Cleft lip and/or palate (CLP) is one of the most common types of birth defects occurring in approximately 2 in 1,000 live births in Singapore. The most common type of cleft deformity is complete cleft lip and palate.

Most babies with cleft lip and/or palate are otherwise healthy with no other birth defects. Some babies who have clefts may have other medical conditions.

Cleft lip and/or palate are congenital conditions characterised by an opening or split in the upper lip, the roof of the mouth (palate) or both, that are present from birth.

A cleft lip can be on one side (unilateral) or both sides (bilateral) of the upper lip. Cleft lip can occur alone, or can occur with a cleft palate. Similarly, a cleft palate may occur in isolation without a cleft lip deformity.

Unilateral Incomplete Cleft Lip	Unilateral Complete Cleft Lip
Bilateral Cleft Lip	Cleft Palate

The causes of CLP among most babies are unknown, but several factors have been known to increase risk such as genetics, the environment and certain drugs (phenytoin, isotretinoin). Most of the evidence points to a multifactorial cause. It is unlikely that parents did anything that would have directly caused a cleft.

Cleft lip can usually be diagnosed during the first trimester of pregnancy by a routine ultrasound. Isolated cleft palate is generally diagnosed after the baby is born, however, certain types of cleft palate (for example, submucous cleft palate) might not be identified until later in life.

Feeding

There is no single/ best method of feeding your baby. The principles to follow are to:

1. Encourage your baby to learn normal reflexes such as sucking and swallowing
2. Treat your baby as normal as possible if there are no further medical complications requiring special attention/management
3. Prevent regurgitation

Typically, a combination of reflexes is used to achieve effective feeding. Two processes occur simultaneously. The first is the ability to create an adequate vacuum by creating a seal around the nipple/teat, and second, is the ability to position the tongue properly below the nipple.

Babies with a cleft usually have difficulty forming a good seal around the nipple to create a vacuum for suction. Fortunately, there are several ways of solving this problem:

1. Assisted squeezable bottles for feeding
2. Modified breastfeeding
3. Spoon feeding

Upon referral to the Cleft Team, the Plastic Specialty Nurse will meet you to assess your baby’s sucking and swallowing skills in order to determine the most suitable mode of feeding for your baby (e.g., positioning, type of bottle and teat).

It is important to position your baby at a 45 degree angle in an upright position while feeding to prevent choking or having fluid flow back up through the nose. During and after each feed, you are encouraged to burp your baby more often than a baby that does not have a cleft. This is because your baby may swallow more air than normal during feeding.

It is normal for a newborn baby to lose up to 10% of their body weight within the first week. This lost weight is usually regained within 2-3 weeks. Your baby is considered well fed if he/she has 6-8 wet nappies a day, has regular bowel movements and is healthy and alert.

Your child may be offered a bottle of glucose water as soon as he or she is awake after Cleft Lip Surgery.

If your child had undergone Cleft Palate Surgery, this may be provided using a spoon/cup/spout feeder/syringe.

When he or she can tolerate clear fluids (e.g., water, glucose water) well, breast or formula milk may be given. Your baby will also be given fluids through an IV drip which may be removed once he /she is drinking well again.

Your child will be reviewed by the cleft team in the ward. The Plastic Specialty Nurse will teach you how to care for the surgical site. You will have to ensure that your child’s wound is kept clean. Further instructions will be given to you together with an educational leaflet.

After surgery, your child may be discharged only when his or her appetite has improved.

When to seek medical attention

• Continuous bleeding / swelling / discharge seen from surgical site
• Fever of 38.5°C and above
• Not drinking / eating well

Follow up Care

Your child will need to return to the Cleft and Craniofacial Centre 7 days after surgery to be reviewed by his/her Plastic Surgeon.