Why Cleft Lip Occurs ? - Risk Factor & Prevention

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Cleft lip or hare lip is the second common birth defect affecting  humans. This happens due to the incomplete formation of the lip/palate  during the first few weeks of pregnancy. A cleft is a lack of  continuity. When its there on the upper lip on one side, it’s called the  unilateral cleft lip. When it’s on both the sides, it’s called the  bilateral cleft lip. Likewise, when there is a gap in the hard palate  and /or the soft palate, it’s called a cleft palate. Again, it could be  unilateral (one-sided) or bilateral (two-sided). Genetics plays an  important factor. 

A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This results in an opening in the upper lip. The opening in the lip can be a small slit or it can be a large opening that goes through the lip into the nose


It is generally believed that about 1 in every 700 live births is born  with a cleft lip or palate. India has a huge population of 1.35 Billion  people, with the second most populous nation in the world. Therefore,  India also has a huge number of kids born with cleft lip and palate. It  is estimated that around 30,000 kids are born with clefts every year.  According to the World Health Organization, this accounts for nearly  half of all craniofacial deformities. 

 Cleft lip and cleft palate occur when tissues in the baby's face and  mouth don't fuse properly. Normally, the tissues that make up the lip  and palate fuse together in the second and third months of pregnancy.  But in babies with cleft lip and cleft palate, the fusion never takes  place or occurs only part way, leaving an opening (cleft).

Researchers believe that most cases of cleft lip and cleft palate are  caused by an interaction of genetic and environmental factors. In many  babies, a definite cause isn't discovered.

The mother or the father can pass on genes that cause clefting,  either alone or as part of a genetic syndrome that includes a cleft lip  or cleft palate as one of its signs. 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.

Several factors may increase the likelihood of a baby developing a cleft lip and cleft palate, including:

• Family history. Parents with a family history of cleft lip or cleft palate face a higher risk of having a baby with a cleft.
• Exposure to certain substances during pregnancy. Cleft lip and cleft palate may be more likely to occur in pregnant  women who smoke cigarettes, drink alcohol or take certain medications.
• Having diabetes. There is some evidence that  women diagnosed with diabetes before pregnancy may have an increased  risk of having a baby with a cleft lip with or without a cleft palate.
• Being obese during pregnancy. There is some evidence that babies born to obese women may have increased risk of cleft lip and palate.

Males are more likely to have a cleft lip with or without cleft  palate. Cleft palate without cleft lip is more common in females. 

 In children with cleft lip and cleft palate, depending on the severity of deformation, various problems are encountered.

In the absence of separation in the palate,  liquids and food can enter into the nose from the mouth. Specially  designed feeding bottles with nipples are now available to stop fluids  and food flowing back into the nose. Even manmade palates are available  to help these children with cleft palate to feed properly until proper  surgical treatment is provided.

Fluid buildup can occur in children with cleft  palate making them more prone to middle ear infections. If these  infections can cause loss of hearing if not treated. To aid regular  fluid drainage from the middle ear, special tubes are needed to be  placed in the ear drums. These children need regular exam at least once a  year to check for any ear problems.

Children with cleft palate may face problems in  their speech as their sounds are not carried on well and may take on a  nasal pitch. In most the children surgery can fix this problem and in  some children, assistance of speech pathologist may be needed who can  work with these children to resolve the problems.

Children with clefts are more inclined to suffer  from dental problems due to malformed, missing, extra or misplaced  teeth.  In addition, children with cleft palate are likely to have  defective bony upper gum part that holds the teeth. This defect may  prevent proper development of the upper ridge, displace and rotate  permanent teeth and hider the appearance of teeth. Most of these  problems can be corrected through surgery.

Due to differences in the appearance from the  normal children and also because of the stress from the intensive  medical treatment, these children with clefts may experience social,  behavioral and emotional problems. A psychologist or social worker can  help your child, you and your family to overcome these difficulties.

After a baby is born with a cleft, parents are understandably  concerned about the possibility of having another child with the same  condition. While many cases of cleft lip and cleft palate can't be  prevented, consider these steps to increase your understanding or lower  your risk:

• Consider genetic counseling. If you have a  family history of cleft lip and cleft palate, tell your doctor before  you become pregnant. Your doctor may refer you to a genetic counselor  who can help determine your risk of having children with cleft lip and  cleft palate.

• Take prenatal vitamins. If you're planning to get pregnant soon, ask your doctor if you should take prenatal vitamins.

• Don't use tobacco or alcohol. Use of alcohol or tobacco during pregnancy increases the risk of having a baby with a birth defect

Nasoalveolar Molding (NAM) is a nonsurgical method of reshaping the gums, lip and nose before cleft lip and palate surgery. The NAM appliance is a small removable device similar to an orthodontic retainer. It gradually applies pressure to decrease the severity of the cleft and improve the shape of the nose. 

The best time to begin NAM is 1  to 2 weeks after birth. At birth there is a high level of hyaluronic  acid in an infant's body. This helps make the cartilage in the nose and  gum easier to shape. The level of hyaluronic acid begins to fall off  after 6 weeks of age.  

Cleft Lip Repair should be done when the baby is 4 kg or more  weight  and age should be more than 4 months. Your baby will be given a general anesthesia (where they're unconscious) and the cleft lip will be repaired and closed with stitches. The operation usually takes 1 to 2 hours. 

Cleft Palate repair  Should be done when the child is 12 months old.   The gap in the roof of the mouth is closed and the muscles and the lining of the palate are rearranged. The wound is closed with dis solvable stitches. The  operation usually takes about 2 hours and is done using a general   anesthesia  The  philosophy is that normal palate must be restored before the kid starts  to babble or start to speak.  

Children born with a cleft palate may need speech-language therapy  to help with problems such as: 

An articulation disorder is when a child has trouble making specific  sounds. "Cleft palate speech" refers to speech sound errors that are more common in kids with a cleft palate. These include:

• Glottal stops: formed by a "pop" of air when the child forces his/her vocal folds (located in the voice box) together. The release of air can make it sound like a child is omitting a consonant (like saying "–all" for "ball").

• Nasal fricatives: formed by directing the stream of air through the nasal cavity, instead of the oral cavity, during speech. It sounds like the child is "talking through his/her nose" for particular sounds, like S in the word "sun."

• Pharyngeal (fair-en-JEE-ul) fricatives: formed by pressing the base of the tongue against the back of the throat and releasing a stream of air for speech. It can sound like the child is using a "raspy H" for particular sounds, like SH in the word "shoe."

• Mid-dorsum palatal stops: formed when the middle of the tongue contacts the middle of the roof of the mouth and used as a substitute for these sounds T, D, K, and G. When the child produces a mid-dorsum palatal stop, it often sounds "in between" a T and a K.

A resonance disorder refers to an unusual amount of nasal sound energy when the child is talking, which can result in:

• hypernasality (too much nasal sound energy): This makes a child sound "nasally."
• hyponasality (too little nasal sound energy): This makes a child sound like he/she                has a cold.
• mixed (a bit of both) resonance
• 
  

Hypernasality may mean that the child's palate is not working properly, called  velopharyngeal (vee-low-fair-en-JEE-ul) dysfunction. This can make it hard for others to understand the child's speech, and might need further treatment.

Speech therapist  who work with children with cleft  palate have extra training to recognize and treat specific problems caused by  a cleft palate.  Our Speech and Language pathologist assesses all cleft palate kids speech at 3-4 years of age once they start talking.

An alveolar bone graft is a surgery to add bone to the gum ridge in a child who was born with both a cleft lip and a cleft palate.   Best done around 8 years of age.  These make the nasal base even. It also creates a nice smile for these kids with cleft lip and palate in India.  

Our Orthodontist aligns the teeth in a perfect manner. It’s usually  around age 12. Again not all kids with cleft lip and palate need this.  Mal aligned teeth are aligned, missing teeth are replaced and impacted  teeth are removed as well. Fixed Orthodontics or braces treatment is  done to close space and arrange the teeth. 

This is surgery is  done to re shape the nose. It is done  patients with cleft lip and palate who have slightly bent nose. Can  also be done for noses which are not symmetrical. It is also done for  patients who can have blocked nose. Either open structure rhinoplasty or  closed approach is used. The cost and recovery varies based on the  treatment done. The results are permanent and lifelong. This removes any  cleft stigma and gives a nice normal shape to the nose. It can be done  after 15 years of age. If done earlier, it is called anterior  rhinoplasty. In younger ages, only the soft tissue is adjusted for cleft  lip kids. .

Some kids whose upper jaw doesn’t grow as well as lower jaw need this  procedure. The best treatment for this is Anterior Maxillary  Distraction. It brings new bone in the upper jaw of cleft lip and palate  patients. It improves speech, and there is no relapse. It can be done  when the kid is 12 years or so. Again, only a few patients need this. .

pharyngoplasty is a  kind of plastic surgery for the pharynx (soft tissue at the back of the  mouth) when the tissue at the back of the mouth is not able to close  properly. It is typically used to correct speech problems in children  with cleft palate. (not require in all patients) we see their growth and suggest as per reuierment. 

There are other alternatives also available including  the modified Furlows z plasty :  

This procedure involves a  plastic surgical technique, which was traditional used for cleft  palates, to lengthen and thicken the soft palate and realign abnormal  placement of the palatal muscles in order to allow the palate touch the  back of throat naturally. which are used when needed  for  cleft lip and palate Children.