We know that approximately one in 500 births in Turkey is born with cleft lip and palate, which means that at least 2500 babies are born with cleft lip and palate annually. However, since not all cleft palates can be diagnosed at birth, there is a need to inform family physicians and pediatricians more about this issue and to conduct epidemiological studies in Turkey.
Successful treatment and follow-up of cleft lip and palate is accepted all over the world by teams working together with many disciplines. Teamwork is of great importance. It should not be forgotten that better treatment results will be obtained in the treatment of cleft lip and palate with the teamwork of plastic surgery, orthodontics, speech-language therapy units and many other branches. In this way, we can ensure that these individuals can adapt to society and continue their lives as successful and happy in their professional lives. In the future, as the teams become stronger in every aspect and the number of centers needed in Turkey is determined, it is obvious that it will be appropriate to treat these patients in these Centers.
In individuals with cleft lip and palate, the deformity may be of different severity and the etiology may be multifactorial. While some of them are syndromic, others are themselves part of a syndrome. The treatment of such a heterogeneous group is long-term and continues with the treatment of many disciplines at different stages.
When cleft lip and palate is diagnosed during pregnancy, teams experienced in cleft lip and palate and cleft lip and palate centers should be consulted. The guidance of a plastic surgeon at this stage will be very good for the family. The expectant mother who has a baby with cleft lip and palate should be given psychological support and the follow-up and treatment plans of these babies should be explained.
Babies born with cleft lip and palate do not necessarily need to be admitted to intensive care units for follow-up and treatment. However, a small number of babies with cleft palate and especially some babies born with a very small jaw may have respiratory problems or cannot be fed due to respiratory distress during feeding. These are life-threatening problems and these babies need to be followed up in intensive care. Babies with cleft lip and palate other than these do not need to be followed up in intensive care just for feeding. Another important issue is that babies with cleft lip and palate do not require an orogastric/nasogastric tube unless there is an additional condition. Cardiologic diseases are the most common comorbidities in individuals with cleft lip and palate. Therefore, when these children are born, they should be seen by a pediatric cardiologist to check for critical heart disease. In some cases, severe cardiologic diseases may be present and surgery may need to be performed before cleft lip and palate surgery.
Babies with cleft lip and palate have the same right to breastfeeding as other babies and it is even more precious for them. This can be overcome by educating the mother while she is still pregnant. The expectant mother should be told that the baby can be breastfed after birth, that it is important to prepare herself for this, the value of breast milk and maternal attachment, the necessity of burping the baby after feeding, and the importance of sleeping position. Breastfeeding and breastfeeding are also important for the development of otitis media. If it is not possible for the mother and the baby to be breastfed despite all efforts, breastfeeding should be provided by other means, but definitely with breast milk. One feeding should not exceed half an hour so that the baby does not spend all its energy on sucking, can sleep and gain weight.
It should be noted that feeding plates (appliances) placed in the mouth are not essential for every newborn baby, many babies do not need them, but compulsory applications are made with the guidance of physicians who are not sufficiently knowledgeable on this subject, and babies and families are harmed. Especially pediatric neonatal departments should be sufficiently informed about this issue. Cleft lip and palate must be included in pediatric guidelines. In some cases with syndromic or additional anomalies, the decision of necessity should be made jointly by surgeon-orthodontics.
In the feeding of babies born with cleft palate, it should be known that bottles and feeding appliances cannot guarantee the prevention of aspiration (fluid leakage into the lung), but in some babies, they can reduce the baby’s air swallowing and provide ease of feeding, so they should not be forced to use them.
The first 3 months are as important in babies with cleft lip and palate as in any other aspect. In unilateral cleft cases where the cleft lip and palate is very severe, the bone deficiency is high and especially the rotation is very high, and in bilateral cleft cases with bilateral and very protruded premaxillae, it may be appropriate to start orthodontic treatment in terms of naso-alveolar shaping for better preparation for surgery and better results, if the family and the physician are in the same city and/or if it is possible for the family to continue the treatment in harmony. Since orthodontic treatment is effective in the first 3-4 months after birth, this important period should not be missed. Today, this treatment has become easier with the use of digital shapers.
As part of the national newborn hearing screening program, a hearing test is mandatory in the first month. Since cleft lip and palate are in the risky group, audiologists should follow up babies who fail the hearing screening as well as those who pass. Since babies with cleft lip and palate have eustachian dysfunction due to anatomical disorder, middle ear problems are also frequently encountered. Early ear examination can also prevent problems that may develop in the future. Effusion (fluid accumulation) in the middle ear reduces hearing, however, it is appropriate to give this opportunity to babies with the fact that tube application to babies may have different complications and palate surgery may have a positive effect, in the surgical treatment of this, it should not be rushed to apply tubes immediately, that is, in early infancy, ENT controls should be performed at frequent intervals in terms of ear and personalized applications should be preferred. Evaluation at least 2 months after cleft palate surgery is valuable. After that, if tube application is necessary, it should be done. Since follow-up is also important after tube application, if possible, it is more appropriate for the ENT physician in the city where the family lives. We do not want to surgically remove tonsils and adenoids in these children as much as possible due to their positive effects on speech. However, tonsillectomy and even partial adenoidectomy are allowed to be performed with the decision of the team if the airway is very narrow and creates problems.
Babies born with cleft palate and cleft lip should be followed up in terms of their language development in the first 3 years and necessary intervention methods should be applied. It is important that speech and language therapists evaluate the speech disorders that occur due to cleft palate with appropriate equipment and make the necessary referrals for the necessary intervention methods in terms of surgery, prosthetics and speech therapy.
Considering that the application of teletherapy in speech therapy contributes to the pandemic conditions, it is thought that it is important to make it widespread in our country.
Surgical treatment of cleft lip and palate is performed within the first year. However, follow-up and treatment of these children should be continuous. Until pre-school, facial development and speech, milk teeth and bite controls should not be interrupted. Orthodontic treatment starting in the mixed dentition period is also a long treatment process and can achieve very successful results with the compliance of the individual. Surgical procedures such as replacing the missing bone with a joint decision of orthodontics-surgery can be included in the treatment intervals. Orthodontic treatment that continues until adolescence can sometimes end with surgical interventions to the jaw despite all efforts. Surgical correction of nasal deformity may also be required in adolescence. The surgeries to be applied here are also quite diverse.
It is important to take into account psychosocial processes and parental involvement in such prolonged treatment. While the family may need moral and support at the beginning of treatment, the child or adolescent may need support later on.
It is important for all teams involved in the follow-up and treatment of cleft lip and palate to speak the same language in order to communicate. Therefore, similar classifications and classifications should be made for our country.
Keeping good records is indisputable and it is well known that patient data will be necessary in the years to come. Therefore, patient data should be systematically recorded and carefully stored.
We must obtain surgical consents before the operation and when we encounter a patient who has been operated on by another colleague, we must act and speak in a way that does not put our colleague under suspicion.
Care should also be taken to ensure that the photos and data of individuals with cleft lip and palate are not shared in the media during the treatment processes, and attention should be paid to these in meetings and congresses, and no one other than the participants should be allowed in the halls. “Family sessions” should be added before or after scientific meetings. Here, the team should answer the questions of the families and seek solutions to their problems. It is not right for these families to participate in scientific sessions.
