Before birth, natural structures form in the body and then join together, or fuse. If they do not fuse, a cleft results. A cleft is a fissure or a gap.
In a cleft lip, the gap occurs in the upper lip, and in a cleft palate, the roof of the mouth is affected. They can also occur together. One side only of the lip can be cleft, or both sides.
The Centers for Disease Control and Prevention (CDC) estimate that, in the United States, around 2,650 infants are born with a cleft palate, and 4,440 babies are born with a cleft lip, either with or without a cleft palate.
A cleft is one of the most common types of birth defects in the US. Among some 15 types of clefting that affect the mouth and face, known as orofacial clefting, cleft lip and cleft palate account for between 50 percent and 80 percent of deformities experienced, depending on the type.
What is it?
The cleft in the lip may be small, or partial, and look like an indentation on the lip. A complete cleft goes as far as the nose. A unilateral cleft affects one side of the lip, either right or left of the "cupid's bow" at the center of the upper lip. A bilateral cleft affects both sides.
A cleft is a relatively common defect in newborns.
A cleft palate happens when the two parts of the skull that form the hard palate are not fused together. The soft palate also has a gap, or cleft. A person with a complete cleft palate may also have a gap in the jaw, while an incomplete cleft palate looks like a hole in the roof of the mouth.
In the U.S., the highest incidence of cleft lip, either with or without cleft palate, is among the native American population and Asian Americans. For this group, the rate is around 2 cases in every 1,000 live births. In people of European descent, the rate is 1 in every 1,000 and for African Americans, it is 1 in every 2,500. The rate of cleft palate is 1 in 2,000, regardless of ethnicity.
Males are twice as likely as females to have cleft lip, cleft palate, or both. Females are more likely to have a cleft palate only.
With modern surgery, most cases can be corrected with minimal scarring.
If not corrected, a cleft lip or palate can lead to:
- Dental problems
- Ear infections and possible hearing loss
- Feeding difficulties
- Low self-confidence
- Speech problems.
A team of specialists, from the family physician to a speech therapist, will work to help a child with a cleft, because of the range of difficulties it can pose.
During first 12 weeks of pregnancy, the fetus' skull is developing.
Two separate plates of bone and tissue form. They gradually move towards each other, and they join, or fuse, at the mouth and nose to form the skull.
If this fusion is incomplete, a cleft will result.
Certain genes make a cleft more likely in some people than in others.
Most parents with a cleft do not have babies with one, but it is common to see a cleft in people who are close relatives.
The risk may be higher if the mother smokes, or drinks over 10 units of alcohol a month during pregnancy, if she has insufficient folic acid or if she has obesity. According to the CDC, certain medicines that treat epilepsy, for example, topiramate or valproic acid, can increase the risk of a cleft if used during the first 3 months of pregnancy.
A range of interventions is available for children born with a cleft.
Surgery can correct a cleft lip, so that is it no longer noticeable.
An orthodontist may start to repair the palate and bring the lips together within a week of birth. This treatment, called nasoalveolar molding (NAM) aims to prepare the infant for future surgery.
Surgery to close the cleft lip may happen within 3 to 6 months of the baby's birth, and repair to the cleft palate from 9 to 18 months. This should enable the child to speak and eat normally.
Cleft palate can be treated with surgery to correct the jaw.
Some doctors prefer to wait until the child reaches the ages of 10 to 12 years before doing surgery. Waiting until all the milk teeth have gone and the adult ones are in place saves having repeated corrective surgeries.
Other specialists prefer to correct the jaw earlier, arguing that speech therapy is less effective when the patient is older.
Around 1 in 5 children need only one surgical procedure, but most will need a combination of surgical methods and operations as they grow.
Sometimes, the gap, or cleft, reaches the maxillary alveolar ridge, which is the edge of the upper jaw, where it meets the teeth. In this case, the surgeon fills the gap with bone tissue, which is taken from another part of the body, such as the hip.
In many countries, the infant is monitored by a cleft palate team or craniofacial team until they reach adulthood, and sometimes for life.
These days, scarring, as a result of surgery, is often minimal, but the individual may undergo further surgery later in life to improve the appearance of the face.
Speech and hearing
Cleft lip and cleft palate can affect speech, because when a person speaks, the lips, palate, and tongue work together to form the words.
Cleft lip and cleft palate can mean a higher risk of ear infections, and this can affect hearing.
If the child has a higher risk of ear infections because of their cleft palate, then tympanostomy tubes may be placed to prevent fluid from building up in the middle ear. A tympanostomy tube, or pressure equalization (PE) tube, used to be known as a "grommet."
A speech-language pathologist can help solve speech problems. In addition to the cleft repair, the child may need other types of surgery to reduce the amount of air that escapes through the nose when the child speaks.
The speech therapist may also help the child to correct speech issues that may have developed before the repair. Children with a cleft learn to compensate when speaking. After repair, they have to learn new ways of forming words.
Nowadays, a child with a cleft is more likely to have effective corrective surgery at an early age. This reduces the chance of being teased or bullied at school.
Even so, the child may need encouragement to interact with other children from an early age. Other children may ask why the person with a cleft lip or palate looks different. The child with the cleft should be able to explain to their friends when asked.
If the cleft causes hearing and speech problems, it is important for parents or carers to speak to the school, so that teachers can make sure the child sits in a place where it is easy to see and hear.
Children with cleft lip or palate tend to have more problems with their teeth than other children, because the alveolar ridge, which is the ridge of bone that supports the upper teeth and gums, might not develop properly.
The child may need dental braces.
Tooth decay is more common among children with cleft lip, cleft palate or both. Good oral hygiene can help reduce the risk of decay and dental problems.
A cleft palate can be challenging for both parents and children, but nowadays, corrective surgery and other interventions are widely available.
There is no way to prevent a cleft palate, but avoiding alcohol and tobacco during pregnancy can reduce the chance of a cleft and other problems. It is also important to check with a physician before taking any medications during pregnancy.
Parents can also seek genetic counseling before pregnancy to help them to understand the risk.