06.03 Cleft Lip and Palate

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Overview

  1. Abnormal openings in the lip and palate that may occur on one or both sides and complete or incomplete

Nursing Points

General

  1. Result of facial tissues not forming properly during development
  2. Child is at increased risk for the following
    1. Feeding difficulties
    2. Speech and hearing problems
    3. frequent , severe ear infections that may result in hearing loss
  3. Surgery is required for repair during the first months of life (Cleft lip: 3-6 months, Cleft palate: 6-24 months)

Assessment

  1. Breathing and feeding are the primary concern
  2. May see drooling with feeding
  3. May choke or cough after feeding

Therapeutic Management

  1. Feeding
    1. Aspiration is the primary concern
    2. Feed in upright position
    3. Direct flow toward the side and back of mouth
    4. Small feedings and frequent burping
    5. Allow for additional feeding time
    6. Have suction equipment available
    7. Key Points
      1. Enlarge nipple
      2. Stimulation of sucking reflex
      3. Swallow
      4. Rest
  2. Postoperative
    1. Avoid placing the child on the surgical side
    2. Monitor for airway obstruction
      1. Position in upright position
    3. Avoid manipulation of surgical site with oral instruments
    4. Restraints may be required to prevent child from touching surgical site

Nursing Concepts

  1. Safety
  2. Nutrition
  3. Human Development

Patient Education

  1. Proper feeding techniques
  2. Signs of aspiration

Reference Links

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Video Transcript

We’re gonna be talking about Cleft Lip Palate or CLP. You can have a cleft lip or a cleft palate or you can both cleft lift palate. So, what does cleft mean? Cleft is the past participle of the word cleave and cleave literally means to split or divide. So, you have a cleft lip, you have a split lip or a cleft palate, you have a split palate. And palate is basically the roof of your mouth. It is separating your mouth. It is separating your nasopharynx from your oropharynx. So, the biggest things that you want to be concerned about with an infant having cleft lip palate is their breathing and their feeding. These are 2 main things that you’re concerned about. And infant with cleft lip palate will have to, until they can have surgery to fix everything, they will have to still be fed, they will still have to have their breathing monitored and then even post surgical can have some issues as well. So, you have to be concerned there. And then, the other concern that you would have for a child with cleft lip palate is their development and we’ll get into why that’s a concern in a little bit.

So, here is a drawing of an infant’s palate, here is the location. This upper portion is the nasopharynx, the bottom portion here is the oropharynx and that is where you are going to find the tongue. This is also where the food comes in. The main reason that we are concerned for an infant’s development is because of their eustacian tubes. So, this is the infant’s ear here. And the eustacian tubes are horizontal and they end in the nasopharynx. If you have a division in the palate, food, specifically, breastmilk or formula, I should say, can get into the eustacian tubes and this can cause frequent ear infections. It may result in hearing loss. So, hearing loss can cause speech and obviously hearing issues. So, you wanna be concerned about that. And then, also, an infant has the suck swallow breathing sequence. So, when feeding a bottle to the infant with a cleft lip or cleft palate, their food, their breastmilk, normally, we would want it to go down here, can sometimes go up into the nasal cavity and we want to make sure that they are not doing that. So, sitting them upright, allowing gravity to bring the food down the esophagus is one way that you can do it. The nipple that we use can be enlarged and those help with the suction that the infant can have. And, you want to make sure that you feed the infant small feedings. So, resting often, giving them just a little bit at a time, and like I said, sitting in the upright position. This is infant’s knees and feet, arms, head, and you will be feeding the infant in this direction.

So, here are a few pictures of what it will look like if there is a cleavage in the infant’s palate or lip or both. As you can see here, this is a major issue with creating that suction to get breastmilk or formula out of the nipple. And then, here would be the crack, an area in which that you would get food up into the nasopharynx. The concern, something I wanna point out here is that the uvula is also split as well. So, these are different types of cleft lift palate that you can have. So, you can have it occurring on one side, you can have it occurring on both sides, it can be called complete or incomplete. And complete would be the palate and the lip. And the incomplete would just be the palate or just lip. So, this actually happens in utero around 6-8 weeks of development. It is when the face starts to develop. It is definitely changed by environmental factors. So, smoking can cause it and sometimes it’s just congenital. It can just happen. And you could actually get a test when baby is in utero, an ultrasound can help confirm if the baby has cleft lip palate.

So, if you go through the surgery, the things that you want to make sure you are doing are monitoring for airway obstruction, so, keeping their airway open. You want to sit them in the upright position, even post surgical. And you wanna make sure if it’s like one side or the other, that you are placing baby on the opposite side of the actual incision or cleft lip actual area. Because, you don’t want the baby to be touching it or having any sort of fluids coming out that area. And sometimes, you know, it can really help a child to not touch the area. So, you have to sometimes restrain, which is really sad, I know. If a child has a cleft lip, it is fixed between 3 and 6 months. And, if it is a cleft palate, it is surgically repaired between 6 and 24 months. And then, you just have to wait for the healing process to go through. Infants are inherently nasal breathers. So, if the nasal cavity is compromised, breathing will be difficult, so, you have to make sure that they are able to get their breaths, their normal amount of breaths in and you wanna make sure that when they feed, they can still do the swallow breathing complex.

So, again, with cleft lip palate, the biggest thing that you are concerned about is their breathing. Can the infant breath properly? Can they feed properly? So, feeding. How do I feed an infant? I feed them upright. I feed them with a larger nipple. I feed them small amounts and I allow them to rest in between. And then development, I wanna be concerned about if they have frequent ear infections, do they get food in their eustacian tubes. And avoiding that, you know, by sitting them upright and feeding them properly and making sure that they are breathing properly while feeding. And the last thing I wanna leave you guys with is that for the intervention for cleft lift palate is surgical intervention. So, the infant will have their lip or their palate repaired surgically in order to restore normal functions for them. And this is vital between the first year or within the first year of them having the cleft lift palate.

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

  • Question 4 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?

  • Question 5 of 7

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

  • Question 6 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 7 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?

Module 0 – Pediatrics Course Introduction

Module 5 – Metabolic And Endocrine Disorders

Module 12 – Musculoskeletal Disorders

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