Cleft Lip and Cleft Palate Nursing Care Management

Cleft lip and cleft palate are the most common facial malformations, and you will see them at birth. They occur alone or together: a gap in the upper lip, an opening in the roof of the mouth, or both. Your job on the floor runs two tracks at once. The infant cannot feed normally and chokes on liquids, so you protect the airway and get calories in. The parents are looking at a visible defect on a newborn they expected to be perfect, so you manage their shock and guilt while you teach feeding and prep them for repair.

What is Cleft Lip and Cleft Palate?

Cleft lip is a gap or split in the upper lip that often extends up toward the nose. It can be small or extensive and can occur on one or both sides. Cleft palate is an opening in the roof of the mouth that may extend from the front of the mouth toward the back, varying in size and severity. Either defect can appear alone, but they frequently appear together.

Pathophysiology

The lip and the palate close at different points in development and fail for different reasons. Cleft lip and palate result from failure of the maxillary and premaxillary processes to fuse during the 5th to 8th week of intrauterine life. The cleft may be a simple notch in the vermilion line or extend up into the floor of the nose.

The palate closes later. In an 8-week-old embryo there is still no roof to the mouth: the tissues that become the palate are two shelves running front to back, projecting vertically downward on either side of the tongue. These shelves swing from vertical to horizontal, meet, and fuse in the midline, after which bone forms within the tissue to make the hard palate. The palate is normally intact by the 10th week of fetal life. Exactly what prevents this closure is not known.

Watch the clinical weight of an isolated cleft palate. A child born with a cleft palate but an intact lip lacks the external disfigurement that distresses parents, but the functional problems (feeding, speech, airway) are more serious.

Statistics and Incidences

Cleft lip occurs in about 1 in 1,000 live births and is more common in males. Cleft palate occurs in 1 newborn in 2,500, more often in females. Cleft palate accompanies a cleft lip about 50% of the time, most often with bilateral cleft lip. Parents are eager to see and hold their newborn, so prepare them for the appearance before they do.

Causes

The defect runs in families. Incidence is higher in close relatives than in the general population, and both hereditary and environmental factors contribute. A parent can pass on genes that cause clefting, either alone or as part of a genetic syndrome. In other cases the infant inherits a gene that raises susceptibility and an environmental trigger then causes the cleft to form.

Clinical Manifestations

A cleft in the lip or palate is usually identifiable at birth. The cleft itself can affect one or both sides of the face: in the lip it ranges from a small notch to a split running through the upper gum and palate into the bottom of the nose, and in the palate it may not change facial appearance at all. Functionally, the newborn chokes easily on liquids, has difficulty swallowing with liquid or food coming out the nose, and (with a palate cleft) has a nasal speaking voice.

Assessment and Diagnostic Findings

Cleft lip is confirmed by physical appearance. Cleft palate is diagnosed at birth on close inspection of the palate, and to be sure you do not miss it, insert a gloved finger into the newborn's mouth and feel the palate to confirm it is intact.

Medical Management

Cleft lip repair, usually done by a plastic surgeon, is the main surgical treatment. Some surgeons favor early repair before discharge; others wait until the newborn is 1 to 2 months old, weighs about 10 lbs, and is gaining weight steadily. If surgery must be delayed beyond the 3rd year, a dental speech appliance can help the child develop intelligible speech.

Nursing Management

Nursing Assessment

A primary concern is the emotional care of the family. Interview the caregivers about their acceptance of the newborn and the feeding methods they have found most effective. Examine the infant fully: temperature, apical pulse, respirations, breath sounds, skin turgor and color, and neurologic status including alertness and responsiveness.

Nursing Diagnoses

• Compromised family coping related to the visible physical defect.
• Anxiety of family caregivers related to the child's condition and surgical outcome.
• Deficient knowledge of family caregivers related to care of the child before surgery and the surgical procedure.
• Risk for aspiration related to reduced level of consciousness after surgery.
• Ineffective breathing pattern related to anatomical changes.
• Risk for deficient fluid volume related to NPO status after surgery.
• Acute pain related to the surgical procedure.
• Risk of injury to the operative site related to the newborn's desire to suck thumb or fingers and to anatomical changes.

Nursing Care Planning and Goals

Adapt goals to the surgical plan. The major goals are to maintain adequate nutrition, increase family coping, reduce the parents' anxiety and guilt over the defect, and prepare them for the future cleft repair.

Nursing Interventions

Maintain nutrition. Breastfeeding may work because breast tissue molds to close the gap; if the newborn cannot breastfeed, express the mother's milk and use it instead of formula, with a soft nipple cross-cut to promote easy flow.

Position for feeding. With a unilateral cleft lip, aim the nipple at the unaffected side and keep the infant upright during feeding.

Use the right tools. Lamb's nipples (extra-long nipples) and special cleft palate nipples molded to fit the open palate help close the gap. One of the simplest effective methods is an eyedropper or an Asepto syringe with a short piece of rubber tubing on the tip (a Breck feeder).

Support the family. Encourage them to voice their feelings and disappointment, and model an accepting attitude toward the child. Give clear information about cleft repair, invite questions, and reassure them that any question is valid. Walk them through the preoperative, intraoperative, and postoperative routine; written material helps, but confirm they understand it.

Evaluation

Expected outcomes: nutrition maintained, family coping increased, and parental anxiety and guilt over the defect reduced.

Documentation Guidelines

Document coping behaviors (current and past), emotional response to the situation and stressors, and available support systems; level of anxiety and precipitating or aggravating factors; the family's description and awareness of feelings; the response to pain, pain inventory, and acceptable pain level; the plan of care and teaching plan; family and client responses to interventions and teaching; progress toward outcomes; modifications to the plan; the longterm plan and who is responsible; and specific referrals made.