Cleft Lip and Palate

What cleft lip and palate are

The lip and palate form from separate pieces of tissue that grow toward each other and fuse. The lip joins between about weeks 4 and 7 of pregnancy and the palate between weeks 6 and 12. When fusion is incomplete, a cleft remains.

A cleft lip can be unilateral (one side, more often the left) or bilateral (both sides). It can be incomplete, a small notch, or complete, running into the nostril. For more on clefts that affect only the roof of the mouth, see our page on cleft palate.

Causes and risk factors

Most clefts have no single cause. They come from a combination of genes and factors in early pregnancy.

• Family history: the chance rises if a parent or sibling has a cleft.
• Syndromes: about 1 in 3 children with cleft palate alone, and fewer with cleft lip, have an associated genetic syndrome, such as 22q11.2 deletion syndrome, Van der Woude syndrome or Pierre Robin sequence.
• Smoking in pregnancy clearly increases risk.
• Alcohol in pregnancy, including as part of fetal alcohol syndrome.
• Certain medicines taken in early pregnancy, including some anti-seizure drugs (such as topiramate and valproate).
• Diabetes before pregnancy and obesity.
• Low folic acid intake around conception.

Nothing a parent did in most cases caused the cleft. Many occur with no identifiable risk factor.

Diagnosis

Cleft lip is often seen on the routine anatomy ultrasound at 18 to 21 weeks. Cleft palate alone is hard to see on ultrasound and is usually found during the newborn exam, when a doctor looks at and feels the roof of the mouth. A submucous cleft may only be suspected later, from a split uvula, a notch in the hard palate, or nasal speech.

After a prenatal diagnosis, parents are usually referred to a cleft team before birth. A genetic assessment may be offered, especially for cleft palate alone or when other differences are found.

Feeding a baby with a cleft

Feeding is the first practical challenge, because a cleft palate stops a baby from making suction.

• Cleft lip only: many babies breastfeed well. The breast can fill the gap.
• Cleft palate: breastfeeding directly is usually not effective. Expressed breast milk or formula is given with special squeezable bottles or valve bottles that let a caregiver help milk flow.
• Feed in a fairly upright position to reduce milk coming out of the nose.
• Burp often, because babies with clefts swallow more air.
• Feeds should take no more than about 30 minutes. Longer feeds burn too many calories.
• A cleft nurse will check weight closely in the first weeks.

Cleft lip and palate surgery timeline

Timing varies between teams, but a typical plan is:

Repairs are done under general anesthesia. Babies usually stay in hospital for 1 to 3 days.

Long-term care and complications

A team that includes a surgeon, specialist nurse, speech therapist, audiologist, orthodontist, dentist and psychologist follows children until adulthood.

• Ears and hearing: the muscles that open the ear tube attach to the palate, so fluid behind the eardrum (otitis media with effusion) is very common. Hearing is tested regularly and ear tubes are often needed.
• Speech: some children have nasal-sounding speech or difficulty with certain sounds even after repair. Speech therapy helps most.
• Teeth: missing, extra or misplaced teeth near the cleft are common, and orthodontic treatment is usually needed.
• Emotional wellbeing: most children adjust well. Teams screen for teasing, self-esteem issues and anxiety.

Outlook and prevention

With modern team care, children born with cleft lip and palate usually eat normally, speak clearly and have good facial appearance. They go to mainstream school and lead ordinary lives. Outcomes are less certain when a cleft is part of a wider syndrome.

To lower risk in a future pregnancy, take folic acid (at least 400 micrograms daily) from before conception, avoid smoking and alcohol, manage diabetes, and review any regular medicines with a doctor before trying to conceive.

Frequently asked questions

What causes cleft lip and palate?

It is caused by a mix of inherited genes and factors during early pregnancy, when the lip and palate are forming. Smoking, alcohol, some anti-seizure medicines, diabetes and low folic acid increase the risk. In many babies there is no clear cause, and nothing the parents did caused it.

Can cleft lip be seen on an ultrasound?

Often, yes. Cleft lip is usually visible on the anatomy scan between 18 and 21 weeks, especially when it is complete. A cleft palate without a cleft lip is much harder to see on ultrasound and is usually found when the baby is examined after birth.

At what age is cleft lip surgery done?

Most teams repair a cleft lip at around 3 months of age, when the baby is gaining weight well and anesthesia is safe. The palate is repaired later, usually between 6 and 12 months, so it is closed before the child starts to talk.

Can a baby with a cleft lip breastfeed?

Many babies with a cleft lip only can breastfeed, because breast tissue fills the gap and allows a seal. Babies with a cleft palate usually cannot create suction, so they are fed expressed breast milk or formula using special bottles. A cleft nurse can help you choose a method.

Is cleft lip and palate genetic?

Partly. A family history increases the chance, and some clefts are part of genetic syndromes. If one parent or child is affected, the chance in a future child is a few percent rather than the general 1 in 700. A genetic counselor can give a more precise figure for your family.