Having a child with a cleft lip and/or palate is stressful and can detract from the joy of bringing a child into the world. Fortunately prenatal screening can usually see cleft lips and cleft palates.
Although we cannot catch them all, depending on how the child is laying in the belly, we usually have a very good idea of whether a child will be born with a cleft lip and/or palate. When there is a chance a child has a cleft lip or palate, I like to meet with the parents before the delivery so we can discuss what the plan will be after birth.
This usually happens around 32-36 weeks of the pregnancy. My goal during this time is to let the family and parents know that we have a plan.
Also, I want to say that in this day and age, cleft care has gotten to the point where this problem can be corrected and corrected well. I fully expect the kids I treat to grow up beautiful, healthy and happy. My passion is to make sure they will not be denied anything in life because they were born with a cleft.
Cleft lip and palate alone doesn’t affect whether the birth is a natural birth or C-section birth. If the child was born here, or comes to Kentucky Children’s Hospital immediately after delivery, I will see you and your child right away and visit as long as needed.
Just let the nurses know that Dr. James Liau saw you in prenatal consultation.
Generally speaking, there is nothing to do when a child with a cleft is born except work on feeding. At Kentucky Children’s Hospital, and the Commission, we have speech therapists and nutritionists who are experienced in cleft feeding and will help with cleft feeding.
Sometimes this can be frustrating and disheartening, but with a little parental bonding and persistence, this is easily overcome. In the meantime, I want parents to enjoy their child as any normal family should!
There is close follow-up until the time of surgery to help make sure everything stays on track and to address any questions or issues which may arise. I also like to give a tentative date for the lip repair so we can plan ahead and not have any scheduling issues.
3- 6 months
3- 6 months old is when I would proceed with a cleft lip repair (cleft palate is fixed later at 10 months). Although this is a very dramatic appearance-changing surgery for the child, it is probably one of the “easier” surgeries for them.
I am able to block most of the nerves with local anesthetic and the kids do great post-surgery. They can have their bottle right after surgery, and they stay overnight as a precaution. This is so that any later effects from anesthesia have time to wear off and in case they need some pain medication in the I.V.
There will be big changes in both the nose and lip appearance, but the lip will be covered up with Steri-Strips, which help support the skin repair. All the stitches I use will dissolve with time, so there is no need to take any out.
After an overnight stay, 99 percent of my kids go home the next day, with a follow-up in the clinic the following week and then three weeks after that.
Next we start to plan the palate repair, if there is a cleft palate.
9-12 months is usually when the palate is fixed, whether or not there is cleft lip. The reason is because the palate surgery is a little harder on their feeding and airway, so I would like them to be a little bit older and more coordinated.
Also, as you will find out, the palate is not necessary for eating, but it is very necessary for speech. Since most kids begin to say words around a year of age, I like to fix the palate and let it heal before their minds want to start talking. This way, when the mind wants to talk, they have a palate to begin talking.
This surgery is somewhat harder on the child, but 95 percent of all my kids with palate repairs go home the next day. The issues tend to be more with postoperative discomfort, as well as feeding.
After palate repair surgery, the kids are taken to the Pediatric Progressive Care Unit, which is a step down from the Pediatric Intensive Care Unit, but a step above the regular pediatric floor.
Immediately post op, I want my kids to eat or drink. The limitations are as follows though.
- For drinking
They cannot make any sucking forces since that will break down the palate repair. Before the cleft palate surgery, we should work on weaning them from the bottle and get them onto a sippy cup that pours into the mouth. Also a pacifier is a no-no since that will directly push onto the palate repair, as well as create suction.
- For eating
Stage 2 or an applesauce consistency diet is fine. As long as we keep the spoon in the front area of the mouth, then I’m not too worried about hurting the palate repair.
After discharge, I will see you the following week, and then three weeks after that.
Cleft palate children may also require a set of ear tubes during surgery. This is for fluid buildup in their middle ear. This is quite common with children with cleft palate because the muscles which help open the middle ear to drain fluid don’t work as well.
Tubes are used to help drain the middle ear to prevent further infections and possible loss of hearing. We like to do the ear tubes in the same surgery with the cleft palate if possible. I will coordinate this with the ear, nose and throat (ENT) doctors.
These are general guidelines for the first year of life, and there is a separate PDF file with the same guidelines (308KB), which you can view as well.
Hopefully this helps answer the questions of when and how often a child with a cleft lip and/or palate will require surgery in the first year. Naturally, these guidelines can change depending on the child’s progress, and I will be intimately involved in the care plan, making sure everything goes as smoothly as possible.
In the next blog entry, I’d like to address the procedures which may be required as a child gets older towards school age.