CLEFT LIP AND CLEFT PALATE PPT.pptx child

CHN

1. CLEFT LIP AND CLEFT PALATE Ms. Nisha S Nair Professor

2. Cleft lip ( cheiloschisis ) and cleft palate ( palatoschisis ), are congenital malformations resulting from the failure of fusion of maxillary processes during intrauterine development. The defect may occur either alone or together. The complete formation of lip often occurs by 5 to 12 weeks whereas the formation of palate may occur only by 12 to 14 weeks of gestational age. Cleft lip and cleft palate may occur in single or in combination. It may be unilateral or bilateral.

3. DEFINITION Cleft Lip: ( Cheiloschisis ) / Hare Lip A cleft lip result from failure of fusion of maxillary processes with nose, elevations on frontal prominence.   The extent of cleft lip is varying from a notch in the vermilion border to a large cleft reaching the floor of the nose. It is apparent at birth as incomplete formation of lip. It may be associated with cleft palate, deformed or absent teeth. Cleft lip may be unilateral or bilateral.

4. Cleft Palate ( Palatoschisis ) Cleft palate results from failure of fusion of hard palate with each other and with the soft palate. It results from the failure of masses of lateral palatine processes to meet and fuse together. It may be unilateral or bilateral or may occur in isolation with cleft lip.

5. Unilateral Complete Cleft Lip

6. Unilateral Incomplete cleft lip

7. Bilateral complete lip

8. Cleft Palate

9. Incomplete cleft palate

10. Unilateral complete palate

11. Unilateral complete lip and palate

12. Bilateral complete lip and palate

13. Etiology Genetic : 2% chance if parents had cleft lip and cleft palate Due to unfavorable maternal factors: May be due to viral infections during 5 th to 12 th weeks of gestation Ingestion of drugs Exposure to x-ray Anemia Hypoproteinemia

14. Incidence 1 in 750 births-cleft lip 1 in 2500 births- cleft palate Cleft lip is predominantly seen in males and cleft palate in females.

15. Pathophysiology Failure or incomplete union of embryonic structures of face     Cleft lip and cleft palate

16. Clinical features 1. Immediate problems: Feeding problems: Due to a separation in the lip or opening in the palate, sucking is ineffective and the food and liquid can pass from the mouth back through the nose. There may be aspiration of feeds. Aspiration of feeds resulting in respiratory infections. Parental anxiety due to defective appearance of the infant.

17. 2.Long term problems: Recurring infections especially otitis media and hearing loss.(usually middle ear infections) Disturbed parent child relationship and maladjustment with non acceptance of the infant. Speech problems: impairment of speech. - may have trouble speaking. The voice of these children may take a nasal sound and speech may be difficult to understand. Malocclusion and malplacement of teeth” Children with these problems are more prone to dental cavities ands often have missing,extra , malformed or displaced teeth requiring orthodontic treatment. Impaired body image due to altered shape of face and oral cavity.

18. Diagnostic evaluation Maternal ultrasonography Physical examination of mouth, palate, and nose confirms the presence of cleft lip and palate

19. Surgical management Cleft lip – cheiloplasty Timing – rule of 10 10 weeks, 10lbs, 10gm% of Hb Preferably at 2 to 3 months of age. The child may be requiring one or two surgeries depending upon the severity of the defect. Common procedures for the repair of cleft lip are Tennison - Randall triangular flap (Z plasty ) and Millard’s Rotational Advancement technique.

20. Cleft palate – palatoplasty Ideal age is about 1 to 2 yrs of age, 20lbs, 10gm% of Hb . Often requires multiple surgeries over the course of 18yrs. The first surgical repair usually occurs when the baby is between 6-12 months. .

21. The initial surgery creates a functional palate, reduces the chances of fluid entering the middle ears and help in proper development of teeth and facial bones. Children with cleft palate may need a bone graft when they are about 8 yrs old o fill in the upper gum line so that it can support permanent teeth and stabilize upper jaw. Once the permanent teeth grow, braces may be put to straighten the teeth

22. Veau-wardill-kilner V-Y pushback procedure Furlow double opposing Zplasty

23. Veau-wardill-kilner V-Y pushback procedure

24. Furlow double opposing Z-plasty Z-plasty results in longer palate

25. Nursing management Care of the baby at birth: Should be detected immediately after birth during initial neonatal assessment. Associated congenital anomalies and life threatening problems to be identified for prompt management. Mother and family members need adequate explanation about the defect correction surgeries. Demonstration to be given to the mother and family members regarding feeding of the baby to prevent aspiration and provide adequate nutrition for growth and development. Breast feeding is possible with palatal obturator (palatal prosthesis )

26. If the baby is unable to suck the breast, then expressed breast milk or artificial feeding to be given with long handled spoon and bowl. Dropper or soft large hole nipple or soft feeder or syringe can also be used. Hygienic measures to be followed strictly to prevent diarrhea and other GI disturbances. Small quantity feeds to be given slowly at the side of the mouth and precautions to be taken to prevent choking. The infant to be placed in upright position during feeding. Burping to be done in between feeds. Essential care of the neonate to be provided with warmth, immunization, prevention of infections, hygienic care and follow up. Explanation to be given about details of surgical correction of the birth defect.

27. Care of the baby before surgery Basic preoperative preparation and care are important. Parents need emotional support. Consent must be taken. All the investigations are to be done. Baby must be in NPO, atleast 6hrs prior to the surgery.  

28. Care of the baby after surgery Immediate care after the surgical repair of the defect should include close observation and monitoring the vital signs, bleeding from the site of operation, oral secretions, vomiting and crying. Special care to be given to prevent injury of the suture line. For repair lips, adhesive or band aid to be placed on the suture line to prevent lateral tension on the repaired lip. ( Longan bow was used previously- an arched metallic device) Infant should be placed within the mummy restraint or hand restraint to be used. The child should be kept dry, well fed and comfortable to prevent injury.

29. Turn the baby’s face to one side, for draining of secretions and preventing aspiration. The child should be placed on back in repair of cleft lip and on abdomen in prone position for repair of cleft palate. Oral feeding to be allowed slowly with precautions, starting with clear liquid to full liquid and then to soft food. Nutrition and hydration to be maintained. NG tube feeding may be necessary in some children. Care of suture line to prevent infection is very important.

30. Mouth care and cleaning of suture line after each feed with normal saline or water or sterile water or antiseptic mouthwash to be done. Antibiotic ointment can be applied on suture line in case of lip repair. Removable suture can be removed on fifth to 14 days depending on the condition of the wound. Antibiotics, analgesics and other prescribed medications to be administered with specific precautions. Do not allow finger or straw inside mouth. Avoid sucking or talking loudly in repair of palate.

31. Play and other diversions can be allowed to the child. Parents need continual emotional support and specific instructions to participate in child care. Discharge advice to be explained especially about prevention of infections of the operated area and follow up. Information to be given about necessary rehabilitation facilities available for the better social adjustment of the child. Speech therapy may be needed.

32. Prognosis Residual speech defect may result even after successful repair of palate. Requires help from speech therapist. Cosmetic problem of scar on the lip. Need cosmetic surgery and counseling.

33. THANK YOU