1. Emily Glaser ASSESSMENT AND MANAGEMENT CARE OF A CLEFT LIP/ PALATE

2.  The lip forms between the fourth and seventh weeks of pregnancy.  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.  A cleft lip can be on one or both sides of the lip or in the middle of the lip, which occurs very rarely. (Facts about Cleft Lip and Cleft Palate, 2014, October 20). CLEFT LIP

3. CLEFT LIP CONT. http://www.thesculpturedimage.com/cleft _lip.php

4.  The roof of the mouth (palate) is formed between the sixth and ninth weeks of pregnancy.  A cleft palate happens if the tissue that makes up the roof of the mouth does not join together completely during pregnancy.  For some babies, both the front and back parts of the palate are open. For other babies, only part of the palate is open. (Facts about Cleft Lip and Cleft Palate, 2014, October 20). CLEFT PALATE

5. CLEFT PALATE CONT. (“CleftPALS QLD INC." CleftPALS QLD INC.)

6.  The etiology of cleft lip and/or palate is still very unknown.  The majority of clefts of the lip and palate is believed to have a multifactorial etiology with several genetic and environmental factors interacting to shift the complex process of morphogenesis of the primary and secondary palates toward a threshold of abnormality at which clefting can occur (Peter Hodgkinson et al.).  The CDC has reported that factors including smoking, diabetes, and use of certain medicine can increase the chance of having a baby with a cleft lip/palate. ETIOLOGY

7.  Diagnosis of a cleft lip can be diagnosed during pregnancy by a routine ultrasound and are usually noticed by week 20. (Peter Hodgkinson, et al. 2005).  Cleft palates, however, are not usually diagnosed until after birth. DIAGNOSES

8.  Microform unilateral cleft lip A subtle cleft on one side of the upper lip, which may appear as a small indentation. Incomplete unilateral cleft lip A cleft on one side of the upper lip, which does not extend into the nose. Complete unilateral cleft lip A cleft on one side of the upper lip, which extends into the nose. Incomplete bilateral cleft lip Clefts on both sides of the upper lip, not extending to the nose. Complete bilateral cleft lip Clefts on both sides of the upper lip, extending into the nose. TYPES OF CLEFT LIP

9. TYPES OF CLEFT LIP CONT.

10. Incomplete cleft palate A cleft in the back of the mouth in the soft palate. Complete cleft palate A cleft affecting the hard and soft parts of the palate. The mouth and nose cavities are exposed to each other. Submucous cleft palate A cleft involving the hard and/or soft palate, covered by the mucous membrane lining the roof of the mouth. May be difficult to visualize. TYPES OF CLEFT PALATE

11.  Careful examination with a bright light and a tongue depressor is required in the case of a posterior soft palate cleft or sub mucous cleft of the palate.  Feeding difficulties may lead to a later diagnosis of an isolated cleft palate (Neonatal Handbook, 2014). TYPES OF CLEFT PALATE CONT.

12. The first visit involves the nutritionist taking the weight and measurements to determine the current nutritional status, the ideal weight, and the energy needs for the optimal growth (Nahai, et al. 2005). “The nutritionist and feeding therapist also act as a team to identify what the infant is being fed (breast milk versus formula), how many ounces the infant is receiving at each feeding, and how many ounces total the infant takes in for a full 24-hour period” (Nahai, et al. 2005). ASSESSMENT

13.  Problems that may results due to cleft lip/ palate:  Feeding difficulties  Failure to gain weight  Poor Growth  Dental and Mouth difficulties  Possible Diagnoses:  Inadequate oral Intake NI-2.1  Inadequate energy intake NI-1.2  Malnutrition NI-5.2  Swallowing Difficulty NC-1.1  Breastfeeding Difficulty NC-1.3 (Academy of Nutrition and Dietetics, 2013) NUTRITION DIAGNOSES

14.  Maintaining nutrition is the first priority, and finding a feeding technique as close to normal as possible is second (Clarren et al.).  Infants with a cleft lip can be breast fed or bottle fed  Infants with a cleft palate usually need a special bottles or techniques to get the adequate nutrition(Clarren et al.).  To breastfeed the mother needs to compress the breast to express milk into the baby’s mouth when breast feeding. This will help the milk flow and the suck swallow reflex if a baby has a unilateral, bilateral or soft palate cleft (Clarren et al.). NUTRITIONAL TREATMENT

15.  When feeding a baby with a cleft lip and palate, hold the baby in a semi upright position to minimize the nasal regurgitation of milk  Squeeze the bottle rhythmically only when the baby sucks (every two, three or five sucks). Burp the baby regularly as the cleft allows extra air to be ingested.  The feed should be completed within 30-40 minutes. (Department of Heath, Victoria Australia, 2014) BOTTLE FEEDING

16.  The Haberman- a slit in the nipple opens when the baby bites on it. Parents can also guide the flow of the milk.  Mead Johnson Bottle with Nuk Nipple- The sides of this bottle are soft, so the parents can help the baby by squeezing it.  Mead Johnson Bottle w/ Ross Syringe Nipple- The nipple is very thin and the baby cannot suck on it. The parents must squeeze the bottle to help the baby eat.  Nuk Cross-Cut Nipple with a Regular Bottle- This is good for babies who are learning to suck after palate repair.  Pigeon Nipple and Bottle- The Pigeon nipple has Y-cut tip and the plastic one-way valve prevents negative pressure. One side of the nipple is softer  Soft Sipp Feeder- This bottle is usually used for post op feeding. The valve prevent liquid from coming out unless the bottle is squeezed. (Cleft Advocate, 2014) SPECIAL BOTTLE TYPES

17. 1)The Haberman 2)The Mead Johnson with Nuk Nipple. 3)Mead Johnson with Ross syringe 4)Nuk cross cut nipple with regular bottle. Cleft Advocate - Feeders, 2014 SPECIAL BOTTLE TYPES CONT.

18. 5) Pigean nipple and bottle. 6) Soft Sip Feeder Cleft Advocate - Feeders, 2014 SPECIAL BOTTLE TYPES CONT.

19. BOTTLE FEEDING CONT. en.wikipedia.org

20.  Infants with airway difficulties may require combined oral and tube feeds.  Airway stability must be determined prior to oral feeding and feeding coordination should be the focus not the volume of the oral feed.  Frequently, airway problems will be exacerbated during feeding. The combination of the inability to maintain adequate sucking and airway problems may lead to the need for an alternative feeding method. (Core Curriculum for Cleft Palate and Other Craniofacial Anomalies)  Solid Foods:  Strained foods can be started at 4 to 6 months.   Foods should be given by spoon, not by bottle.   Position your baby upright to reduce food coming out of his/her nose. Start with tiny  tastes in the front of the mouth. Never try to place food far back in the mouth. Allow  the baby to take the food from the spoon.   Start with rice cereal made to about applesauce consistency. Some runny fruits may be thickened with a small amount of cereal.   4-6 months:  Introduce cereals and pureed foods by spoon  8 months:  Give pureed foods, stage 2 and 3 foods and mashed table foods. Offer sips of expressed breast milk, formula, juice, and water from an open lidded cup or an indented sippy cup. (Childrens Mercy Hospital) OTHER FEEDING TECHNIQUES

21.  Ultrasound is the primary source to assess the condition during pregnancy.  After birth, the conditioned is assessed by checking the macro and micronutrient intake of CLP babies. Generally the nutrient intake is not significantly different than those without CLP (Gopinath, 2013).  To assess the right feeding technique, the baby’s sucking ability must be observed. They can swallow normally, but suck abnormally. (Clarren, et al.)  After assessing this, a general solution is to breastfeed, bottle feed, or deliver milk directly to the mouth (Clarren, et al.). PARAMETERS USED TO ASSESS THE CONDITION

22.  Closure of the cleft in the lip and palate requires a surgical repair (Peter Hodgkinson, et al. 2005).  There are many techniques, but a few requirements must be fulfilled.  1. Cosmetic restoration- normal appearance to the baby  2. Functional restoration- to the lip and palate for normal eating and drinking and development of normal speech  3. Optimum facial growth and development- to prevent deformity developing in association to impaired growth (Peter Hodgkinson, et al. 2005).  There is evidence that good facial growth and good speech can be achieved before one year of age (Peter Hodgkinson, et al. 2005). SURGICAL REPAIR

23.  Several other therapies may be necessary to help improve child’s quality of life (Peter Hodgkinson, et al. 2005).  Hearing  Speech and language  Dental-facial development and treatment  Orthodontic treatment (Peter Hodgkinson, et al. 2005). OTHER TREATMENTS

24.  Cleft Lip: 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.  Cleft Palate: A cleft palate happens if the tissue that makes up the roof of the mouth does not join together completely during pregnancy.  Problems that may result due to cleft lip/ palate:  feeding difficulties, failure to gain weight, poor growth, and dental and mouth difficulties.  Infants with a cleft lip can be breast fed or bottle fed  Infants with a cleft palate usually need a special bottles or techniques to get the adequate nutrition(Clarren et al.).  Strained foods can be started at 4 to 6 months. SUMMARY

25.  Peter D Hodgkinson, Brown, S., Duncan D., Grant C., Mcnaughton A., Thomas P., and C Rye Mattick (2005). Management of children with cleft lip and palate: a review describing the application of multidisciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the unted kingdom. Fetal and maternal medicine review, 16:1 1-27  Ingrid P. Krapels, Keers C., Muller M., Klein A., Theunissen R. (2006). Nutrition and Genes in the Development of Orofacial Clefting. Nutrition Reviews, volume 64, No. 6, 280-288.  Gil-da Lopas, Lucia V., Carolina A., Antunes A., (2013). Feeding infants with cleft lip and/or palate in brazil: suggestions to improve health research. The cleft palate- craniofacial journal 50.5, 577-590.  Vellore Kannan Gopinath, (2013). Assessment of nutrient intake in cleft lip and palate children after surgical correction. Special communicartion, 20(5), 61-66.  Sterling K. Clarren, Anderson B., Wolf L., (1987). Feeding infants with cleft lip, cleft palate, or cleft lip and palate. Cleft Palate Journa, volume 24, No. 3, 244-249.  Nahai, F., Williams, J., Burstein, F., Martin, J., & Thomas, J. (n.d.). The Management Of Cleft Lip And Palate: Pathways For Treatment And Longitudinal Assessment. Seminars in Plastic Surgery, 275-285. REFERENCES

26.  Cleft Advocate - Feeders. (n.d.). Retrieved November 13, 2014, from http://www.cleftadvocate.org/feeders.html http://www.cleftadvocate.org/feeders.html  Cleft Lip and Palate. (n.d.). Retrieved November 13, 2014, from http://adoptionnutrition.org/special- needs/cleft-lip-and-palate/  Neonatal ehandbook. (n.d.). Retrieved November 13, 2014, from http://www.health.vic.gov.au/neonatalhandbook/congenital/cleft-lip-and-palate.htm  Core Curriculum for Cleft Palate and Other Craniofacial Anomalies. (n.d.). Retrieved November 13, 2014, from http://acpa-cpf.org/core_curriculum/airway_feeding.html  Facts about Cleft Lip and Cleft Palate. (2014, October 20). Retrieved November 13, 2014, from http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html  "Cleft Lip and Palate." Cleft Lip. Web. 13 Nov. 2014..  Feedin g an Infant with a Cleft Lip or Palate. (n.d.). Retrieved November 25, 2014, from https://www.childrensmercy.org/content/uploadedFiles/Care_Cards/CMH-99-123p.pdf  International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. (4th ed.). (2013). Chicago, IL: Academy of Nutrition and Dietetics.  All pictures from Google REFERENCES CONT.