ºìÐÓÊÓƵ

How to Identify a Cleft Palate in a Newborn Baby 

It is recommended that those performing a newborn baby examination should not only perform a finger-assisted palpation of the intraoral structures but crucially directly visualise the oral cavity from the gingiva (gums) to uvula using a wooden tongue depressor and light (such as a pen torch). Diagnosis is therefore possible immediately after birth and is recognised as a national minimum standard of care by cleft services in the UK, with ongoing referral to the local cleft team within 24 hours of diagnosis.  

Diagnosis of a cleft palate after 24 hours following a birth in the UK is considered delayed. Indeed, this standard, that all cleft palates should be diagnosed at within 24 hours of birth, has never been achieved in the UK.  

In September 2017 the Royal College of Paediatrics and Child Health (RCPCH) launched an eLearning module with the aim of improving the early identification of cleft palate. Prior to this up to a third of all babies born with a cleft palate were not identified in the first 24-48 hours following birth.  

“If the cleft palate was not detected what else may have been missedâ€Å¨¶Ä¯ 

“I knew something was wrong, but no one looked in her mouthâ€Å¨¶Ä¯ 

“I was told that nasal regurgitation of milk was normalâ€Å¨¶Ä¯ 

"I just wasn't able to feed him and give him that important nourishment that he needed.  

And that is very hard. You start blaming yourself, thinking I must be doing something wrong, there's something wrong with my childâ€Å¨¶Ä¯ 

This lack of awareness from professionals is difficult for new mothers to overcome and often leaves them feeling isolated and frustrated.  

The commonest condition to be associated with a cleft palate is Pierre-Robin Sequence (PRS). PRS is usually detected at birth because these babies can be born with an unusually small chin (micrognathia). These babies often experience breathing difficulties and therefore it is imperative that the palate is visualised due to increased risk of upper airway obstruction.  

 

Perspectives of Cleft Palate Detection and Management in Low and  Middle Income Countries 

Having discussed and highlighted the importance of identifying a cleft palate in the UK as soon as possible after birth,  there is a noted disparity in lower middle income countries regarding cleft detection. The impact of this on babies and families can be catastrophic, often due to a shortage of trained professionals and inaccessible cleft care. As a result of the cleft palate not being identified at birth, they have a risk of malnourishment and potential death.   

Nepal 

In low and middle incomes countries, including Nepal, there may be patients living in isolated areas or in places with difficult terrain with little or no access to the expert medical care and minimal awareness regarding the consequences of the delayed detection of surgical repair of a cleft palate. Consequently, some patients may not be diagnosed at the time of birth and only diagnosed when they have persistent feeding problems, faltering growth or problem with the clarity of speech. Some parents believe surgery should be deferred as they are scared of their children undergoing surgery at a young age. Patients may then come for palate surgery in adulthood when they realize their speech is not good enough, there is difficulty in communication and palatal surgery can improve the speech. Socioeconomic condition of the families may result in a delay of palate repair as it is may not be the first priority when daily activities are need for survival.   

  

Ethiopia 

In Ethiopia, there is no neonatal screening program, and structured neonatal physical examinations are not routinely practiced. In addition, a large proportion of deliveries are unattended, and traditional birth attendants assist many. These factors contribute to the delayed diagnosis of birth defects such as isolated cleft palate, hypospadias, minor clubfoot, and other anomalies that are not immediately visible at birth. At Yekatit 12 Hospital Medical College, which serves as the main cleft care centre for the entire country, only 94 children with isolated cleft palate were operated on over 19 years. The majority (71%) underwent surgery after the age of two years. When we interviewed mothers about the reasons for delayed presentation, most explained that they were unaware their child had such a condition. Many reported taking their child to a health facility for complaints such as ear discharge, where treatment was provided, but no one examined the child’s mouth. Families often sought care only when the child failed to develop normal speech.