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Wednesday, Feb. 22, 2023

TRANSDISCIPLINARY APPROACH TO CLEFT LIP AND PALATE CARE

Patients require unique treatment plans

Approximately 600,000 people in the United States live with a craniofacial condition or facial difference.

Craniofacial conditions include but are not limited to, clefts of the lip and palate, deformities of the tongue, dentition, skull, upper or lower jaw, airway or ear. These conditions require a multifaceted care team and a specialized treatment approach in order to achieve optimal outcomes.

Most patients with facial differences will experience difficulties with one or all of the following: hearing, seeing, feeding/ swallowing, speech or overall self-image. From the moment a facial cleft is first noticed on an ultrasound to the time a child matures into adulthood, these patients will require unique treatment plans, and their experiences will differ from those around them. The team providing care must understand the unique obstacles encountered by their patients and families as well as have the ability to provide the most ideal treatment.

The cleft and craniofacial team at Shriners Hospitals for Children, Shreveport, was founded in 2013 and is comprised of multidisciplinary services, including cleft and craniofacial specialist – trained oral and maxillofacial surgeons (OMFS), a speech language pathologist (SLP), otolaryngologist, pediatric psychologist, orthodontist, pediatric dentists, physical and occupational therapists, and a nurse coordinator. Our team manages a wide array of conditions, including cleft lip and palate and velopharyngeal dysfunction. It focuses on all aspects of care from the initial evaluation through continued treatment and post-operative care. The OMFS will evaluate your child for any functional problem or anatomical difference that could cause issues with essential life functions and incorporate all specialists required to resolve those issues.

One of the more common issues faced by children with cleft lip and palate are issues with speech and feeding. A speech-language pathologist (SLP) works closely with a cleft and craniofacial-trained oral and maxillofacial surgeon (OMFS) to perform screenings and evaluations of children with a cleft lip and/or palate. Children who show signs of velopharyngeal dysfunction but no overt cleft can also be referred to a cleft palate team. When a cleft palate team sees a child, the SLP will assess numerous areas of development and specific speech characteristics prevalent in children with cleft lip and/or palate (CLP). These areas include:

• Does the child currently receive speech therapy? Over half of the children born with CLP will require speech therapy at some point in their life, typically before age 5. The role of an SLP in a cleft palate team is to ensure that a child receives adequate speech therapy services. Consultations with the child’s treating therapist are critical to monitor the child’s progress in therapy and educate SLPs about evidence-based practices when working with children with CLP.

• Does the child demonstrate any speech, resonance or voice errors? Approximately 25% of children without CLP have a speech sound disorder, which is when a child cannot correctly produce age-appropriate sounds. Children with CLP have a much higher incidence of speech sound disorders due to anatomical differences. An SLP on a cleft palate team will determine if a child’s articulation disorder is related to their CLP. The SLP will also assess for co-occurring resonance disorder, which is when a child has velopharyngeal dysfunction (VPD). Normal velopharyngeal closure separates the child’s oral and nasal cavities as they speak. Children with CLP may have hypernasality (excessive airflow through the nasal cavity), hyponasality (decreased airflow through the nasal cavity) or mixed nasality. The child may also have other characteristics of VPD, such as audible nasal emission, nasal rustle, facial grimacing and compensatory articulation errors. Suppose the SLP has concerns that a child’s speech errors are related to a structural abnormality such as a cleft lip or palate. In that case, the SLP will recommend the child undergo an instrumental assessment such as nasoendoscopy, nasometry or a modified barium swallow study. Finally, the SLP will monitor for any voice concerns such as hoarseness or a “soft voice” as they speak.

• Does the child also present with language and/or social emotional concerns? During an appointment with the cleft palate team, the SLP will screen the child for any delays in expressive or receptive language and/or social emotional difficulties at home or at school. The SLP will refer the child for a complete language assessment if a language delay is suspected.

• Does the child have any feeding difficulties? Many children with CLP have difficulties with feeding and/or swallowing. This could begin as an infant bottle or breastfeeding. Children with CLP can have trouble building up pressure to form a strong suck on a nipple; therefore, specialized bottles are utilized to assist the infant with feeding. As a child becomes ready to try baby food and then solids, they may have difficulty manipulating the food in their mouth or behavioral aversions to the new texture. An SLP can introduce feeding strategies to assist the family in making feeding a positive experience for the child. Children with CLP may also demonstrate difficulty chewing and/ or using a straw, have a limited variety of foods they will eat and cough while they eat.

At Shriners Hospitals for Children, our cleft team relies heavily on our specialist in SLP to help diagnose speech and feeding-related issues. It is imperative to incorporate the SLP in the evaluation and planned treatment in order to properly plan surgical intervention to ensure it is the most appropriate course of treatment. Suppose it is determined that a surgical procedure would help your child with speech or feeding difficulties. In that case, our cleft and craniofacial specialists will discuss all treatment options and prepare you and your family for the care your child needs.

Rachel Bishop, DDS, MD, Megan Lerchie, MCD, CCC-SLP; Jennifer Woerner, DMD, MD, FACS

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