Cleft lips and palate are congenital abnormalities that manifest at birth. It is the most common craniofacial birth defects.
Q: What is the prevalence of the condition in Malaysia?
A: It occurs once in every 600 births in Malaysia.
Image shows lack of nutrition causing the face development to be compromised due to disruption of migration of neural crest cells.
Q: What are the chances of child born in this condition? Is it genetic or hereditary?
A: It has a very strong association with genetics, but it also has some environmental influence, in which termed as ‘acquired genetic mutation with environmental influence’. It has a multifactorial aetiology, thus there are many reasons why a child can born with cleft lips & palate. One of the associations is the habit of the mother during pregnancy, eg. smoking or alcohol abuse during period of pregnancy, in which then there is a high chance for the baby to develop such abnormalities. If there is family medical history of this particular deformity, there is a higher chance that the baby will develop this deformity as well when compared to those without.
Any mother might deliver a cleft-lips-and-palate child. However, the risk increases if there is family history of cleft. 30% of cleft lips and palate is part of a syndrome. The other 70% may have genetic association with environmental influence. Since the aetiology is multifactorial, therefore it is difficult to 100% prevent/ eliminate the risk.
Maternal risk factors may include
- Pregnancy above 40 years old
- Habits such as smoking & alcohol drinking
- Lack of nutrition and supplements (eg. folate)
- Drug abuse.
Q: I understand that it sorts of follow from the mother side, is that correct?
A: That is a myth. Quite often when the child is born with cleft lips and palate, the mom will be accused for so many things (in superstitions, things which the mother should not have done during the pregnancy, like cutting something forbidden etc). But it is all a myth. The genes that you pass down to your child can be inherited from either parent. You would not know which side of your parents that you would inherit these genes from, and these genes do not manifest (do not develop into cleft lips and palate) in you, but in certain environment, it can be passed to the child and when combine with the father's gene, it may develop into cleft lips and palate.
Genes from maternal side should not be the only contributing factor to cleft.
Q: So we will be able to detect this condition prior to birth/in vitro?
A: The face develops between 4th- 8th weeks of pregnancy. The developing foetus can be seen through anomaly ultrasound scan. Fortunately, now with high-resolution ultrasound, we can perform this at 12-13 weeks of pregnancy. This ultrasound performed by trained technicians and then it has to be interpreted by experienced doctors in order to identify cleft lips and palate and other deformities, including hole in the heart, abnormal developed organs etc. This because, sometimes the position of the baby may make the anomaly unclear in the ultrasound image.
Q: How do we do if we know that the baby has cleft lips and palate?
A: Upon detection, the parents-to-be can be given counselling to help them prepare for the birth of the specific baby. In Malaysia Law, it is prohibited to abort the baby unless if child/mother has poor survival prognosis birth of the special baby.
Q: We mentioned some of the causes of cleft lips and palate, but what actually happens biologically in the womb to cause the lips not to join?
A: The formation of the face is very interesting. It is complex. Our face is formed from fusion of several processes. For example, the forehead and the nose, comes together and meet with the upper part of the lips, left and right side. And then the lower lips and the lower jaw fuse from the left and right (meet in the centre and fuse). When they fail to fuse together, a gap will be seen and this is what we called as a ‘cleft’. Clefts do not only develop on the lips and palate. It can develop along any line of fusion on the face. There are some clefts developed along the side of nose and it affects the eyes as well. These are called facial cleft. Fortunately these groups of clefts are more rare than the cleft lips and palate.
Formation of face is formed from fusion of several processes.
Q: So, while you mentioned just a few of those, how many types of ‘clefts’ are there actually? How extreme can the physical defects be?
A: Right, if you just look at cleft lips and palate, they can be broadly divided into unilateral or bilateral. Unilateral means it occurs on one side of the face only, bilateral occurs on both sides of the face. And then again you could classify them into the severity of the cleft whether it only affects the lips, in this case it is only a ‘cleft lip’; or it affects the lips and the gums, then we call it ‘cleft lip and alveolus’; or it affects lips, gums and palate, we call it ‘complete cleft lip and palate’. We do receive interesting cases where there is a cleft lip, no cleft gum, but a cleft palate behind. So those varieties can happen.
Types of cleft lip and palate
Q: What other complications can cleft lip and cleft palate cause, besides the effect on physical appearance?
A: The growth of the face is strongly influenced by function, this is called the functional matrix theory. When the lips and the nose don't develop, the upper jaw cannot develop. The teeth will not be able to develop as well, if you do not develop (the lips) normally. So the functions that will be affected will be the functions of the mouth, for example speech. Swallowing may also be difficult. The other one is hearing, because the part of the function of the soft palate is to try and equilibrate the pressure in the ear. It is like when you go to a high altitude and you find that there is this buzzing sound on your ear that you can hear quite loudly. This is what an unrepaired cleft palate baby would experience.
Cleft lips and palate deformity affects the development of the nose, jaw and teeth. It affects hearing and speech significantly. All these abnormalities of appearance and function have a great psychosocial impact on the patient's family. Therefore, it's not uncommon for a cleft child to by shy, quiet and have difficulty socialising with other children. This inevitably affects their school education too.
Cleft baby usually takes long time to feed and lots of energy wastage during feeding.
Q: What are the challenges of the baby is born with cleft lip and palate? Breast feeding is an issue isn't it?
A: Yes. Feeding is an issue because it is not easy for the child to suckle from the normal bottle/teats, because they could not develop adequate pressure to draw milk into the mouth.
Therefore the cleft baby may take very long to feed and waste a lot of energy during feeding resulting in poor weight gain. Maternal breastfeeding, amazingly, it is NOT IMPOSSIBLE to breast feed a cleft baby. In fact, most cleft babies in underdeveloped countries are breastfed. Breastfed babies are much healthier. However, regardless of the feeding method, mothers must beware of baby's feeding position in order to avoid aspiration and choking that can cause death.
So there are certain techniques in regards to this, depending on the severity of the cleft. If you find that your cleft baby is feeding but it takes him so long to complete a certain amount of feed, other feeding methods can be suggested by the paediatrician, including tube feeding in certain cases.
1. CLEFT BABY NURHIDAYAH WITH SUCCESSFUL SURGERY IN UMMC
1. CLAPAM website: www.clapam.org.my/
2. Community baby center website: www.community.babycenter.com
3. UM Dentistry Website: http://dentistry.um.edu.my/