Cleft Palate

What a cleft palate is

The palate forms the roof of the mouth. The front part (hard palate) contains bone; the back part (soft palate) is muscle that lifts during speech and swallowing to close off the nose. Between about the 6th and 12th weeks of pregnancy, two shelves of tissue grow toward each other and fuse in the middle. If they do not fully join, a gap remains.

Types of cleft palate

When the lip is also involved, see cleft lip and palate, which covers lip repair as well.

Causes and risk factors

Most clefts have no single cause. They result from a mix of genes and factors in early pregnancy. Known risk factors include:

• Family history: the chance rises if a parent or sibling had a cleft.
• Smoking in pregnancy.
• Diabetes that was present before pregnancy.
• Certain medicines in early pregnancy, including some anti-seizure drugs such as topiramate and valproate.
• Low folate levels; taking folic acid before and during early pregnancy is advised for all pregnancies.

About 1 in 3 children with a cleft palate alone have an associated genetic syndrome. The most common are 22q11.2 deletion syndrome, which can also involve heart defects and low calcium, and Stickler syndrome, which affects the eyes and joints. Pierre Robin sequence combines a small lower jaw, a tongue that falls back, and a U-shaped cleft palate, and can cause breathing problems after birth.

How it is diagnosed

• Before birth: a cleft lip can often be seen on the 18 to 22 week anatomy ultrasound. A cleft palate alone is much harder to see and is usually found after birth.
• At birth: the newborn check includes looking at and feeling the palate. A complete cleft is obvious.
• Later: a submucous cleft may only be found when a child has nasal-sounding speech or milk comes out of the nose.

A genetic assessment and, where needed, a heart ultrasound are offered because of the link with syndromes.

Feeding a baby with a cleft palate

The gap means a baby cannot create the suction needed for breastfeeding or a standard bottle, so feeding problems are the main early challenge.

• Special bottles: squeezable bottles or bottles with a one-way valve let the parent or the baby's own compression push milk into the mouth.
• Upright position: feeding with the baby sitting up reduces milk coming through the nose.
• Breast milk: many parents express breast milk to feed by bottle. Direct breastfeeding is rarely successful with a complete cleft palate, but it is sometimes possible with a cleft of the lip only.
• Frequent burping: babies swallow more air.
• Weight checks: a cleft nurse or feeding specialist monitors growth in the first weeks.

Treatment

Care is coordinated by a cleft team: a cleft surgeon, specialist nurse, speech-language pathologist, ear, nose and throat (ENT) specialist, audiologist, orthodontist, dentist, geneticist and psychologist.

Typical timeline

1. Birth to 3 months: feeding support, hearing screen, genetic review. Lip repair at about 3 months if the lip is involved.
2. 6 to 12 months: palate repair (palatoplasty). The surgeon closes the gap and, importantly, reconnects the soft palate muscles so they can close off the nose during speech. Doing this before speech develops gives the best results.
3. Toddler and preschool years: speech assessments. About 1 in 5 to 1 in 3 children need further surgery to improve speech if the soft palate does not close the nose fully (velopharyngeal insufficiency).
4. Around 8 to 11 years: a bone graft to the gum ridge if the cleft extends through it, timed before the adult canine tooth comes through.
5. Teen years: orthodontics and, in some, jaw surgery once growth is complete.

Ear and hearing care

Children with a cleft palate very often have glue ear because the muscles that open the Eustachian tube are part of the soft palate. Regular hearing tests are needed, and many children need ear tubes (grommets).

Possible complications

• Speech difficulties: nasal-sounding speech, air escaping through the nose and unusual sound substitutions. Speech therapy is effective for most.
• Hearing loss from fluid in the middle ear.
• Dental problems: missing, extra or misplaced teeth near the cleft, and a higher risk of decay.
• Fistula: a small hole that remains or reopens in the palate after surgery.
• Emotional and social effects: some children benefit from psychological support, particularly at school age.

Outlook

Most children with a cleft palate who receive team care grow up with clear speech, normal hearing and good dental health. Treatment spans childhood and adolescence, so it involves many appointments, but the long-term results are good. If a child's cleft is part of a syndrome, the outlook also depends on the other features of that syndrome.

Frequently asked questions

What causes a cleft palate?

A cleft palate happens when the two halves of the roof of the mouth do not join during weeks 6 to 12 of pregnancy. Usually there is no single cause. Genes, smoking, pre-existing diabetes and some anti-seizure medicines raise the risk. Nothing a parent did after the first trimester could have caused it.

When is cleft palate surgery done?

Palate repair is usually done between 6 and 12 months of age, before the child starts to talk. The operation takes a few hours and most babies stay in the hospital for 1 to 3 days. Some children need a second operation later to improve speech.

Can a baby with a cleft palate breastfeed?

Direct breastfeeding is difficult with a cleft palate because the baby cannot make a seal and suction. Many parents express breast milk and feed it with a special squeezable or valved bottle. A cleft nurse can help set up feeding in the first days.

What is a submucous cleft palate?

It is a cleft where the lining of the palate is intact but the muscle or bone underneath has not joined. It can be missed at birth. Clues include a split uvula, a notch in the back of the hard palate, nasal-sounding speech and milk coming from the nose.

Will my child's speech be normal after cleft palate repair?

Most children develop normal or near-normal speech after repair with speech therapy. Some need a second operation if air still escapes through the nose when they talk. Regular assessments by a cleft speech-language pathologist pick this up early.