Early and late operation of cleft lip and intelligence quotient and psychosocial development in 3-7 years

Impact of early cleft lip and palate surgery on maxillary growth in 5- and 10-Year-old patients with unilateral cleft lip and palate: a cross-sectional study

OBJECTIVES

This study evaluated maxillary growth and dental arch relationships at 5 and 10 years of age in patients with unilateral cleft lip and palate (UCLP) who underwent early cleft lip and palate surgery.

METHODS

28 patients with UCLP who underwent cleft lip surgery in neonatal age and cleft palate surgery at average age of 7 months without orthodontic treatment (intervention group) were measured for intercanine and intermolar distances and for dental arch length. These measurements were compared with those of 30 healthy participants in a control group. Dental arch relationships in the intervention group were evaluated by 5-YO index at 5 years and the GOSLON Yardstick score at 10 years of patients' age.

RESULTS

Patients in the intervention group had significantly shorter mean intercanine distance and arch length than control patients at both 5 and 10 years of age (p<.001 for all). There were no significant differences in intermolar distance at both 5 (p = .945) and 10 years (p = .105) of patients' age. The average 5YO index increased from 2.46 to an average GOSLON 10-year score of 2.89 in intervention group.

CONCLUSION

Intercanine distance and dental arch length of patients with UCLP are significantly reduced at 5 and 10 years after early cleft lip and palate surgeries compared to the healthy population. Dental arch relationships at 5 and 10 years of patients with UCLP show comparable outcomes to those reported by other cleft centers.

CLINICAL SIGNIFICANCE

This study evaluates maxillary growth in UCLP patients 5 and 10 years of age who underwent early primary lip and palate surgery.

Single-Stage Posterior Vomerine Ostectomy and Primary Cheiloplasty in Patients with Bilateral Cleft Lip & Palate and Protuberant Premaxilla

OBJECTIVE

A protruded premaxilla has always been challenging to care for by cleft care professionals. This study aims to fortify the use of a single-stage premaxillary setback, with posterior vomerine ostectomy and primary cheiloplasty to achieve proper care for patients with bilateral cleft lip and palate (BCLP) and protruded premaxilla.

DESIGN

Longitudinal retrospective analysis.

SETTING

Twenty-three outreach programs to four countries (Ecuador, Lebanon, Peru, and El-Salvador) between 2016-2022.

PATIENTS/PARTICIPANTS

Sixty-five patients between the ages of 3 months and 6 years and 5 months, with BCLP and severely protruded premaxilla underwent premaxillary setback via posterior vomerine ostectomy and primary cheiloplasty. Patients with diagnosed syndromes and inaccessible vomer bone due to fused palates were excluded from the study.

INTERVENTIONS

Premaxillary setback with posterior vomerine ostectomy, bilateral gingivoperiosteoplasties (GPP), and primary cheiloplasty.

MAIN OUTCOME MEASURE(S)

Postoperative complications and aesthetic outcomes.

RESULTS

The mean age at surgery was 13.17 ± 14.1 months, with an average follow-up time of 26 ± 17 months. Patients underwent their procedures in Ecuador (72%), Peru (9%), Lebanon (8%) and El-Salvador (1%). The majority of patients were aged 1 year or less (66.7%) and were males (58.5%). All patients were operated on successfully and had good aesthetic outcomes. Only one patient developed partial necrosis.

CONCLUSION

Patients with BCLP and severe premaxillary protrusion have always carried immense social, psychological, and financial burdens, especially in outreach settings. Our described single-stage technique has proven to be safe and effective with good aesthetic results. Further follow-up after primary repair should be done to document and ensure proper facial growth and normal nasolabial maturation.

Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND/IMPORTANCE

Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery.

OBJECTIVES

The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.

EVIDENCE REVIEW

MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023.

FINDINGS

Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown.

CONCLUSION

The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients.

PROSPERO REGISTRATION NUMBER

CRD42022364788.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without.

RESULTS

In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level.

CONCLUSIONS

Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic

OBJECTIVE

To quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31 March 2021; 2020/2021) compared with the preceding year (1 April 2019 to 31 March 2020; 2019/2021).

DESIGN

National observational study of administrative hospital data.

SETTING

National Health Service hospitals in England.

STUDY POPULATION

Children <5 years undergoing primary repair for an orofacial cleft Population Consensus and Surveys Classification of Interventions and Procedures-fourth revisions (OPCS-4) codes F031, F291).

MAIN EXPOSURE

Procedure date (2020/2021 vs 2019/2020).

MAIN OUTCOMES

Numbers and timing (age in months) of first primary CLP procedures.

RESULTS

1716 CLP primary repair procedures were included in the analysis. In 2020/2021, 774 CLP procedures were carried out compared with 942 in 2019/2020, a reduction of 17.8% (95% CI 9.5% to 25.4%). The reduction varied over time in 2020/2021, with no surgeries at all during the first 2 months (April and May 2020). Compared with 2019/2020, first primary lip repair procedures performed in 2020/2021 were delayed by 1.6 months on average (95% CI 0.9 to 2.2 months). Delays in primary palate repairs were smaller on average but varied across the nine geographical regions.

CONCLUSION

There were significant reductions in the number and delays in timing of first primary CLP repair procedures in England during the first year of the pandemic, which may affect long-term outcomes.

General anesthesia in children and long-term neurodevelopmental deficits: A systematic review

Background

Millions of children experienced surgery procedures requiring general anesthesia (GA). Any potential neurodevelopmental risks of pediatric anesthesia can be a serious public health issue. Various animal studies have provided evidence that commonly used GA induced a variety of morphofunctional alterations in the developing brain of juvenile animals.

Methods

We conducted a systematic review to provide a brief overview of preclinical studies and summarize the existing clinical studies. Comprehensive literature searches of PubMed, EMBASE, CINAHL, OVID Medline, Web of Science, and the Cochrane Library were conducted using the relevant search terms “general anesthesia,” “neurocognitive outcome,” and “children.” We included studies investigating children who were exposed to single or multiple GA before 18, with long-term neurodevelopment outcomes evaluated after the exposure(s).

Results

Seventy-two clinical studies originating from 18 different countries published from 2000 to 2022 are included in this review, most of which are retrospective studies (n = 58). Two-thirds of studies (n = 48) provide evidence of negative neurocognitive effects after GA exposure in children. Neurodevelopmental outcomes are categorized into six domains: academics/achievement, cognition, development/behavior, diagnosis, brain studies, and others. Most studies focusing on children &lt;7 years detected adverse neurocognitive effects following GA exposure, but not all studies consistently supported the prevailing view that younger children were at greater risk than senior ones. More times and longer duration of exposures to GA, and major surgeries may indicate a higher risk of negative outcomes.

Conclusion

Based on current studies, it is necessary to endeavor to limit the duration and numbers of anesthesia and the dose of anesthetic agents. For future studies, we require cohort studies with rich sources of data and appropriate outcome measures, and carefully designed and adequately powered clinical trials testing plausible interventions in relevant patient populations.

Safety of general anaesthetics on the developing brain: are we there yet?

Thirty years ago, neurotoxicity induced by general anaesthetics in the developing brain of rodents was observed. In both laboratory-based and clinical studies, many conflicting results have been published over the years, with initial data confirming both histopathological and neurodevelopmental deleterious effects after exposure to general anaesthetics. In more recent years, animal studies using non-human primates and new human cohorts have identified some specific deleterious effects on neurocognition. A clearer pattern of neurotoxicity seems connected to exposure to repeated general anaesthesia. The biochemistry involved in this neurotoxicity has been explored, showing differential effects of anaesthetic drugs between the developing and developed brains. In this narrative review, we start with a comprehensive description of the initial concerning results that led to recommend that any non-essential surgery should be postponed after the age of 3 yr and that research into this subject should be stepped up. We then focus on the neurophysiology of the developing brain under general anaesthesia, explore the biochemistry of the observed neurotoxicity, before summarising the main scientific and clinical reports investigating this issue. We finally discuss the GAS trial, the importance of its results, and some potential limitations that should not undermine their clinical relevance. We finally suggest some key points that could be shared with parents, and a potential research path to investigate the biochemical effects of general anaesthesia, opening up perspectives to understand the neurocognitive effects of repetitive exposures, especially in at-risk children.

Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis

Importance

Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results.

Objective

To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children.

Data Sources

PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021.

Study Selection

Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded.

Data Extraction and Synthesis

Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model.

Main Outcomes and Measures

The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses.

Results

A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002).

Conclusions and Relevance

These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.

Nasoalveolar Molding: Assessing the Burden of Care

ABSTRACT

Over the last 3 years a shift at our institution has taken place in which patients who would have been offered nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.

Exceptionally early tympanostomy tube placement in pediatric patients with cleft lip and palate

OBJECTIVE

At our institution, cleft lip repair is performed at or before 8 weeks of age, and tympanostomy tubes (TT) have been inserted concurrently in some of these patients. Our objective was to determine the feasibility and present the preliminary results of TT placement at this early age.

METHODS

A retrospective review was conducted of 22 patients born with cleft lip and/or palate who had TT placement in the first 8 weeks of life. Data collected included complications and audiologic function post TT placement.

RESULTS

Subjects had a mean age of 3.9 weeks at the time of TT placement and cleft lip repair. Thirteen patients (59%) reported otorrhea during the follow-up period. Eighteen of 21 (86%) patients who underwent auditory evaluation had normal audiological function following TT placement. One patient had sensorineural hearing loss and 2 patients had mild conductive hearing loss due to bilateral extruded TT and OME at 15.9 and 39.2 months after surgery.

CONCLUSION

Exceptionally early TT is feasible. Placing TT at or before 8 weeks of age did not result in any major complications but demonstrated a high incidence of otorrhea. A randomized, prospective study with a larger sample size is necessary to determine the benefits of TT placement at this age.

The effects of early anesthesia on neurodevelopment: A systematic review

BACKGROUND

There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity.

METHODS

Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms "general anesthesia and neurodevelopment" as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence.

RESULTS

In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures.

CONCLUSION

There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly level 3-4).

Duration of Surgery, Ventilation, and Length of Hospital Stay Do Not Affect Breastfeeding in Newborns After Early Cleft Lip Repair

OBJECTIVE

There are minimal data available on nutrition after early repair of cleft lip and the factors influencing initiation of breastfeeding. This study assessed the impact of the length of surgery, length of ventilation support, and duration of hospital stay on breastfeeding rates after early cleft lip surgery.

DESIGN

This is a prospective observational cohort study comparing 2 hospitals providing early surgical repair of facial clefts from January 2014 to December 2016. Both hospitals are designated as Baby-Friendly Hospitals. Demographic and anthropometric data from mothers and newborns were recorded.

SETTING

Tertiary neonatal and pediatric surgery center.

PATIENTS

Hospital A: 61 newborns, Hospital B: 157 newborns.

INTERVENTIONS

Early (day 5 to 14) cheiloplasty in newborns with cleft lip or cleft lip and palate.

MAIN OUTCOME MEASURES

Influence of duration of hospital stay, length of operation, and artificial ventilation on the rate of breastfeeding.

RESULTS

Significantly, more newborns were breastfed following early surgical repair of an isolated cleft lip compared to those with both cleft lip and palate, in both hospitals (hospital A 82% vs 0%, P = .0001, hospital B 66% vs 5%, P = .0001). Duration of hospital stay, length of operation, and duration of artificial ventilation did not significantly affect the rate of breastfeeding.

CONCLUSIONS

The factors associated with early cleft lip repair (length of operation, length of ventilation support, and duration of hospital stay) do not affect breastfeeding rate.

Three-dimensional development of the palate in bilateral orofacial cleft newborns 1 year after early neonatal cheiloplasty: Classic and geometric morphometric evaluation

OBJECTIVES

The aim of this study was to assess palatal growth in newborns with complete bilateral cleft lip and palate (cBCLP) and bilateral cleft lip and palate with tissue bridges (BCLP + B) 1 year after early neonatal cheiloplasty (ENC).

MATERIAL AND METHODS

The methodology was based on classic and morphometric analysis of dental models of newborns with cBCLP or BCLP + B. These analyses included metric analysis, coherent point drift-dense correspondence analysis, superprojection methods, and multivariate statistics. Dental casts were observed in two age categories, which were compared with each other. The first cast was obtained from each patient before ENC (T0, 5 ± 5 days) and the second one prior to palatoplasty (T1, 12 ± 6 months).

RESULTS

Fifty-two dental models obtained from 26 newborns with cBCLP and BCLP + B were evaluated. The results showed that over the 12-month period, alveolar clefts were narrowed in both cleft types due to anterior growth combined with the formative effect of suturing. This was confirmed by decreases in the dimensions of the right (T0 9.93 ± 2.80 mm, T1 6.64 ± 2.43 mm; p ≤ 0.003) and left (T0 10.71 ± 4.13 mm, T1 6.69 ± 4.29 mm; p ≤ 0.003) alveolar clefts in cBCLP patients. Similar reductions in alveolar cleft widths occurred on the left side (T0 11.69 ± 4.75 mm, T1 4.34 ± 2.97 mm; p ≤ 0.001) of BCLP + B patients, while on the right side, which was connected by a combined tissue bridge, there was non-significant narrowing of the alveolar cleft (T0 1.61 ± 1.34 mm, T1 1.04 ± 0.70 mm; p = 0.120). The ENC did not restrict posterior palatal growth, meaning that intertuberosity width was extended in cBCLP (T0 32.80 ± 3.15 mm, T1 35.86 ± 2.80 mm; p ≤ 0.001) and in BCLP + B neonates (T0 34.01 ± 2.15 mm, T1 36.21 ± 2.14 mm; p ≤ 0.004). Width and length measurements in the observed groups showed growth tendencies equivalent to those in noncleft or LOP patients. Palatal variability was greater in neonatal cBCLP, but was reduced during the monitored period, approximating that for BCLP + B. Regions with the most notable palatal growth were located primarily at the premaxilla and at the anterior and partially posterior ends of the maxillary segments.

CONCLUSION

Early neonatal cheiloplasty had no negative effect on palatal growth in any direction. There was no reduction in the length or width of the palate during the first year of life, nor was there narrowing of the dentoalveolar arch. The formative effect of the operated lip on the anterior part of the palate was confirmed. This, in combination with the favorable growth, lead to closure of the alveolar cleft.

Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities

Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.

A Model of the Unmet Need for Cleft Lip and Palate Surgery in Low- and Middle-Income Countries

BACKGROUND

There is a significant unmet need for the cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) ; however, country-level estimates that can be used to inform local and international cleft care program strategies are lacking.

METHODS

Using data from Operation Smile surgical programs in twelve LMICs and country-level indicators from the World Health Organization and World Bank, we developed a model to estimate the proportion of individuals with CL/Ps older than respective surgery age targets for cleft lip and cleft palate surgery (1 and 2 years, respectively). After extrapolating this model to other LMICs with available indicator data, we combined these findings with estimates of CL/P prevalence among live births to estimate the total number of unrepaired CL/P cases in LMICs worldwide.

RESULTS

The models were constructed from a total of 887 cases of cleft palate and 576 cases of cleft lip across the twelve countries. From these, we estimated that there are 616,655 cases of unrepaired CL/P (95 % CI 564,893-678,503) in the 113 countries with available data for extrapolation. The rate of unrepaired CL/Ps ranged from 2.5 per 100,000 population in Romania to 28.5 per 100,000 in Cambodia, respectively (median rate 10.7 per 100,000 population).

CONCLUSIONS

Our model provides marked insight into the global surgical backlog due to cleft lip and palate. While the most populated LMICs have the largest number of unrepaired CL/Ps, low-income countries with relatively less healthcare infrastructure have exceptionally high rates (e.g., Cambodia, Afghanistan, and Nepal). These estimates can be used by local and international cleft care organizations to set program priorities, estimate resource requirements, and inform strategies to support cleft care.

Breastfeeding After Early Repair of Cleft Lip in Newborns With Cleft Lip or Cleft Lip and Palate in a Baby-Friendly Designated Hospital

BACKGROUND

Goals of treatment of orofacial cleft are to improve feeding, speech, hearing, and facial appearance. Early surgery brings faster healing, better cosmetic effect, and fewer complications. Breastfeeding rates after early surgery are unknown. Early repair of the cleft lip may influence breastfeeding rates. Research aim: The aim of this study was to evaluate breastfeeding after early repair of the cleft lip in a Baby-Friendly designated hospital. The rate of breastfeeding in newborns with cleft lip was compared to cleft lip and palate.

METHODS

This was a retrospective cohort study. The study group included infants with cleft lip and cleft lip and palate operated on in the first 2 weeks of life. Newborns and their mothers were supported by a team promoting breastfeeding.

RESULTS

One hundred four infants (70 boys and 34 girls) were included. Isolated cleft lip was present in 56 (53.8%) infants, and cleft lip and palate in 48 (46.2%). Forty-four (78.6%) of the infants with a cleft lip were breastfed, 3 (5.4%) received human milk via bottle or syringe, and 9 (16.0%) were formula fed. Three (6.2%) of the infants with a cleft lip and palate were breastfed, 31 (64.6%) received human milk via bottle or Haberman feeder, and 14 (29.2%) were formula fed.

CONCLUSION

The rate of breastfeeding in patients following early surgery of the cleft lip was high and comparable to the general population. The rate of breastfeeding in babies with cleft lip and palate after early repair of the cleft lip remained low.

Early Cleft Lip Repair Revisited: A Safe and Effective Approach Utilizing a Multidisciplinary Protocol

Background:

The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices.

Methods:

In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13–69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair.

Results:

Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair.

Conclusions:

We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.

Estimate of Unmet Need for Cleft Lip and/or Palate Surgery in India

IMPORTANCE

The unmet need for cleft lip and/or palate (CL/P) care in India is significant. However, estimates required for CL/P care program planning are lacking.

OBJECTIVE

To estimate the unmet need for CL/P surgery in India at the state level.

DESIGN, SETTING, AND PARTICIPANTS

To determine the proportion of individuals with CL/P who presented for care in India, data were used from patients who received care at Operation Smile programs in 12 low- and middle-income countries from June 1, 2013, to May 31, 2014. The resulting model describes the prevalent unmet need for cleft surgery in India by state and includes patients older than the surgery target ages of 1 and 2 years for cleft lip and cleft palate repair, respectively. Next, the total number of unrepaired CL/P cases in each state was estimated using state-level economic and health system indicators.

MAIN OUTCOMES AND MEASURES

Prevalent unmet need for CL/P repair.

RESULTS

In the 28 states with available data, an estimated 72 637 cases of unrepaired CL/P (uncertainty interval, 58 644-97 870 cases) were detected. The percentage of individuals with unrepaired CL/P who were older than the respective target ages ranged from 37.0% (95% CI, 30.6%-43.8%) in Goa to 65.8% (95% CI, 60.3%-70.9%) in Bihar (median, 57.9%; interquartile range, 52.6%-63.4%). The rate of unrepaired CL/Ps ranged from less than 3.5 per 100 000 population in Kerala and Goa to 10.9 per 100 000 population in Bihar (median rate, 5.9 [interquartile range, 4.6-7.3] per 100 000 population).

CONCLUSIONS AND RELEVANCE

An estimated 72 000 cases of unrepaired CL/P are found in India. Poor states with less health care infrastructure have exceptionally high rates (eg, Bihar). These estimates are useful for informing international and national CL/P care strategies, allocating resources, and advocating for individuals and families affected by CL/P more broadly.

LEVEL OF EVIDENCE

NA.

Treatment outcome after neonatal cleft lip repair in 5-year-old children with unilateral cleft lip and palate

INTRODUCTION

The aim of this study was to assess speech outcomes and dental arch relationship of 5-year-old Czech patients with unilateral cleft lip and palate (UCLP) who have undergone neonatal cleft lip repair and one-stage palatal closure.

METHODS AND MATERIALS

Twenty-three patients with UCLP, born between 2009 and 2010, were included in the study. Three universal speech parameters (hypernasality, articulation and speech intelligibility) have been devised for speech recordings evaluation. Outcomes of dental arch relationship were evaluated by applying the GOSLON Yardstick and subsequently compared with the GOSLON outcome of other cleft centers.

RESULTS

Moderate hypernasality was present in most cases, the mean value for articulation and speech intelligibility was 2.07 and 1.93, respectively. The Kappa values for inter-examiner agreement for all the three speech outcomes ranged from 0.786 to 0.808. Sixty-three percent of patients were scored GOSLON 1 and 2, 26% GOSLON 3, and 10% GOSLON 4. GOSLON mean score was 2.35. Interrater agreement was very good, represented by kappa value of 0.867.

CONCLUSION

The treatment protocol, involving neonatal cleft lip repair and one-stage palatal repair performed up to the first year of UCLP patient's life, has shown good speech outcomes and produced very good treatment results in regard to maxillary growth, comparable with other cleft centers.

Three-dimensional evaluation of facial morphology in pre-school cleft patients following neonatal cheiloplasty

PURPOSE

To evaluate the facial morphology of pre-school patients with various types of orofacial cleft after neonatal cheiloplasty in pre-school aged children; and to compare facial variability and mean shape with age-corresponding healthy controls.

MATERIALS AND METHODS

The sample included 40 patients with unilateral cleft lip (CL), 22 patients with unilateral cleft lip and palate (UCLP), and 10 patients with bilateral cleft lip and palate (BCLP). Patients were divided into two age categories, with a mean age of 3 years and 4.5 years, respectively. The group of healthy age-matched controls contained 60 individuals. Three-dimensional virtual facial models were evaluated using geometric morphometry and multivariate statistics methods.

RESULTS

Statistically significant differences were found between each of the cleft groups and the controls. Color-coded maps showed facial shape deviations, which were located mainly in the nasal area and philtrum in all groups examined, and also in the buccal region and the chin in patients with UCLP or BCLP. These differences became more apparent, but not significantly so, in the older age category.

CONCLUSION

Facial deviations typical of patients with clefts were observed in all of the patient groups examined. Although the analysis showed statistically significant differences in overall facial shape between patients and controls among all groups tested, the facial morphology in patients who have undergone only neonatal cheiloplasty (CL) is influenced to a small extent and may be considered satisfactory. More severe cleft types (UCLP, BCLP) together with palatoplasty, are reflected in more marked impairments in facial shape.