What is Cleft Lip?
A cleft lip is a common birth defect that affects the upper lip, making it split or indented. Treating a cleft lip requires a team of professionals since it not only affects the appearance but can also lead to issues with speaking and swallowing. There are a few different types of cleft lips. Some might happen along with a cleft palate, another birth defect that affects the roof of the mouth. A ‘microform’ or ‘occult’ cleft is a slight indentation where the lip hasn’t fully separated. An ‘incomplete’ cleft lip is more visible with the lip split apart, often causing a noticeable downward shift in the nostril with a slightly fibrous connection called a Simonart band. A ‘complete’ cleft lip means the lip is fully separated, including the base of the nostril.
Children with cleft lips often need several surgeries and specialized care. The cost of treating a cleft lip can be quite high, and often these children can experience psychological challenges throughout their lives.
What Causes Cleft Lip?
The development of the nose and lip happens between three to six weeks of pregnancy and it involves several parts of the body’s early structure. This includes two structures on the side of the nose, two structures in the middle of the nose on the forehead, and two structures in the upper jaw. The sides of the nostrils come from the side structures of the nose, while the tip of the nose, the middle part of the lip, and the area around the upper front teeth come from the middle structures of the nose.
A cleft lip, which often involves a split in the roof of the mouth in front of the large opening behind the front teeth, happens when the middle nose structure on the forehead doesn’t merge with the upper jaw structure. Also, the middle nose structures can blend together to form a segment between the jaws, which then connects to each of the structures at the sides of the nose. If these processes fail, splits or clefts involving the nose could result.
Risk Factors and Frequency for Cleft Lip
In boys, cleft lips usually appear on the left side. The likelihood of having a cleft lip, with or without a cleft palate, in the general population is 0.1%. However, among different races, this occurrence varies. The condition is more common in Asian babies, with 2 out of 1000 babies being affected, compared to 1 out of 1000 Caucasians and 0.5 out of 1000 African American babies.
About 29% of children with cleft lip also have other birth defects. It’s widely believed that a person’s genes and several contributing factors can cause a cleft lip. Expectant mothers who are not receiving enough nutrients, or who are exposed to certain substances like phenytoin, steroids, tobacco, alcohol, and Accutane, have a higher chance of having a baby with a cleft lip. On the positive side, folate, a type of vitamin, has been found to help prevent the condition.
- Cleft lips are commonly found on the left side in boys.
- The overall risk in the general population is 0.1%.
- Cleft lip is more common in Asians with 2 out of 1000 babies affected, compared to 1 out of 1000 Caucasians and 0.5 out of 1000 African Americans.
- About 29% of children with cleft lip also have other birth defects.
- Factors like genetic make-up, poor nutrition in mothers, and exposure to specific chemicals or substances can increase the chances of a baby having a cleft lip.
- Folate, a type of vitamin, can help prevent cleft lips.
Signs and Symptoms of Cleft Lip
Patients with cleft lip are usually evaluated at a very early age as the physical signs can be easily seen just after birth. In these early assessments, it’s important to check for a co-existing cleft palate since this can impact feeding, swallowing, and speech. Details to be noted include the size of the cleft, if it’s on one side (unilateral) or both sides (bilateral), and whether it’s partial or full. The presence of alveolar clefts should also be carefully noted. For cases of bilateral clefts, where both sides are affected, the premaxilla (the part of the jaw holding the front teeth) might be pushed forward and require treatment using a technique known as naso-alveolar molding (NAM) before surgery can be performed.
Testing for Cleft Lip
When dealing with cleft care, it’s crucial to have a multi-disciplinary team of professionals involved from the start. This team should thoroughly evaluate the child for any other health conditions or linked syndromes. Neonatal and pediatric intensive care teams play a significant role in early care, addressing the child’s immediate medical needs.
If any syndrome is suspected to be linked with the child’s cleft, seeking advice from a genetic specialist is essential. Any noticed abnormalities should be investigated accordingly.
In many cases, speech therapists and dieticians are necessary. They can guide parents on how to feed their children, who often need special feeding techniques due to their cleft. If a child struggles to get enough nutrition from regular feeding, particularly if they also have a cleft palate, additional support from a pediatric surgery team may be needed.
Getting the child under the care of orthodontists, plastic surgeons, or ear, nose and throat doctors who specialize in cleft lip patients is essential. This ensures they get the necessary treatments and are monitored over the long term.
Nowadays, a cleft deformity can be diagnosed during the second trimester of pregnancy via an ultrasound scan. This enables medical professionals and parents to prepare and enact a comprehensive care plan in advance.
Treatment Options for Cleft Lip
In newborns with a cleft lip, there are three main worries: feeding difficulties, risk of swallowing food or fluids into the windpipe (aspiration), and issues with their airway. Treating patients with a cleft lip requires long-term dedication and a variety of treatments.
One of the main focuses, particularly for infants with other inborn health conditions, is meeting their nutritional needs. Within the first few weeks to months of life, a dental expert (orthodontist) can use a technique called Nasoalveolar Molding (NAM). This involves creating a special device that helps guide the child’s upper jaw and gums into a more suitable position. This process makes it easier to surgically repair the cleft lip later on. The device requires frequent adjustments by the orthodontist. Lip taping and lip adhesion are also sometimes used to reduce the size or severity of the cleft.
The first surgery to repair a cleft lip usually happens between 3 to 5 months of age. A helpful guide used in deciding the safe age for surgery is called the “Rule of 10s” – if the baby is ten weeks old, weighs 10 pounds, and has a hemoglobin level of 10mg/dL, then they should be ready for surgery if there are no other health concerns. Different surgical methods are available for repairing cleft lips, but all aim to restore function and appearance of the lips while minimizing visible scars.
After surgery, the care for these patients involves many medical specialties and continues throughout their life. If there’s also a cleft palate, ideally it would be repaired from 9 to 12 months, followed by assessments for any swallowing or speech issues at 2 to 3 years old. Bone grafting, which involves placing bone into the gap in the upper jaw, is usually performed when the child is 7 to 9 years old. Additional procedures like fixing nasal deformities, revising scars, and orthodontics may be needed at different stages of the child’s life. Also, around the age of 16 to 18, the need for facial bone surgery to address associated skeletal abnormalities will be evaluated.
What else can Cleft Lip be?
- Sudden and severe inflammation of the liver and mouth ulcers
- Sores in the mouth also known as canker sores
- A rare skin condition that causes painful blisters
- A skin disease that causes blisters and sores on the skin or mucous membranes
- A type of skin disease that can cause painful, erosive, and blistering lesions in the mouth
Possible Complications When Diagnosed with Cleft Lip
- Excessive, bulky scar tissue
- Poor cosmetic result
Recovery from Cleft Lip
Feeding infants who have recently undergone surgery for a cleft lip requires special care. Standard feeding methods like breastfeeding or bottle-feeding are typically avoided soon after surgery. This is to prevent strain on the wound. Instead, doctors often suggest spoon-feeding as a different way to feed these infants. There are many other methods that have been tested by healthcare providers around the world, such as using syringes, cups, or soft nipples.
While many surgeons are in favor of using these alternative feeding methods, not all agree. There have been instances where introducing new feeding techniques after surgery leads to an increase in crying and squirming from the infant. This can make feeding difficult and impact wound healing. As a result, there could be weight loss in the infant, making the alternative feeding method less effective.
However, alternative feeding methods are still recommended for infants who have had cleft lip surgery to avoid unnecessary pressure on the surgical site. Although, it’s important to note that there isn’t conclusive evidence to suggest traditional feeding methods make the wound worse.
