Cleft lip and palate are correctable birth defects. Treatment of cleft begins with first few months of birth with corrective surgery, and continues in one form or another until the person reaches their later teens.

Primary surgery with the lip repair at about 3 to 4 months and palate repair between 6 and 12 months. Cosmetic surgery on the nose may occur before the child attends school. A corrective rhinoplasty may be performed on the nose in the teenage years. Orthodontic surgery begins with Maxilla expansion at around 9 to 10 years followed by bone grafting. Further corrective surgery (an osteotomy) may be carried out at about 18 years.  

All the Operations are done at:

Bashir Hospital,
Railway Road Gujrat.
Pakistan.

Phone: 0092 053-3521102 and 053-3524139

In order to feed, your baby must be able to form a vacuum inside his / her mouth, and position the tongue properly. This is usually done by  sealing the lips around the nipple or treat and closing off the back of the mouth with the soft palate. Babies with clefts may not be able to create this vacuum or position the tongue properly. Some have smaller lower jaw (mandible), making swallowing difficult.

A feeding specialist will decide an appropriate feeding plan with you. A thin feeding tube may be used to help those babies who also have a small jaw. Maternity staff and someone from your team. A specialist nurse (health visitor) should be available to you during the first months back at home. Within the first 24 hours following the birth and through the early years. Breast feeding is possible for babies with a cleft lip only, but is rarely possible for thos with a cleft palate or cleft lip and palate. So a mother should not feel guilty if their baby cannot suck. Supplementary bottles of expressed or formula milk may be necessary if breast feeding is the mothers choice. Many babies will need extra help with feeding using different types of bottles and teats. The specialist nurse will supply you with these initially. Some babies may not have the energy to suck from a teat, and can benift from a Rosti Scoop, which requires less effort from the baby. You are able to on-going feeding equipment.

In order t assist with feeding, your orthodontist may be asked to provide a small dental feeding plate. For the majority of babies these are not necessary but there may be other reasons why their use is advised. In some cases, the plate may be used to keep the tongue out of the cleft palate.

A special orthopedic plate may also be used to begin to apply pressure to close and align the cleft prior to surgery. The baby will need several of these plates before surgery. Be aware that surgeons do not agree on the benefits of using feeding and orthopaedic plates from birth. So ask members of your team if any why a plate is being used and do not be afraid to give out your opinion. Make sure your baby is given enough time to get used to feeding before trying alternatives. Unless your baby has other problems, you should not need to be separated from your baby. Note the name and telephone numbers of your consultant.

On the day of operation your baby will be given no food for a few hours before hand to reduce the chance of being sick. A sedative drug (‘pre-med’) is given by injection or as a drink. Dental impressions may be taken before or during the operation to give an accurate record of the extent of the cleft to compare with the future development of the mouth. Some bleeding from the mouth afterwards is to be expected. You will see some stitches, swelling and crusting on the lip. A small piece of foam may be used to hold the nose in its new shape. You may find that splints have been placed on your baby’s arms to prevent the child from touching the stitches. It is common to find that the baby’s scars become red and swollen afterwards, but this will clear up.

The cleft surgeon will carry out the above-mentioned procedure, and usually it is done in the first few months. Surgeons do not agree on the best time to operate or the order of the operations (e.g., some prefer to repair the palate before the lip). You may want to ask the surgeon why he / she carries out lip repair at a particular time.

You may have strong feelings about when your baby should have its operation. The surgeon should take account of your feelings in this decision. Ask how long your baby will have to stay in hospital. Ask a member of the cleft team about this. You might also ask to accompany your baby to the operating theater and recovery room. You should be prepared that your baby may look very different after the operation. Dummies (comforters) should be given to pacify your baby only when really necessary, as some surgeons are concerned about their effect on the healing wound following the operation. If so in your case, you may be requested to practice spoon feeding prior to the operation. Other surgeons are happy for the baby to feed by bottle or breast immediately after surgery.

Surgeons still do not agree on the best time to operate or which operations produces the bets results. Most surgeons in the UK repair the palate at some time from about 4 months to 12 months. Repairing the palate before the child learns to speak is thought to help normal speech development. Unfortunately, some parts of the palate surgery may restrict future growth of the palate and upper jaw. Surgeons are actively working on ways to reduce this. Everyone agrees that, despite these potential problems palate repair in infancy is vital for good speech development.

The cleft surgeon will be able to tell you at what age the left will be repaired. Do not be surprised if the operation is postponed if your child is not felt to be strong enough for the operation, or if there is another medical problem. Ask how long your baby will have to stay in the hospital. You as the parent can expect to stay in the hospital. Ask a member of the cleft team about this. You might also ask to accompany your baby to the operating theatre and recovery room. Dummies (Comforters) should be given to pacify your baby only when really necessary, as some surgeons are concerned about they effect on the healing wound following the operation. Some surgeons prefer babies to feed by spoon after the operation. If so in your case you may be requested to practice spoon-feeding prior to the operation. Other surgeons are happy for the baby to feed by bottle or breast immediately after the surgery. In some cases, the repair is unable to hold and separates. Most of these holes are small and close completely on their own. Others contract and become very small.

Complete clefts of the lip and palate usually require some adjustment of the original repair. Future surgery may be needed for other reasons. A small hole (fistula) may remain in the palate after the original repair, and may need to be closed if it affects speech or lets food or drink run down the nose. A dental plate may be fitted to cover the hole. Around one in five children with a repaired cleft palate may need further surgery to improve speech (Pharyngoplasty).  

In other cases, the repair may degrade as the child grows. The nose tip may distort and the child may find it difficult to breath although the nose, particularly on the cleft side. It may be possible to improve the shape of the lip and nose and the look of the scar. It may not have been possible for the surgeon to make as good a repair as desired the first time, because the cleft severe.

The age for such procedure varies considerable and depends on the assessment of the cleft team. Not all problems can be corrected by surgery. The side-effects of treatment may outweigh the benefits. The decision about further surgery must include the views of the parents and, of course, the child.

Your child is very likely to suffer hearing loss because of the cleft palate. This is nearly always due to fluid in the middle ear (glue ear) and may correct itself as the child grows up. More rarely, the inner ear is not fully developed as the baby grows during pregnancy. In this case the loss of hearing may be permanent, and may be more severe is accompanies by ‘glue ear’. Your specialist nurse and health visitor will closely monitor your baby’s responses to sound and talk to your cleft surgeon if it is suspected there is hearing problem, this may be confirmed by the otologist or audiologist. Regular hearing tests will be arranged to an otologist, who may treat him / her with medicine or propose an operation to insert a small tube (grommet) to allow air to enter the middle ear. Rarely, a hearing aid may also be considered. An audiologist, an otologist and a specialist nurse.

Any hearing loss which is severe enough to affect your baby’s language development must be discovered as soon as possible, and steps taken to overcome the loss. Regular hearing tests (performed by playing special games) will be arranged for your baby from age 5-6 months and probably into their teens. Be sure that you are consulted about the best way to treat your baby’s hearing difficulties. If you are concerned about your baby’s hearing ask to be referred to audiologist. Temporary deafness is possible and the grommet operation may not be necessary. However, the otologist may recommend surgery for a reason other than hearing loss. Make sure your are satisfied with the explanation for this. If a grommet operation is necessary, ask if this can be combined with any other operation you baby may need. Your audiologist may wish to contact the local education services so that your child can be monitored in school, and given extra support if necessary.

When there is a repaired cleft palate the upper jaw and arch of teeth may become too narrow. This is especially likely in a complete cleft. As a result, some upper teeth may fit inside the lower ones – called a ‘crossbite’. Over time the upper jaw may not grow forward as well as the lower jaw, and so crossbite of the front teeth becomes more common.  

The orthodontist will usually take impressions of the teeth to make plaster models that are used as a record, to plan treatment, and to help construct appliances of braces. X-rays are generally required too as these give information about the jawbones and the position of the teeth that will have to come through. Teeth move into position gradually as gentle pressure is applied by the braces. Small metal brackets are attached to the teeth by means of a special plastic glue or bands cemented to the back teeth. These brackets are joined by wires or elastics that guide the teeth into position. Some can be taken out for cleaning.  

Crossbites and other irregular teeth are noticeable as soon as they come through in the baby’s mouth. However, orthodontic treatment is not normally recommended for baby teeth. This s because it is difficult for a baby to tolerate and provides no lasting benefit. Treatment is best given for the second set of teeth around 8-9 years old if they interfere with the bite or are difficult to clean. A bone grafting operation may be necessary to provide bone as a base for new teeth to grow if the original cleft has involved the jaw bone beneath the lip cleft. This is usually done when the child is around 8-10 years old, before the permanent canine teeth come through. If its necessary, the upper arch of the teeth is widened before bone grafting and some straightening of the front teeth can be combined with this, taking 6 –12 months. The same appliance is usually left in place for 3 months while the bone graft is healing. The main treatment for children with clefts is provided around age 11- 12.  

You should decide with your orthodontic how much of this treatment your child should have. Ask to see examples of treatment and typical appliances. The main reasons for offering it are to improve appearance and to make the teeth easier to clean. Teeth do not have to be perfectly straight to look acceptable or remain healthy. If you are un happy with the way your child’s permanent front teeth are coming through an earlier start to treatment may be possible. Wearing any form of appliance calls for extra teeth brushing to avoid tooth decay and gum problems. Younger children may need help. In the first few days after the appliance is fitted the teeth may be little tender.

If there is a ‘nasal’ sound to your child’s voice, the therapist may use special computer equipment, or a mirror under the nose to monitor the air passages as your child speaks. Often a tape recorder or video is used. There are methods to examine the way the soft palate and sidewalls of the throat move during speech. One is moving X-ray called fluoroscopy. A second method called nasopharyngoscopy involved lightly anaesthetizing one side of the nose. The doctor gently passes a thin fibreoptic telescope to a position above the palate and observe and records the palate and sidewalls of the throat as they move during speech. You and your child may be able to watch what is happening inside the mouth on a the television during these tests. Once the surgeon understands the nature of the problem, he/she may then choose to do an operation (called a pharyngoplasty). This is to remove the nasal sound from your child’s voice and make the child speech stronger and clearer by stopping too much air escaping down the nose.

You are seen by the team’s therapist at the clinic. When regular speech therapy is required this will be arranged with the local therapist at your health center.  You will usually meet the speech and language therapist during your first clinic visit, but definitely by the time your baby’s palate has been repaired. Therapy may continue into school age.  

If you have not met your therapist by the time of the palate repair, ask to be referred. Know their name and phone number. During the clinic sessions, it may appear that the therapist is ‘just playing’ with your child, but this is the way of monitoring progress. Moreover, you should be involved in the process of helping your child, joining in with the therapist, and carrying-out activities give to you to do at home. As services tend be oversubscribed, tell the cleft team if you need that your child is receiving insufficient therapy. If a second operation is proposed, be sure this is done after video fluoroscopy and nasopharyngoscopy. Be ware of agreeing to an operation if neither investigation has taken place, and make sure that the possible side effects are explained. Also be aware that there are causes of speech problems other than a cleft.  

At around 7 to 8 years the extent of the bony gap beneath the gum is investigated by a dental X-ray. This, and the position of the growing second set of teeth allow the team to plan timetable for the bone graft. The operation is usually carried around 9 to 10 years so that the new bone is in place before the canine teeth grow through.

The graft is done inside the mouth. During the healing process, small chips of bone may loosen and come out painlessly. Normally, a mouth rinse and antibiotics are prescribed. Bone grafting is not always necessary and you should discuss the reasons for this with your surgeon and the orthodontist.  

here can be a family link (heredity), but in most cases a child with a  cleft will be born without any known previous history. Sometimes clefting is linked other conditions. You will be offered the opportunity to talk to a clinical geneticist or counselor, who can help families understand why they had a child with a cleft. He /she will ask questions about other members of the your family, and even ask to examine them to look for minor signs of clefting or related characteristics. You  will be asked about your pregnancy and your child’s health and progress. Your child will be examined and a blood test taken to look at your childs chromosome pattern. Ask if you wish to be involved in researching the genetic link.

The severity of the cleft and sex of the child (more baby boys are born with clefts) will give some indication of the possibility of any family member giving birth to a child with a  cleft (or the child’s own future family being affected). Cleft lip and palate is also more likely to recur than cleft palate alone. The geneticist will also offer prenatal testing in the case of future pregnancy. Counseling will be given to help you decide whether you wish to become pregnant again.