Cleft lip and cleft palate

 also known as orofacial cleft, is congenital birth defect that

includes cleft lip, cleft palate, and both together.
 that mean May occur separately or together

 A cleft lip contains an opening(split or separation) in the upper

lip and appears as a narrow opening or gap in the skin of the
upper lip that may extend into the nose. The opening may be on:
1- one side (unilaterally,)
2- both sides (bilaterally )
3- rarely in the middle
 Cleft lip May be:
1- complete (extending into nose)
2-incomplete (bridge of intact tissue between
oral and nasal cavities)

Unilateral incomplete Unilateral complete Bilateral complete

The palate which is the roof of the mouth is divided into
the 2 part:
1- the front part has ridges and is hard(hard palate)  
2- the back part is smooth and soft(soft palate)

A cleft palate occurs when the roof of the mouth

contains an opening into the nose
Cleft palate: May involve:
1- complete cleft: extend to both the soft palate and hard
palate
2- incomplete cleft: only the uvula (a 'hole' in the roof of
the mouth, usually as a cleft soft palate)
Incomplete cleft palate Unilateral complete lip Bilateral complete lip and
and palate palate
 Path physiology
The lip forms between the 4 and6 weeks of pregnancy
while the palate is formed between the 6 and 12 weeks
of pregnancy .
The lips and palate originate from 3 areas of the baby’s
developing face:
1-Central or Frontal Nasal Prominence: normally grows
to become the forehead, nose, middle portion of the
upper lip and the primary palate (part of the upper jaw
that holds the middle four teeth)
 Pathos physiology
2-Left and Right Maxillary Prominences: grow and become
the lower face, lower lip and jaw, middle portion of upper lip
and jaw, and the secondary palate (behind the four upper
middle teeth to back of mouth.

These three prominences on the child’s developing face

grow towards the center of the face and fuse together
during pregnancy. When this happens correctly, the
child’s lips, mouth, and palate develop normally.
When this happens incorrectly , the lips and mouth do
not form properly, leaving a cleft or split in the lip.
 Pathos physiology
• Otherwise, in CL result from incomplete fusion of the
embryonic structures surrounding the primitive oral
cavity.
• In addition, CP occurs due to the failure of fusion of
the primary and secondary palatine palates .The hole
in the roof of the mouth caused by a cleft connects
the mouth directly to the inside of the nose.
 Causes
• the exact cause is Unknown in most cases.
• But some factors may play role such as genetics: The
mother or the father can pass on genes that cause
clef ting

• and environment. 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.
 Risk factors:

• Having a family history of cleft lip or palate.

• Using tobacco, drugs, or alcohol during pregnancy.
• Not getting enough nutrients during pregnancy, such
as folic acid.
• Having diabetes before pregnancy.
• Taking certain medicines, such as some for epilepsy,
during pregnancy.
• Being obese during pregnancy.
• Having certain infections during pregnancy, such
as rubella (German measles).
 Sign and symptoms

o A split in the lip and palate that affects one or

both sides of the face
o Difficulty swallowing
o Nasal speaking voice. Due to the split in the
palate,
o Difficulty with feedings: The newborn easily
becomes choked on liquids.
 complication
• Feeding problems because the cleft make sucking
difficult.
• Chronic otitis media and hearing loss caused by the
obstruction of the Eustachian tube, negative middle
ear pressure and fluid build-up
• Speech difficulties  Because the palate is used in
forming sound (Speech may sound nasal.)
• Airway obstruction
• Dental problems. If the cleft extends through the
upper gum, tooth development may be affected.
 Diagnostic Test Results

• the diagnosis is made at the time of birth by physical

examination:
Inspection: Diagnosis of cleft palate.  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

•  prenatal diagnosis by ultrasound

 Treatment
• Orthodontic prostheses to improve sucking
• Airway management
• Speech therapy
• Use of specialized nipples, including large soft nipples
with large holes  to improve feeding patterns and to
promote adequate nutrition
• Medications
Acetaminophen for discomfort
Antibiotic for otitis media
• Surgery
-Surgical correction of cleft lip is recommended within the first
12 months of life, and is usually performed between 3 and 6
months of age.
-Surgical palate repair is recommended within the first 18
months of life. Generally, surgery is performed after age 9
months but before 14 months to improve any hearing or
breathing concerns and to decrease potential speech and
language difficulties. 
- Tracheostomy may be required if the airway is completely
obstructed.
 Nursing process
• Assessment
1- History
• Family history of cleft defects
• Maternal exposure to teratogens during
pregnancy, such as alcohol, nicotine
• Maternal diabetes diagnosed before pregnancy
• Fetal exposure to anti-convulsant, such as valproic
acid, during the first trimester
 Assessment
2-Physical Findings
includes temperature, apical pulse, and respirations; listen
to breath sounds, observe skin turgor and color, infant’s
neurologic status, noting alertness and responsiveness.
• Cleft that runs from the soft palate forward to either
side of the nose
• Possible association with anomalies of the face, heart,
and extremities
 Diagnosis
• 1-Imbalanced Nutrition: Less Than Body Requirements R/T
Inability to ingest food AMB Presence of cleft lip/palate,
Difficulty sucking, Poor feeding, Underweight
• Altered Swallowing R/T split in palate AMB pt take over time in
swallowing or potential for liquids or foods to come out the
nose.
• Ineffective breathing pattern related to anatomical
changes AMB Cyanosis, Dyspnea, Productive/non-
productive cough,Tachypnea
• Risk for aspiration related to a reduced level of
consciousness after surgery
 Diagnosis
• Risk for Injury related to Surgery
• Risk for deficient fluid volume related to NPO status
after surgery.
• Risk for infection (otitis media).
Goals: Objective
1-To Maintaining adequate nutrition. Pt will be able to exhibit adequate
nutritional status without defeculty to
maintain growth and healing. During my
shift

2- To improve swallowing The child will be able to demonstrate

proper swallowing technique during my
shift

3- To enhance breathing pattern The child will be able to maintain

breathing as evidenced by clear breath
sounds, respiratory rate of 20 to 30
breaths per minute, absence of cyanosis
and respiratory distress during my shift

4- to prevent aspiration The child will be able to show no signs of

aspiration such as choking or soughing
5- to prevent injury during feeding, weak sucking, stopping or
faster breathing while feding

Infant will be free of trauma, accumulation

of substances, infection.
 Implementation
 Teach the family about the prescribed diet and the proper
way to feed their infant.

 Teach the family about the use of specialized nipples,

including large, soft nipples with large holes, such as a
lamb’s nipple, to improve feeding patterns and promote
adequate nutrition.

 Administer tube feedings or parenteral nutrition as ordered,

and monitor the infant’s response.

 Offer small, frequent feedings and Provide oral hygiene

before and after meals
• An alternative is for the mother to pump her breasts and feed the
infant with a bottle to provide an excellent source of nourishment.

• Instruct mother who bottle feed to use some cereal to thicken the
milk. Thicker milk will make swallowing easier due to the increased
gravity flow.

• teach mother on 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.

• Record daily weight of the infant to evaluates the whether the

feeding pattern is successful or needs to be adjusted.
 Improve swallowing
• Elevate the infant’s head while the child is feeding; keep the head of
the bed elevated for 30 minutes after feeding.

• Allow adequate time during feedings; don’t rush feedings

• Provide the appropriate consistency, texture, and type of food to
enable the infant to swallow without choking, as ordered.

• Assess for symptoms of impaired swallowing and symptoms of

aspiration
• allow the infant to rest frequently to provide time for swallowing
• Teach the family measures to take if the infant chokes.

• Teach the family the proper method to feed their infant to promote
proper swallowing, as appropriate.
 Continue
• Hold the infant in an upright or a sitting position while feeding
to improves swallowing and prevents milk from coming
through the defect and out of the nasal cavity.
• Instruct the mother to apply pressure to the areola using her
fingers, guide the nipple to the side of the infant’s mouth to
allows the infant to nurse with its gums rather than by sucking
if sucking is difficult
 To prevent aspiration
• Teach the family how to feed the infant and how to prevent
aspiration of feedings, as appropriate.
• Administer tube feedings as ordered and Ensure of
placement of the feeding tube prior to administering
medications or tube feedings.
• Review care of any orthodontic prosthesis used to improve
sucking
• Suction the infant’s airway as needed to remove secretions.
• Administer nebulizer treatments as prescribed
• Encourage frequent burping after feeding to remove from
air that child was swallawing during feed
 To enhance breathing pattern
• Assess the infant’s respiratory rate, depth, and effort. Aspiration of
secretions or milk may cause tachypnea

• Place the infant in an infant seat at a 30° to 45°.This position prevents

the infant’s tongue from falling back and obstructing the airway.

• Provide oral and nasal suctioning as needed. to maintain a patent airway

and improve oxygenation by removing excess fluids and secretions in the
oral and nasal cavity.

• Assess for abdominal distention. he infant may swallow excess air during
bottle feeding causinupward pressure on the diaphragm and lungs hence
compromising respiration.
 To prevent injury
• Assess suture line for cleanliness, redness, swelling, or
drainage frequency. to Provides information indicating
possible infection and need for cleansing away formula or
drainage.
• Clean suture site of lip repair with gauze or cotton tipped
applicator with saline to prevent inflammation
• Remove sharp objects or toys, avoid the use of forks, straws
or other pointed objects. Prevents trauma to mouth and
suture line
• Feed with a cup or spoon if palate repair was done to
prevents damage to the suture line
 Contineu
• Teach parents in feeding method of infant and allow to practice
appropriate technique using a syringe soft tube in mouth away
from any suture line to Promotes nutrition following surgery
without sucking on a nipple.
• Instruct parents in soft diet inclusions and avoidance of toast, hard
cookies, or foods, as ordered to Provides nutritional needs until
incisions heal completely.
• Monitor lip protective device taped on operative site to Relaxes
the site and prevents tension on sutures caused by facial
movement or crying.