic palate so that feeding is made easier. Proper information can be offered by a doctor about the appropriate feeding aids.

Clinical manifestations

The scope of cleft lip and palate is very wide. It varies from minimal notches to grooves on the lip or palate. When the condition is minor, research describes slight defects on the lip, roof of the mouth and the dental ridge. Histologically, it is evident that the defects may extend further to the muscles of the superior orbicularis oris OO muscle.

Recent research shows defects in the OO muscle in a number of fetuses with no visible evidence of the cleftig condition. This means that the cleft lip and palate phenotype might have occult clefts. The OO defects might be present but without symptoms of cleft lip or palate. Other researchers argue that it is possible to use of ultrasonography to view sub-epiphilical OO defects for health control reasons.

Other forms of clinical manifestations include excessive secretions associated with constant drooling and large amounts of secreta through the nose. Cyanosis that is unexplained and laryngospasm brought about by the aspiration of saliva. Other manifestations are abnormal distention and violent responses immediately after swallowing food evident by coughing, choking, return of fluid through the mouth and nose and struggling.

There is generally poor feeding and also the child is not able to pass catheter to the stomach through the nose or mouth. The child appears to be premature in addition to complicated pregnancies.

There is also deformity of the uvula, anorexic complications, impaired speech, teeth that are well arranged, change of the shape of the nose, difficulty in weight gain and recurrent infections of the ear (Anne, et al., 2009).

Examination of the nose, mouth and the roof of the mouth work to give a confirmation for a cleft palate or cleft lip. Thorough medical examinations are used to disqualify other opportunistic health problems that are not related to clefting.

Diagnosis

At the time of birth is when these conditions are discovered. Technology has enabled the diagnosis of the same using ultrasound even before the baby is given birth to. When an infant is affected by cleft lip for instance, this signal is usually discovered by the routine ultrasound scanning in the period between eighteen to twenty weeks of pregnancy.

Upon discovery of a cleft lip then the parent is registered under hospital that deal will cleft treatment. The hospital definitely has a specialized team which consists of professional and well qualified doctors in this particular field.

Special arrangements are usually made to ensure that the patient sees the doctor on a regular basis depending on the extent of the condition. Unfortunately, a cleft palate is usually discovered only after birth unlike the cleft lip. The team of specialists includes a nutritionist, social worker, and pathologist of speech, dentist, oral surgeon, plastic surgeon, otolaryngologist, geneticist, orthodontist, audiologist and a psychologist.

The sub-mucous cleft is kind of special since it is usually discovered during the first examination. It is usually covered by a smooth lining in the mouth. It therefore calls for the child to be assigned to a team of experts for proper treatment.

In the event that a cleft is discovered, then a doctor can get a sample of amniotic fluid from the mother’s uterus so as to check for more abnormalities in the chromosomes. This is called amniocentesis and it is made possible because clefting is a syndrome that affects the genes. a needle is usually inserted in the uterus wall to suck some amniotic fluid that is taken to the laboratory for testing.

The final results are usually ready after ten to fourteen days. The preliminary results are usually given by the famous fluorescence in situ hybridization. This test is normally ready between twenty four to forty eight hours. Over the years of use, this particular type of testing has been found to be very accurate and therefore reliable especially in the three common chromosomal disorders. The disorders are trisomy 13, 18 and 21 (Anne, et al., 2009).

Generally after the baby is born, genetic examination helps to determine the extent of treatment for the affected child. This is easier when the clefting is a genetic condition. Genetic examination is very important since it points out the risk that they might undergo if they decide to have more children.

In the event that cleft lip and cleft palate is discovered during the prenatal care, it should be brought to the doctor’s attention so that the mother is referred to a perinatologist who is a specialist for high risk pregnancies. It is advisable that more ultrasounds are performed to further diagnose the conditions and proper action is taken.

Feeding is one of the major issues that are associated with clefting in children. The problem varies from mild to complicate depending on the extent of the effect of the condition. Special bottles and proper positioning will help ease the problem before it is corrected.

Treatment of cleft lip and palate

Treatment of clefts entirely depends on the individual. This depends on the severity and location of the cleft. In the life of the patient continuous surgical sessions and follow up are needed. More surgeries are meant to achieve the best results. It is therefore believed that the earlier the treatment, the better. in the case of a one sided lip, it should be corrected in the first one month not forgetting a follow up surgery at the age of six months.

The one or two sided cleft palate and lip correction should be done before the age of six months. In the case of a two sided clefting an orthodontic devise is needed to assist in feeding of the baby.

When the child is born and it is discovered to have either cleft lip or palate conditions or even both, the mother and the child are referred to a specialist centre. At the centre one will meet a team of experts in this field who are expected to take care of the baby.

As mentioned earlier the team consists of a nutritionist, social worker, pathologist of speech, dentist, oral surgeon, plastic surgeon, otolaryngologist, geneticist, orthodontist, audiologist and a psychologist. a comprehensive care plan to monitor the affected child will be drawn.

According to Ilza & John (2009), surgery helps the child to grow and develop like other normal children. Surgery is meant to repair clefts in addition to plastic surgery for the severe cases. Usually, in the case of an incomplete cleft it still requires the same surgery like the one needed for a complete cleft.

The reasons for this action are that the muscles needed usually run through the upper lip. Therefore a full incision must be made to restore the mass of muscles. The second reason is to reduce the visibility of the scar to necessitate easy stitching. It is true that in the event of an incomplete cleft, the surgeon enjoys to work with more tissue. Chances are that the upper lip will be more supple and natural.

The earlier mentioned specialists are charged with the duty of regularly evaluating the progress of the child in addition to monitoring their nutrition, speech, hearing, teeth and emotional status. They are expected to point out their recommendations to the parent (mother) and may even advice on the therapists who can offer additional assistance. The specialists are also expected to share feedback on any progress made by the child.

The baby is expected to have an operation that will close up the cleft lip before three months. After the first phase of surgery is completed, the speech pathologist fully assesses the patient. The use of a number of sounds is necessary in evaluation of the development of the child in terms of his or her communication skills.

The kids play and socializing behavior are closely observed. This helps to determine that best exercises that are needed by the child. The speech therapist is expected to continue interacting with the infant even through its successive additional surgeries. Surgery to repair the cleft palate is done later at least before the child clocks one year. The severity of the cleft dictates the type of surgery that the child needs. Surgery is done under anesthesia to put the baby to sleep during the exercise.

An incision is made on the two sides of the cleft right from the lip ending at the nostril. Suturing up of the two lips then follows. In the case of a bilateral cleft, two surgeries are required. The two surgeries are usually one month apart. It also requires that the infant stay in the hospital for a while.

Surgery of the cleft palate requires that the surgeon draws tissue from the two sides of the mouth in order to reconstruct the palate. The first night is usually spent in the intensive care unit and a total of two to three days in the hospital under special medical attentions.

Ilza & John (2009) stipulate that the purpose of the first stage of surgery is to come up with a palate that is functional, to minimize a possibility of fluids flowing into the middle ears and finally assist the affected bones develop as required. On the other hand the functional palate will help in feeding and speech capabilities.

The skill of the surgeon will determine the number of successive surgeries that are needed. The extent of the cleft, shape and thickness of the tissue that is available will also greatly contribute to the number of surgeries required by the patient. This tissue is normally handy when it comes to creation of a functional palate. It is for this reason that you will find that some infant will need more surgeries than others in order to improve their speaking capabilities.

It is true to state that additional surgeries have really worked to recover facial appearance of the affected patients. Apart from the appearance aspect, additional surgery has also been vital to close up gaps, assisting in breathing, realigning and also making the patient’s jaw stable. Further surgeries are usually done after six months so that the child is given enough time to heal so that incidences of scaring are lowered.

The final correction is usually performed during the adolescence stage. This is so because at this particular time the facial structure is almost fully developed.

After the operation the baby will need to be in hospital for at least four days and utmost five days. It is expected that the mother stays in hospital with her child. There are cases where the baby might need more surgical attention. For a child with a gap in the gum, a bone graft is done at the age of nine years. This helps in proper anchorage of the child’s second teeth. Palatoplasy is a procedure that is used to correct the cleft palate.

When the surgery is done, an IV is used for provision of fluids, medicine and food till he or she is able to eat without assistance. Antibiotics will be necessary to prevent infection and also to relieve pain when the baby is healing. Immobilization of the baby’s arms is necessary to prevent the elbows from bending. These efforts are meant to necessitate proper healing.

The mother should be able to care for the baby even after surgery since it is expected that the baby will be taken to a nursery for the new born. In case the mother needs to breast feed the baby, she should consult the lactation consultant (Ilza & John, 20090. The baby is therefore ready to go home when it is able to eat food without any difficulty and is gaining weight steadily.

The treatments for the infants are also applicable for the respective affected adults. The adults usually need to get genetic counseling. This spells out the likelihood of bringing forth a sibling with a cleft.

The cleft palate team is charged with the responsibility of evaluating the situation of the adult and then advice on its management. It is common knowledge that adults are very sensitive about how they look especially their lips, nose, quality of hearing, ability to speak, and the arrangement of the teeth in their mouth.

The scars that left after a reconstructive surgery are there to stay so the affected patient should learn to live with it. Surgery is capable of changing how whatever is being repaired. To this point a revision surgery should be placed into effect normally on the basis of outpatient. The surgeon should be able to answer questions about the change of appearance before and after surgery depending on the patient.

The improvement of speech is more effective on children as compared to adults. A speech pathologist is able to evaluate the speech of the adult patient in question and determine the possibility if speech improvement. To this stage the patient may be advised to undergo a renewed therapy of speech, a successive surgery or an appliance for speech. Since also adults can have difficulty in hearing they are liable to experience communication difficulty. a routine check for the adults ears and nose is advised.

Adults affected by clefts also have irregularly shaped dental formula, missing or even crooked teeth. This condition can be corrected by use of braces. When the teeth are not well shaped they can be replaced by implants. When the jaw and teeth don’t meet, then feeding and also beauty is affected. Surgery is the answer to this problem. The special team of doctors will definitely be in a position to determine the best treatment procedures.

The cleft condition may seriously affect a person’s self esteem. The patient can be assisted by psychological counselors (Jiang et al., 2006). Some of the things that will be discussed in such sessions include: appearance concerns, the ability to socialize, job satisfaction, future goals and hopes to be loved. it should be understood that interaction with other affected adults is very healthy.

There are organizations around the world through which the patients can access funding so as to correct their conditions. A social worker should be in a position to assist the patient get a source of funding. Patients can also benefit when they get attached to support groups. The adults living with cleft conditions are necessary especially in the area of being a role model in the lives of the children who are growing and therefore are affected by this condition.

Emotional and social issues

Emotional and social aspects are very important in the growth and development. Knowing how to deal with them effectively opens up a window for proper healing of the infant. Since the society is attracted by physical appearance, it will be very difficult for someone who has defects due to clefts in that very society. When these affected children are teased by others, it greatly lowers their self esteem thus the dire need for emotional support for the kid.

There are number of ways through which the parent can offer support to the kid. One should be ready not to always think about his or her child’s defects and not letting them to define her or his child. One should make the home environment at home very warn so that the kid can feel accepted at home as compared to other places away from home.

The kid should be encouraged to make friends with different people. The parent should lead by example. The child should be taught how there are other positive attributes that are equally important as just physical appearance.

The child should be free to make independent decisions. Through this simple act, the child will definitely develop confidence and in turn self-esteem. The child should also be supported to make presentations about his or her condition to the classmates in class. This can easily be made possible through an arrangement with the teacher.

According to Jiang et al. (2006), another way could be a situation where the parent talks to the class instead. When it is discovered that the kid has recurring self-esteem issues then he or she should be booked in for a session with a psychologist or an appropriate social worker.

Dental care and orthodontia of patients

Children affected by clefts also need dental care as well as the normal ones. Brushing and flossing of teeth should be done on a regular basis when the six year molar teeth are in place. A toothate should be used according to the specialist in place for a tooth brush. a toothate is simple a sponge which has mouth wash.

The parent is advised to change to a soft brush as the child grows. All these efforts are meant to ensure mouth hygiene of the child is maintained on a regular basis. This helps to reduce chances of opportunistic oral infection that might hamper the proper healing and development. The alveolar effect of the ridge is usually experienced by infants with cleft palate.

The ridge is the hard upper gum area that has teeth and therefore the defects are capable of preventing the appearing of permanent teeth; prevent the formation of the alveolar ridge and rotating the permanent teeth and even displacing or tipping the teeth.

As explained earlier, these complications can be corrected by grafting to allow the placing of teeth. There are number stages. The first stage is referred to as orthopalatal expansion which begins when the permanent teeth set in. the expander is strategically positioned in the mouth. a graft of the bone comes after the jaw widening (Andrew & Lina, 2005).

It is advisable that the orthodontist of the child waits for the permanent teeth to come then he or she may go ahead with the second phase. The second phase usually involves the removal of the extra teeth. Addition of implants in the case of missing teeth or placing braces where teeth alignment is required.

Statistically, twenty five percent of children who have unilateral cleft lip and cleft palate, the upper and lower jaws grow at different paces. When this situation is observed in children then it calls for orthognatic surgery which will ensure that the teeth are well aligned and assist the development of the upper jaw (Jiang et al., 2006)

This particular group of children requires osteotomy on the upper jaw. An additional bone graft is necessary in this scenario. The bone grafting assists in the stability of the jaws.

Speech therapy

Oral clefting affects the ability of the child to speak thus difficulty in communication. In some cases, the surgery fixes the problem. When speech therapy is done to the child in the early stages of his or her development is very important. A speech therapist should be visited at the age between eighteen months and two years.

Speech therapists usually take the initiative of talking to parent during the first six months so that the parent has a clear picture of what is expected of her way before the right time for the speech therapy. The therapists also take his or her time to explain to the parent the king of games that are important in stimulating the speech of the affected child.

The specialists are able to determine the right time for a full assessment of the condition of the child after completion of the first stage of the surgery.

Prognosis

A multidisciplinary management approach is necessary for a kid who is born having the cleft lip with or without cleft palate. When there is no condition of a syndrome, it possible that the kid can have good aesthetic and functional results. It is a good thing to have long-term prognosis the isolated cleft lip and or palate.

Certain issues such as the dental complications and problems usually need follow ups. All the kids with clefts will need braces for alignment purposes. On the other hand a delay is prompted in the event of eruption of permanent teeth.

Andrew &Lina (2005) propose that a good percentage (25-35%) of kids with cleft lip and palate require secondary speech therapy and palate surgery. the defects in the nose and the cartilage which divides it into two may be present.

Prophylaxis

When a family brings forth a child with the clefting condition, it means that the chances of having more children being affected by the same condition are increased by a certain significant margin. It is for this reason that genetic counseling is required so that the parent can comfortably weigh their options so whether to have more children or not considering what is at stake.

Research has shown that the best was to avoid chances of giving birth to children with defects is to ensure that the mother has a healthy pregnancy. This will greatly help to avoid clefting conditions unless if they are hereditary.

Another simple method of preventing clefts is by swallowing supplements of folic acid on a daily basis. This easy procedure is capable of saving a kid from developing a cleft lip. It is worth noting that 400 micrograms of the acid is also the kind of amount used to lower the risk of developing defects of the neural tube for instance spina bifida.

Non-allopathic management of clefts

The practice of closure of the gaps or clefts is a general management practice. Other important management actions are: the preventing complications, facilitating normal growth and development of the infant and finally habilitation.

It should be ensured that the cleft lip is corrected first before fixing the cleft palate. The correction should be immediate and a successive one should be done when the kid has reached the age between six to twelve weeks. It is advisable to do cleft palate correction at the between six months and five years considering the extent of deformity, oropharynx width, function of pharynx and palate neuromuscularly and the opinion of the surgeon.

It is good to repair the defect when the child has attained the age of nine to eighteen months before speech patterns get set. a special denture palate is usually utilized in the event that correct or fixation of the defect is delayed for instance up to at least four years (Andrew &Lina, 2005).

In addition, the nurse has to intervene in his or her capacity to ensure that proper and adequate nutrition is properly adhered to, prevent all the infection that might hamper the proper healing of the kid, enhance acceptance, and prevent obstruction of the airway and ambition and finally generally ensuring good home management that will enhance comfort of the infant.

Conclusion

In summary, cleft lip and or cleft palate are very serious conditions that need support and encouragement to the affected family and even the patient. It is advisable that in the event that any of the above-discussed defects are pointed out or discovered, one should seek medical attention so that proper correction and treatment measures can come into place.