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What are the causes of cleft?
A cleft occurs when something interrupts the normal development of the face. The face develops in the 4 - 8th week of pregnancy. The facial structures are formed from three planes (nasal, palatal, lip). Each migrating towards a meeting point in the middle of the face. The lip is formed by the obicularis muscle. The two lateral halves are joined in the middle at the philitrum lines. If you rub your finger above your top lip, you will feel those two ridges. Those are in fact the "cleft scars" of a non cleft-affected person. Those tissues naturally join by the fourth week of pregnancy, if they don't, a cleft lip results.
       The palate is formed out of the structure that begins as the tongue. Between the fourth and the eighth weeks of gestation, the tongue drops down and the palatal segments moves from the sides to the middle, ultimately fusing in the center. Run your tongue across your hard palate from side to side and you will feel the seam where the two sides fused.
       Everyone began life with a cleft. For 699 out of 700 of us, the cleft fuses before birth. For that one in 700, it fails to fuse. So we are not talking about something that happens so much as something that fails to happen. If the tissues of the lip and/or the palate fail to fuse at the proper time (4th to 8th weeks of gestation) for some reason or another, a cleft is formed.

There are lots of theories given for the non-union of these halves, but the actual cause is largely unknown. Many factors contribute to the cleft condition ---- heredity, congenital, pre-natal nutrition, drug exposure, environmental factors, syndromes, etc.

• If the tongue fails to drop down because the baby is not in the proper position in the womb (tucked too tightly) at that critical time (4th to 8th weeks in-vitro), may result in a horseshoe-shaped cleft of the palate.
• If the blood flow to the region, through the placenta is disrupted, the fusion may not occur. Drugs, alcohol or medications may disrupt normal patterns of development.
• Sometimes clefts run in families and sometimes a baby is born with a cleft without anyone else in the family having one. Some genetic code may simply dictate that the normal union will not happen. Clefts commonly have a genetic basis. If the gene is transmitted from one affected parent to their offspring, then it is generally considered to be dominant. If neither parent is affected, then the gene could be recessive, and would require that both parents contribute the same recessive gene to their affected child. In the latter case, a clear inheritance pattern may not exist.
  This is indistinguishable from a "susceptibility" or "multifactorial" model that is the basis of the assessment of recurrence risk used by geneticists, for parents who already have a child with a cleft. Unaffected parents with an affected child, according to this model, have an approximately 5% chance of having another similarly affected child. This risk increases if the couple has more than one affected child. In dominant inheritance, the risk of recurrence is 50%, and in recessive inheritance it is 25%. The risk does not change with each pregnancy, regardless of the outcome.
• Cleft lip and/or palate may be associated with a syndrome. A syndrome is a collection of physical findings, which run together in the same person. Syndromes are more common in cleft palate alone, than in cleft lip with cleft palate. Syndromic clefts are commonly inherited as single gene defects, but can be due to abnormalities in the baby's chromosomes, to something used during pregnancy or can be of a sporadic nature.
• Substances used during pregnancy rarely seem to cause cleft lip and cleft palate. Those known to do this are alcohol, smoking, Dilantin (a seizure medication) and excess of vitamin A. Women who smoke are twice as likely to give birth to a cleft-affected child. Women who ingest large quantities of Vitamin A or low quantities of folic acid are also seen to have children with cleft.

Parents should not search for reasons to blame themselves for "causing" a cleft lip or cleft palate, because it is not their fault. Many factors can contribute to anyone having a child with cleft, and may not have left the parents with much choice. Cleft lip and cleft palate occur early in a pregnancy (the face develops in the fourth to the eighth week of pregnancy) often before a mother is aware that she is pregnant.

What are the problems associated with clefts?

1. Chronic or recurring ear infections. The ears of a child with a cleft have a tendency to collect fluid because the Eustachian tubes, which connect the middle ear to the mouth, do not drain the fluids effectively. Pressure can build up and infection can occur. Children who suffer from a lot of untreated ear infections over a period of time may face the inevitability of permanent hearing loss.
2. A child with a cleft will need speech therapy. The oral and nasal cavities are extremely important structures in the production of speech. Cleft-affected child have to learn how to make the same sounds as everyone else using a different oral and nasal structures.
3. A child with a cleft may face some emotional challenges. If he or she is very self-conscious about the cleft scar or her speech, she may become introverted and her self-esteem may plummet. Children who were born with clefts may feel different from their peers and occasionally professional counseling may be needed to help the child identify her strengths and put the cleft scar into its proper perspective.
4. If the alveolar ridge (bone) was disturbed by the cleft, the teeth in the cleft line may be totally absent, or so late in erupting that proper natural alignment is impossible. The need of orthodontic intervention is necessary to unlock impacted palatal segments and permit more normal growth. Some patients with cleft palates present a unique combination of both skeletal and dental abnormalities. Their dentition will require long periods of treatment with use of braces and/or appliances, and later may have to undergo Orthognathic surgery.
5. It is also common for children born with clefts to have supernumerary (extra) teeth. Supernumerary teeth are usually located next to the cleft site. Some emerge into the oral cavity, while others may remain unerupted. The supernumerary may have to be removed to facilitate the treatment of the remaining dentition. Occasionally a tooth may be switched in position with another tooth (transposition), or the tooth in the line of the cleft will be absent (missing).
6. Nasal deformities are often seen along with deformities of the jaw. Some common deformities of the nose are: deviated nasal septum, flared or constricted ala of the nose, saddle nose, hooked nose, asymmetrical nose etc.
7. Deficient growth of lower jaw (mandible) and the nasal structures may cause difficulty in breathing. Difficulty in swallowing may also be seen. The growth of maxilla will also be retarded due to scar formed after surgical correction.

How to feed a baby with cleft?
All babies spend most of their early weeks feeding and sleeping. Feeding is a time for social interaction, the baby is most alert during this period and the mother and baby begin to get to know each other. Unless your baby has other problems you need not to be separated from your baby.
       In order to feed, babies need to form a vacuum inside the mouth. This is usually done by sealing the lips around the nipple or teat and closing off the back of the mouth with the soft palate. Babies with clefts may not be able to do this efficiently and need some extra help. Those with a small lower jaw (mandible) may at first have difficulty in coordinating swallowing and breathing. Ways of helping may include

• A different approach to breast-feeding.
• A different shaped teat with enlarged or newly positioned holes.
• A different bottle for bottle-feeding. A soft squeezy bottle to help the flow of milk or a bottle with a scoop attached, which requires less effort if the baby has not got the energy to suck from a teat.
• Initially a thin feeding tube may be passed into the stomach through the nose or mouth to help those babies who have a small jaw.