Neonatal cleft lip and cleft palate repair - Cover Story

AORN Journal, March, 2002 by Debra J. Sandberg, William P. Magee, Jr., Michael J. Denk

Home Study Program

NEONATAL CLEFT LIP AND CLEFT PALATE REPAIR

The article "Neonatal cleft lip and cleft palate repair" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from

Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 2 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is March 31, 2005.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on neonatal cleft lip and cleft palate repair, the nurse will be able to

(1) discuss the epidimiology of cleft lip and cleft palate deformities,

(1) define the anatomy pertinent to cleft lip and cleft palate deformities,

(2) identify the risks involved with neonatal surgery,

(3) discuss current options for repairing cleft lip and cleft palate deformities,

(4) describe the intraoperative care of the neonate undergoing cleft lip and cleft palate repair, and

(5) explain the postoperative care required by the neonate recovering from cleft lip and cleft palate repair.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

The birth of an infant is an exciting and stressful event, even when the pregnancy, labor, and delivery go well. For the parents of an infant born with a facial anomaly, however, it can be a devastating experience. Facial clefting is one of the most common birth deformities. Feelings of fear, guilt, resentment, inadequacy, shame, and grief are common among parents and family members of babies born with cleft deformities. (1) Such feelings can interfere with parent-infant bonding and may have psychosocial effects on both the infant and family members. (2) Reactions of family members, friends, and even strangers can be painful for the parents of these babies. The usual smiles of others often turn to looks of discomfort and surprise. Infants with facial deformities also may have substantial feeding difficulties and impaired speech development. Speech difficulties, in combination with abnormal facial appearance, can heighten parental stress and decrease acceptance from society when repair of a cleft lip and palate are delayed. Early repair of cleft lip and palate deformities during the neonatal period improves parent-infant bonding; aids in feeding, which promotes growth; and has positive effects on speech development.

EPIDIMIOLOGY

Cleft lip and palate is a common birth defect, occurring in approximately one out of every 700 live births. (3) Cleft deformities are more prevalent among people of Asian descent (ie, 2.1 out of every 1,000 live births). The incidence in people of Caucasian descent is one out of every 1,000 live births and the incidence among people of African American descent is among the lowest (ie, 0.4 out of every 1,000 live births). (4)

History shows that heredity plays a role in the occurrence of cleft lip and palate deformities. There is a 40% increase of clefting in siblings of a child with a cleft lip or palate. (5) Parental age also seems to be a contributing factor; the risk of having an infant with a cleft lip or palate deformity increases in parents older than age 30. (6) Certain medications, such as phenytoin sodium, have been shown to increase the incidence of cleft lip and palate. (7) No matter the cause, surgical repair is necessary for these babies.

EMBRYOLOGY

Clefting occurs when there is failure of fusion or diminished mesenchymal penetration between migrating embryological processes. An infant may be born with a cleft lip, a complete or incomplete cleft palate, or both. Between the fourth and eighth week in utero, the upper lip and palate form from the migration and connection of three bilateral processes (ie, nasomedial, nasolateral, maxillary). The nasomedial process forms the columnella of the nose, prolabium of the lip, and alveolar ridge of the maxilla. This portion of the true maxilla eventually will hold the two central and two lateral incisors. The premaxilla is the segment of bone from the back of the teeth to the incisor foramen from which the anterior palatal vessels and nerves emerge.

The nasolateral process forms the ala, dome, and sil of the nose. The maxillary process forms the canine to molar teeth. The junction of these three processes produces the intact maxilla and intact lip. Two maxillary processes produce the areas of the maxilla. The maxilla begins to close anteriorly and closure proceeds in the posterior direction. The maxilla fuses with the vomer bone and the nasal septum. When this process faults, a splitting of the normal anatomy may occur.