A cleft palate is a V- or U-shaped gap in the tissue between the mouth and the inside of the nose. It includes variable separation of the muscular soft palate and uvula (the small piece of tissue that hangs down in the back of the mouth), and it may also involve the bony roof of the mouth, or hard palate.
Symptoms of cleft palate
Often, the first sign of a cleft palate is feeding difficulty or nasal regurgitation when a baby is born. This happens because the gap in tissue between the mouth and nose prevents a baby from effectively generating the suction needed to latch onto and suck from a nipple. When a cleft palate is not quickly detected and feeding appropriately modified, the baby may struggle to gain weight.
Another symptom of cleft palate in an infant or young child is ear problems, specifically conductive hearing loss and frequent ear infections. This happens because the muscles that are separated in the soft palate are the same muscles that pull on the Eustachian tubes to equalize pressure in the ears (this is why yawning helps “pop” the ears when you are flying or driving up a mountain). When the muscles in the palate are separated by a cleft, they cannot pull effectively on the Eustachian tubes. As a result, fluid may build up behind the ear drum, reducing hearing and increasing frequency of infections.
Without proper treatment, a child with cleft palate cannot make certain speech sounds. This includes sounds that require pressure, such as “b,” “d,” “p” and “ch.” The primary goal of cleft palate repair is to help facilitate normal speech.
Causes of cleft palate
In the majority of cases, an exact cause cannot be identified to explain the presence of a cleft palate. This can be frustrating to families looking for answers. Some factors thought to increase the risk of having a child with a cleft palate may include smoking during pregnancy, certain medications (for example, anti-seizure medications) and maternal diabetes. Having a family member with a cleft may also increase risk, especially when cleft lip and palate happen together.
In some children, cleft palate occurs in combination with other conditions or birth defects. When this happens, there may be a genetic cause for all of the conditions. Some of those include Sticker syndrome, 22q11.2 deletion syndrome (also known as velocardiofacial syndrome) and Van der Woude syndrome, but cleft palate has been associated with nearly 400 different syndromes.
Cleft lip vs. cleft palate: What’s the difference?
Cleft lip and cleft palate often happen together, but each may happen independent of the other. A cleft lip involves a gap in tissue of the upper lip below the nostril and usually includes some degree of deformity of the nose, gums and teeth. A cleft lip may happen on one or both sides and is visible when looking at a person. In contrast, a cleft palate involves soft tissue and bone inside the mouth and typically cannot be seen from the outside, except through the opening of a cleft lip.
How early can you detect a cleft palate?
Cleft lip is usually detected around 18-22 weeks of pregnancy because ultrasound provides a good view of a fetus’ face. If there is a cleft lip, sometimes cleft palate is suspected at that same scan. In contrast, cleft palate only is rarely detected by ultrasound because the view inside the mouth is limited. Sometimes, other findings, like a small jaw or a heart problem, will prompt referral for a fetal magnetic resonance imaging (MRI), where a cleft palate will be identified more readily. In most cases, cleft palate only is identified shortly after birth, either during routine examination or when feeding problems arise.
Treatments for cleft palate
Cleft care is provided by a multidisciplinary team of different specialists who work together, each focusing on a specific aspect of treatment. This team may include nurses, plastic surgeons, otolaryngologists, dentists, nutritionists, pediatricians, audiologists and more. The type of specialists involved depends on an individual child and their needs.
Early care focuses on feeding and weight gain. In most cases, special bottles are used that allow milk to be expressed without suction. Most children with cleft palate cannot effectively breastfeed, but many mothers pump and feed breast milk by bottle in addition to comfort suckling at the breast for bonding. Weight is often followed more closely than for a child without a cleft so problems with feeding and weight gain may be treated promptly.
Later in infancy, the focus of cleft care turns to hearing. All babies, whether they have a cleft or not, undergo a newborn hearing screen after birth. Babies with a cleft palate have more detailed follow-up testing at a few months of age. In some cases, a hearing aid may be recommended prior to cleft palate repair.
The primary treatment for cleft palate is surgical repair. In most cases, this happens around 9-12 months of age, but timing can vary depending on the extent of the cleft and the individual needs of the child. Surgery for cleft palate closes the opening and repositions the muscles of the palate to facilitate speech. In addition, most children benefit from placement of ear tubes to optimize hearing and reduce the risk of ear infection.
After cleft palate repair, children typically stay in the hospital overnight for observation. Aftercare includes pain management and a modified diet. In some cases, speech therapy or Early Intervention may be recommended starting a few months after surgery.
Is there a way to prevent cleft palate?
Because the cause of cleft palate can rarely be pinpointed, there are no specific ways to prevent a cleft palate. Avoiding environmental factors is advisable, for example, avoiding smoking during pregnancy. However, in most cases, no single action will cause or prevent a cleft palate.
Living with cleft palate
As an attending physician at Boston Children's Hospital, I’ve seen that individuals with cleft palate overall have excellent quality of life, but may have ongoing medical needs over the course of childhood and sometimes into adulthood. This may include the need for additional sets of ear tubes and hearing-related care. Speech therapy is often beneficial to optimize speech, and sometimes additional surgery is needed. Finally, many older children need orthodontic treatment, such as a palate expander or braces.