Regional Cleft Care

Standards for Cleft Care

All children born with clefts will be enrolled in the Cleft Registry. At birth, each of these families will receive a booklet with a complete outline of care for children with clefts; this booklet will include the recommendations that have been established during this conference. The recommendations will include space for each family to document the date of completion for each of the recommendations.

Initial Evaluation

The recommendation of the Palestinian Cleft Society is that at the birth of a child with a facial cleft, he/she will be evaluated by the following people: an Otolaryngologist (ENT), Pediatrician, Geneticist, Audiologist, and a Feeding Specialist. Within a month of birth, the child will be evaluated by a surgeon capable of performing cleft lip and palate repair.

Because feeding is a problem in children with cleft palates, special bottles and nipples are required by these children. Pigeon and Haberman nipples will be provided for all children and feeding will be monitored by a Feeding Specialist. These bottles and nipples will be made available to all centers with cleft teams for distribution in the regions near those hospitals.

Because a child with a cleft is likely to have problems with hearing, an ENT surgeon who is capable of placing myringotomy (ear) tubes, will evaluate the child. An Audiologist will assist in evaluating the children’s hearing. A Pediatrician will perform a thorough exam to rule out other congenital anomalies. Because there is a strong genetic component to clefting, each child will be seen by a Geneticist.

Preparation for Surgery

If the cleft of the lip is wide, a taping regimen will be initiated (See picture). Taping involves placing duoderm on both cheeks, and then placing either tape or a steri strip from the check areas across the open area of the lip. Swallowing and feeding evaluations need to be continued if the child is not gaining weight adequately.

At 3 to 6 months of age, the child will undergo cleft lip repair by a Surgeon capable of performing lip repair. Children with clefts should see a Dentist at six months of age, and then every six months. At 7 months of age, the child will see a Speech Therapist. This is in preparation for palate repair, which will be performed between 9 to 18 months of age. Early palate repair benefits speech outcomes. Delaying the palate repair may improve facial growth. At the time of cleft palate repair, ear tubes (myringotomy tubes) will be placed by a qualified ENT surgeon. The ENT surgeon placing the ear tubes will see the patients every year. Hearing will be re-evaluated every year. One month after palate repair, the child will be seen by a Speech Therapist who will guide the child’s speech development (There are PRCS speech centers in Qalqilia, Tulkarm, Hebron, Jericho, Ramallah, and Nablus).

Orthodontic Care

Orthodontists will evaluate every child with a cleft at 5 years of age, and then once a year. The Orthodontist will help to determine the time for alveolar (gumline) bone grafting, and will continue to guide care following the bone graft (see below). The Orthodontist will also assist in preparation for Orthognathic surgery (see below). In these cases, the Orthodontist will work carefully with the surgeon performing these procedures.

Alveolar Bone Grafting

Between the ages of 7 and 10, a child with an alveolar (gumline) cleft will require a bone graft. The Orthodontist will help to determine the timing of the graft, which is based on the eruption of the lateral incisior. The bone is taken from the hip, and placed in the alveolar cleft. The bone graft is taken from the hip and placed into the alveolar cleft. After the bone graft, the patient will follow-up at 4 months with an orthodontist, who will continue to be in contact with the surgeon. The Palestinian Cleft Society will assist in providing inexpensive, dental and orthodontic care for all individuals with clefts. Materials will be provided for dentists and orthodontists in order to assist them in lower costs for their services.

Orthognathic surgery

At skeletal maturity (for girls 15 years of age and males, 18 years of age), patients with clefts will be evaluated for Orthognathic surgery. Orthognathic surgery involves surgical movement of the jaws in order to place the teeth in a proper relationship. Surgeons will carefully plan with Orthodontists regarding preparation and timing for surgery.

Completion of Care

At 21 years of age, young adults with clefts will have completed their surgical care. The goal of the Palestinian Cleft Society will be to assist these individuals in becoming fully functional parts of society.