THE TREATMENT PLAN
To provide timely, comprehensive, compassionate medical, dental and surgical care for all children with either cleft lip, cleft palate or cleft lip and cleft palate in Lombok Province needs a plan. Of essence is the development of a database, such as that developed in Palestine. The timeline can be viewed at wikipedia.org. Our team may develop our own protocols and treatment lines, adapting to available resources and staff.
Next information stems from source: palestiniancleftsociety.com. Very informative are the video's by Prof. ElNassry on Youtube. See the treatment protocol part 1 and part 2.
3 years
Cleft Lip: A cleft lip can be unilateral (one sided) or bilateral (both sides). In the cleft lip operation (cheiloplasty), incisions are made and the separate portions of the lip are brought together to form a single full lip. The repair is performed at three to six months of age and takes about two hours. The nose is also partially reconstructed during this operation in order to give better facial symmetry. At the end of the operation, the patient may have temporary nasal stents placed. These will be removed a week after surgery. The child should wear arm restraints for one week and may resume his or her pre-operative feeds (bottle or breastfeeding).
Cleft Palate: A cleft palate is a hole in the roof of the mouth. This may involve only part or the entire palate. A child with a cleft palate may or may not have a cleft lip. Children with cleft palates often having difficultly with weight gain during the first weeks of life. When feeding a child, position the baby upright and frequently burp the child. Special cleft nipples are ideal. A slow drip should come out of the nipple when the bottle is held upside down. Cleft palate babies should not be breastfed, as it is too difficult for the baby to create the necessary suction on the breast. A child should be given a no ball valve sippy cup at least two months prior to the cleft palate operation.
The repair of the cleft palate (palatoplasty) is usually performed at nine months of age and takes approximately two hours to perform. The surgery will help speech, drainage of the middle ear and create a barrier between the mouth and the nose. The operation involves making incisions and sewing the separated portions of the palate back together in layers. Following the operation, the child should wear arm restraints for two weeks, stay on a soft diet and only drink from a no ball valve sippy cup or syringe (no sucking with a bottle or pacifier). Sharp objects should not be placed in the child’s mouth for over a month. A child should eat a soft diet (applesauce-like consistency) for at least two weeks following the repair.
Following the operation, the child’s speech should be evaluated by a Speech Pathologist. This person may recommend short or long-term speech therapy. On occasion, a child may require additional palate surgeries to improve speech or repair a fistula (hole) in the palate.
Ear Tubes: Ear tubes, also known as Pressure Equalization (PE) tubes, are placed in the ears by an Otolaryngologist (Ear Nose Throat) Surgeon during the cleft palate repair. These tubes are placed using a microscope and take twenty minutes. These small tubes allow the middle ear to drain and decrease ear infections and hearing loss. Antibiotic drops are placed in both ears for five days after the procedure.
Anesthesia and Hospitalization: Cleft lip and palate surgeries require general anesthesia. The patient is asleep during the procedure and a ventilator (breathing machine) helps the patient breathe. The patient will be admitted to the hospital the night before the surgery and will stay one night after surgery. Your child will go home with both oral pain medicine and an antibiotic.
Cleft Care: Children with clefts have complex needs. In order to fully take care of these issues, your child should ideally be evaluated and followed by a Pediatrician, Surgeon, Dentist, Orthodontist, Otolaryngologist, Oral Maxillofacial Surgeon, Psychologist, and Speech Pathologist.
Age 4-18 years
Cleft Lip and Nare Revision: If your child had a cleft lip repair, future surgical revisions of the nose and lip scar may be needed at four years of age. A final revision is often performed during the teenage years. These surgeries take approximately three hours to perform. Nasal stents may be placed during the surgery and removed a week later.
Cleft Palate Secondary Surgeries: Additional surgeries of the palate may be needed if the child has a fistula (hole) that communicates with the nose following the first cleft palate repair. This hole may allow food and liquids to come out of the nose during feeding. The child may also have speech concerns after palate repair. The Speech Pathologist and/or Surgeon will determine the need for additional palate surgeries. Following these surgeries, the child will need to avoid sucking and remain on a soft diet for two weeks.
Alveolar Cleft: An alveolar cleft is a defect in the teeth and gum line. An alveolar bone graft replaces the missing part of the gum line with bone. Bone is taken from the hip. This surgery is done between seven and ten years of age, and the new bone allows permanent teeth to come through the gums. Sometimes a small fistula (hole) is in the alveolar cleft and communicates with the nose. In this case, the graft will help improve speech and reduce food or liquids draining from the nose. An X-ray film (panorex) will help decide when it is time for the child to have his or her alveolar bone graft.
Othodontic Care: Each patient should be seen by an Orthodontist before the alveolar bone graft in order to help coordinate orthodontic care before and after surgery.
Orthognathic Surgery: Children with a repaired cleft palate often have poor upper jaw growth. Surgery may be needed in the teenage years to move the upper jaw forward. This surgery takes several hours to perform.
Anesthesia and Hospitalization: All of these surgeries require general anesthesia. The patient is asleep during the procedure and a ventilator (breathing machine) helps the patient breathe. The patient will be admitted to the hospital the night before the surgery and will have to spend time in the hospital after surgery. Your child will go home with both oral pain medicine and an antibiotic.
Cleft Care: Children with clefts have complex needs. In order to fully take care of these issues, your child should ideally be evaluated and followed by a Pediatrician, Surgeon, Dentist, Orthodontist, Otolaryngologist, Oral Maxillofacial Surgeon, Psychologist, and Speech Pathologist.