Cleft lip and cleft palate

this ppt contain information about child with cleft lip and palate and include nursing management of child with cleft lip

1. CLEFT LIP AND CLEFT PALATE   Mrs. Pinky Antony Assistant professor Chirayu college of nursing Bhopal

2. Objective At the end of the class student will able to know : Anatomy of mouth Embryology of oral cavity Definition of cleft lip and palate Classification of cleft lip and palate

3. Anatomy of Mouth

4. Embryology The face develops between 4 and 8 weeks of gestation from 5 prominences. They are, Frontonasal prominence Paired maxillary prominence Paired Mandibular prominence, around the stomodeum

5. The maxillary prominences from both sides grow towards each other and towards the medial nasal prominence and fuse together to form the midface . The defect in the mesenchymal migration and fusion of these prominences leads to cleft lip and palate. Cleft lip occurs when the medial nasal processes fail to fuse with maxillary process. Palatal clefts are due to failure of the fusion of the palatal shelves and occur later, between 7 -12 weeks of gestation. The cleft can involve the lip-, alveolus (gum), hard palate and/or soft palate and can be complete or incomplete, unilateral or bilateral.

6. Definition Cleft lip Cleft lip refers to open space between lip especially in part of vermilion line or failure in fusion of lip. It is also known as “harelip”. . .…. WONGS text book of pediatric

7. Definition Cleft palate Cleft palate refers to failure in development of parts which making the palatine bone (maxillary process), soft palate (uvula). . .…. WONGS text book of pediatric

8. CLEFT LIP & PALATE

9. Incidence Cleft lip-1:750 births, predominantly seen in males. Cleft palate-1:2500 births, mostly seen in females If the sibling has disorders – 1 in 20 to 1 in 10. If parent has disorders – 1:30 Monozygotic twins are more prone to get than the non-zygotic twins. Cleft lip and palate is higher in Asian and lowest in Africans, Americans.

10. Etiology Genetic factors- It has been estimated that the chances of a child having a cleft lip and cleft palate is two percent when one of the parents has a cleft lip or cleft palate. Unfavorable maternal factors- Illness especially viral infections during the fifth and twelfth weeks of gestation, e.g. rubella Anemia Hypoproteinemia Maternal malnutrition Maternal smoking – severity is depending upon the number of cigarettes smoked Ingestion of drugs, e. g. thalidomide, corticosteroids. Exposure to radiation during pregnancy  

11. CLASSIFICATION Indian classification A simple Indian classification is in current use. It is called the Nagpur classification and was first described by Prof. C Balakrishnan in Indian plastic surgeon. Group I - Cleft lip only Group IA - Cleft lip alveolus Group IB - Subsurface cleft lip Group II - Cleft palate only Group III - Cleft lip and cleft palate.

12. According to the site Left unilateral Right unilateral Bilateral

13. According to the anatomy Cleft of primary palate Cleft of primary& secondary Cleft of secondary alone Bilateral

14. Clinical manifestations Cleft lip has the following manifestations A notched vermilion border Dental anomalies – supernumerary teeth, extra teeth, teeth may be absent Variably sized clefts that involve the alveolar ridge

15. Clinical manifestations Cleft palate includes, Opening in roof of the mouth felt with examiners finger on palate Nasal distortion Breathing difficulty Exposed nasal cavities Recurrent ear and throat infection Speech defects and psychological problems.

16. Clinical manifestations Feeding problems Inability to coordinate breathing and feeding leads to inadequate nutrition. Difficulty in feeding leads to anemia, malnutrition and failure to thrive. Mouth breathing.

17. Diagnostic Evaluation History collection – collect history of parent with cleft lip and cleft palate, and antenatal check up. Prenatal ultrasonography - enables many cleft lips and some cleft palates to be identified in utero . Physical examination – cleft lip and palate is diagnosed by inspection. Physical examination reveals the anemia, breathing difficulty, speech defects and dental anomalies.

18. X-ray – it shows the deformity of palatine bone. MRI-to evaluate extent of abnormality before treatment Dental imprecision’s for expansion prosthesis. Genetic evaluation – to determine recurrence risk.

19. Management Management is based on the severity of the defect. Management of cleft lip and cleft palate requires a team effort involving a pediatrician, a plastic surgeon, orthodontist ENT specialist and speech therapist, psychologist and community health nurse.

20. Children with Cleft Lip and Palate Cleft lip repair: 3 to 6 months Cleft palate repair: 9 to 12 months Ear tubes at palate repair: 9 to 12 months Lip/ nare revision: 4 years Phase I orthodontics: 7 years

21. Alveolar bone graft: 6 to 10 years Phase II orthodontics: 15 to 17 years Orthognathic surgery: 15 years for females; 18 years for males Definitive rhinoplasty : Teenage years

22. Historically, the surgery for cleft lip and cleft palate is planned by “ Kliners rule of ten” For cleft lip – 10 weeks of age, 10 pound weight and 10 grams of hemoglobin.

23. For cleft palate – 10 months of age, 10 kg weight and 10 gm of hemoglobin was the norm.

24. Surgical repair technique for cleft lip Cheiloplasty Ralph Millard's Rotation advancement technique

25. Logan bow

26. Cleft palate repair technique Palatoplasty Von langenback procedure Veau wardil kilners Three flap technique & Millards Double revising ‘Z’ plasty

27. Nursing management Preoperative care: Keep the infant NPO for 6 hours before surgery. Administer premedication as per doctors order Physical, physiological, psychological and legal preparation should be done.

28. Post operative care Keep the airway clear from accumulation of mucus in the nose and mouth. Mild sedation may be prescribed to prevent infant from crying. Careful positioning (never on the abdomen) Restraining the arms if necessary.

29. The mother and father should be encouraged to remain with their child as much as possible. The infant is fed with a medicine dropper. Clear fluids offers initially, breast milk or formula can be given when tolerated.

30. Post operative care The mouth should be rinsed with water before and after feeding. Do not brush the teeth 1-2 weeks after the surgery. The suture line must be cleaned gently with cotton or gauze-tipped swab dipped in hydrogen peroxide or saline solution and dried carefully several times a day to ensure proper healing.

31. The parents are taught the ways by which injury to the palate can be prevented after discharge and prevention of upper respiratory tract infection. Speech therapy should be given. Encourage the child to socialize with family members and others.

32. Preoperative Nursing diagnosis

33. Imbalance nutrition; less than body requirements related to inability to suck. Describe the degree of cleft and impairment of sucking The mother should be encouraged to breast feed their babies and whenever there are feeding problems expressed breast milk may be give. Use special feeding technique if needed In case of failure of breast feeding, artificial feeding has to be substituted When extreme difficulty is encountered with feeding, gavage may become necessary. Burp frequently and hold the infant in a more upright position. Keep an accurate record of Childs growth by using a growth chart.

34. Feeding technique: Equipment Description Soft, thin walled nipple - compresses easily, readily available NUK orthodontic nipple - large surface for compression Cross-cut nipple - allows easy flow of milk with compression Ross cleft palate nurser - for infants with weak suck; has soft tube like nipple. Mead Johnson cleft palate nurser -soft, long cross-cut nipple, soft bottle for squeezing Can monitor the milk flow

35. Haberman feeder- large, squeezable nipple with a slit cut, has one way valve to reduce amount of air ingested. Pigeon cleft palate nurser - larger, more bulbous Y-cut nipple; firm on top with soft bottom; has air valve to prevent collapse and airflow; has flow setting in bottle collar. Asepto syringe, rubber tip- readily available; places with milk beyond cleft

36. A and B : Above, left and center: Soft squeezable bottle with cross cut orthodontic nipple (top right). C. Ross Syringe Nipple. D. Cross cut in top of nipple.

37. Mead Johnson Cleft Palate Nurser Unit comes with a soft plastic bottle that works well and a long, cross-cut nipple. This nipple and nipple ring should be discarded and the "syringe nipple" substituted for post surgical feeding.  

38. Methods: Use a nipple or feeding system that provides a controllable flow rate and is energy efficient for the infant Hold infant in upright position to assist in reducing the amount of nasal regurgitation. Use a pillow for additional support for infant to assist with longer feeding time Keep chin tucked because neck extension inhabits swallowing.

39. If regurgitation occurs, stop feeding and allow infant to cough / sneeze to clear the air way. Place nipple on top of tongue. Nipple insertion may push tongue to the back of mouth. Burp the infant frequently because of increased air ingestion Monitor for distress and fatigue during feeding Limit feeding time to approximately 30 minutes to avoid fatigue Follow feeding with sterile water to clean any rapped food in the cleft Clean mouth and nose.

40. 2 . Interrupted family processes related to emotional reaction to an infant with a visible defect. Encourage parents to discuss their fears, concerns and negative emotions Encourage touching and holding to prevent delayed attachments. Express acceptance of baby by modeling and close physical contact. Make appropriate referral to a cleft lip and palate team of nurses, physicians and other specialists.

41. 3. Parental fear and anxiety related to special care needs and surgery. Use a calm, reassuring, accepting approach with infant and family. Explain all procedures and their rationale including sensations likely experienced by their child. Listen actively to parents and their concerns, encourage verbalization of feelings and perceptions Encourage parents to stay with their child in the immediate pre and post operative periods.

42. 4. Parental knowledge deficit about feeding techniques and surgery. Explain pre and post operative procedures Teach about surgical procedures and its advantages to the parents Clarify the parent doubts or any questions. Explain about long-term follow up care.

43. 5. High risk for respiratory distress or dyspnea related to cleft lip and cleft palate. Assess the respiratory movement Auscultate the lungs Prevent respiratory obstruction, especially on inspiration and when the infant is quiet – place the infant in prone so that tongue and jaw fall forward, tilt head back as best tolerated by the infant & slightly elevate upper trunk. Provide adequate suctioning in order to remove secretions Administer oxygen as per doctor’s order.

44. Post-operative Nursing diagnosis

45. 1. Dyspnea related to anesthetic effect Assess the respiratory rate Provide comfortable position Administer oxygen Do suction frequently Position the child on the abdomen or side in order to encourage drainage from the mouth If increase respiratory rate, coughing, choking or cyanosis should be reported immediately

46. 2. Fluid and electrolyte imbalance related to fluid restriction Maintain IV fluids as per doctors order. Feed the child after 3 hours of the surgery by using bottle or syringe Soft foods are usually continued for about 1 month after surgery at which time a regular diet is started. Check weight periodically Feed the child in the manner used pre operatively (never use straw, nipple or plain syringe)

47. 3. Acute pain related to surgical incision and elbow restraints Provide comfort measures, especially holding, rocking and parental voices Provide analgesics and sedatives as ordered Report it pain not managed by usual means.

48. 4. High risk for complications related to surgery Assess the breathing pattern Note respiratory rate Provide moisture to mucus membrane that may become dry because of mouth breathing.

49. 5. Risk for infection related to surgical repair and aspiration. Irrigate the mouth with normal saline solution or water Direct a gentle stream over the suture line using an ear bulb syringe While irrigating held the child in sitting position with his head forward Keep the mouth moist to promote healing and provide comfort Rinse the mouth after each feeding Administer antibiotics as prescribed.

50. Layla’s turn

51. References : 1. Dorothy R. marlow .text book of pediatric nursing ,south asian edition . Elsevier publication . 2. Wong’s. Essentials of pediatric nursing 8th edition elsevier publication.