06.03 Cleft Lip and Palate

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Overview

  1. The most common congenital deformity in the United States
  2. Abnormal openings in the lip and palate

Nursing Points

General

  1. Facial structures not  forming properly in utero
  2. Diagnosed at birth or 12 wk  ultrasound
  3. Child is at increased risk for-
    1. Feeding difficulties
    2. Aspiration
    3. Speech and hearing problems
    4. Ear infections
  4. Surgery is required for repair
    1. Cleft lip: 3-6 mo
    2. Cleft palate: 6-24 mo

Assessment

  1. Respiratory status
    1. Coughing, choking while feeding
  2. Nutritional status
    1. Weight gain
  3. Hydration status

Therapeutic Management

  1. Feeding
    1. Specialized bottles
    2. Stimulation of sucking reflex
    3. Allow time for rest during feeds
    4. Encourage maternal bonding
    5. Aspiration prevention
      1. Feed in upright position
      2. Direct flow toward the side and back of mouth
      3. Small feedings
      4. Frequent burping
      5. Allow for additional feeding time
      6. Suction equipment on hand
  2. Postoperative
    1. Protect operative site
      1. Elbow immobilizers for child
      2. Syringe feeds
      3. Avoid hard foods
      4. Avoid suction
    2. Monitor for airway obstruction
      1. Position in upright position

Nursing Concepts

  1. Safety
  2. Nutrition
  3. Human Development

Patient Education

  1. Proper feeding techniques
  2. Signs of aspiration

References:

Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of pediatric nursing (10th ed.) St. Louis, MO: Elsevier Limited.  

Lissauer, T. & Carroll, W. (2018). Illustrated textbook of pediatrics (5th ed.) Europe: Elsevier Limited.

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Video Transcript

Hey guys, in this lesson we’re going to be talking about cleft lip and cleft palate. We are primarily going to focus on how these deformities are treated and the nursing care related to that treatment.

Cleft lip and cleft palate are abnormal openings in the lip and in the palate. These abnormal openings occur during the child’s development in utero and is actually the most common congenital deformity in the United States. Usually it’s diagnosed during the 12 week ultrasound, but a lot of times it is first detected a birth. You can see in this top line of photos what a cleft lip can look like and then the bottom row shows you what different degrees of the cleft palate.

Surgery for a cleft lip is usually done between 3 and 6 months and the cleft palate is usually repaired a bit later between 6 and 24 months.

Your assessment for a child with cleft lip and cleft palate is all about assessing complications that can occur from the difficult time they have with feeding. Now, feeding is actually a really complicated thing for babies to learn how to do. It takes a lot of coordination and uses a lot of energy. With a cleft lip and palate this is made even more difficult. These babies really struggle to get a proper latch on a nipple and they’re also at risk for aspirating because they have this extra hole that’s connecting their mouth to their nose. So the first thing that we need to assess for are signs of respiratory distress and aspiration. so we are looking for things like coughing and sputtering and choking while they’re feeding.
We also have to pay close attention to the infant’s hydration status and their nutritional status. Remember, feeding is hard work for every baby, but for these babies it takes even more effort so they are really at risk for not getting enough fluids and calories to make up for the extra work they are putting in to feed. Because of this frequent weights and strict I’s and O’s are super important.

So like I said management of these two deformities is ultimately down to surgical repair. But if you remember back to that first slide, they actually have to wait to have these procedures. So the cleft lip is usually done between 3 to 6 months and the cleft palate is repaired from 6 to 24 months, so there’s this gap of time where parents have to go on feeding while they wait. So a lot of what we do during this time is provide feeding support. Our priorities with this are to prevent aspiration and ensure growth is happening as it should. These babies will likely use specialized bottles and nippes that help promote a good suction and reduce the flow of the formula to reduce the risk of choking. With all of these added stressors parents can have a really tough time, so it’s important to make sure our nursing interventions are encouraging maternal bonding.

Once the child does have surgery our nursing interventions are focused on protecting the operative site and monitoring the airway. A lot of times these babies will need to wear splints on their arms to keep them from reaching up and putting things in their mouths. They also need to avoid using anything that creates a suction in the mouth because this can damage the repaired palate – so no pacifiers or straws or sippy cups!

Long term issues to keep in mind for these patients are an increased risk for ear infections, dental problems and speech problems. These will require follow up and support – especially in the early years of life.

Your priority nursing concepts for a patient with cleft lip and cleft palate are safety, nutrition and human development.
Ok, so let’s just go back through and highlight the key points for this lesson. So the first thing is just remember that cleft lip and cleft palate are facial malformations and this just means that they are abnormal openings in the lip and the palate. Because these affect feeding we have to monitor for aspiration, weight loss and dehydration. The majority of our nursing care is going to focus on providing support to parents so they can feed their baby while they’re waiting on the surgical repair. these surgeries usually take place between 3 and 6 months for the cleft lip and 6 and 24 months for the cleft palate. Our post-op nursing care is focused on protecting the incision and monitoring their airway.

That’s it for our lesson on cleft lip and cleft palate. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!

Read more

  • Question 1 of 7

The parents of a one-week-old with a cleft palate demonstrate understanding of the diagnosis by making which of the following statements?

  • Question 2 of 7

A nurse is educating parents on feeding techniques for their newborn who has a cleft lip and a cleft palate. The nurse accurately includes which of the following teaching points? Select all that apply.

  • Question 3 of 7

The nurse caring for a three-week-old with a cleft palate prioritizes which of the following nursing interventions?

  • Question 4 of 7

An infant has a cleft palate. The nurse knows that this infant should be in which of the following positions to prevent prolapse of the tongue?

  • Question 5 of 7

The nurse caring for a one-month-old with cleft lip and cleft palate knows which of the following is the most concerning complication of this diagnosis?

  • Question 6 of 7

The nurse caring for an 18-month-old who has just had his cleft palate repaired knows which of the following interventions is a top priority?

  • Question 7 of 7

A 10-month-old child is recovering from a cleft lip repair, and the provider has determined the child would benefit from restraints post-operatively. Which kind of restraints would the nurse most likely apply to this child?

Module 0 – Pediatrics Course Introduction

Module 5 – Metabolic And Endocrine Disorders

Module 12 – Musculoskeletal Disorders

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