Trends of cleft surgeries and predictors of late primary surgery among children with cleft lip and palate at the University College Hospital, Nigeria: A retrospective cohort study

Disparities in Surgical Intervention in Pediatric Patients With Submucous Cleft Palate and Velopharyngeal Dysfunction

OBJECTIVE

To evaluate factors impacting access to and timing of surgery in patients with submucous cleft palate (SMCP) and velopharyngeal dysfunction (VPD).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single academic medical center.

METHODS

Patients with SMCP and VPD between 2004 and 2021 were identified. Variables included national and state area deprivation index (ADI) percentiles, child opportunity index (COI) categories, distance to care, and insurance status. χ2, Fisher's exact test, Wilcoxon rank-sum, Spearman rank correlation, t test, and linear regression (α = .05) were used to investigate the relationships between these variables and surgical status and timing.

RESULTS

A total of 168 patients were included, 94 surgical and 74 nonsurgical. Patients were predominantly white (160/168; 95.2%), Male (103/168; 61.3%), and non-Hispanic (153/168; 91.1%). There were no intergroup differences with respect to ADI, COI, insurance status, or distance from the hospital. Surgical patients were more likely to have overt SMCP (P = .03), earlier age at SMCP diagnosis (P = .02), and higher baseline Pittsburgh weighted speech score (PWSS) (P = <.001). In multivariable regression, younger age at surgery was found to be significantly associated with higher baseline PWSS (P = .001) and lower state ADI deciles (P = .03). Patients with private insurance had a lower baseline PWSS than those with public insurance (P = .04). Insurance status was not significantly associated with age at diagnosis (P = .79) or age at surgery (P = .08).

CONCLUSION

In this study, patients from less disadvantaged neighborhoods were found to have earlier surgical intervention, highlighting the importance of incorporating social determinants of health in the evaluation of VPD and SMCP patients to prevent treatment delays.

Barriers to timely primary cleft surgery in patients treated by an international cleft-focused NGO across 18 countries

INTRODUCTION

Cleft lip and/or palate (CL ± P) constitutes a significant portion of the global surgical burden. Patients in low- and middle-income countries (LMICs) face disproportionate barriers that result in delayed surgical repair, worse long-term outcomes, and increased morbidity.

OBJECTIVES

This study aimed to identify patient-reported barriers and demographic characteristics associated with delayed CL ± P surgery in LMICs where Operation Smile provides surgical care.

METHODS

A retrospective chart review of patients treated by Operation Smile between 2021 and 2024 was conducted. Variables included patient demographics, socioeconomic information, and self-reported barriers to care. Delayed repair was defined as greater than 9 months for cleft lip and 18 months for cleft palate. Data were analyzed using chi-squared and t-tests. Significant variables then underwent uni/multivariate logistic regression analysis.

RESULTS

Six hundred and sixty-eight patients were included, of which 339 (50.7%) underwent lip repair and 329 (49.3%) underwent palate repair. The most common patient-reported barrier was surgical cost (n = 561 and 84.0%). On multivariate regression, increased maternal age significantly increased odds of delayed surgery (OR = 1.03[1.003, 1.07] and p = 0.04) and maternal postsecondary education decreased odds among lip repair patients (OR = 0.22[0.05, 0.77] and p = 0.03). For palate repair, maternal age (OR = 1.05[1.01, 1.09] and p = 0.02) and surgical cost (OR = 2.85[1.42, 5.71] and p = 0.003) increased odds of delay, whereas paternal university-level education decreased odds (OR = 0.15[0.02, 0.81] and p = 0.04).

CONCLUSION

Surgical cost is a primary barrier to timely CL ± P repair among patients in LMICs. Higher education among parents is associated with lower odds of delay. These barriers can inform global surgical organization strategies to improve access for patients at risk of delay.

Nutrition and diet in children with orofacial clefts in Africa: a scoping review

BACKGROUND AND AIM

The burden of orofacial clefts (OFCs) has declined globally except in sub-Saharan Africa, with a great disease burden in North Africa. Children with OFCs have a high risk of malnutrition, and African countries have some of the highest malnutrition rates. This scoping review assessed the status of research on OFCs and nutrition and feeding among children living in African countries.

METHODS

We followed the Joanna Briggs Institute guidelines for conducting scoping reviews. We searched eleven databases for articles on malnutrition and feeding among children with OFCs living in African countries. No restriction was done by type of study or publication date. Books, book chapters, and reviews were excluded. Only publications in English language were included. We extracted information about the publication year, study design, setting, location, participants' age, data collection methods, international collaboration, and funding. We classified articles into studies assessing (1) the impact of nutritional deficiencies during pregnancy on OFCs, (2) the impact of OFCs on malnutrition, (3) feeding problems in children with OFCs, and (4) the impact of nutritional status on OFCs repair outcomes. We calculated frequencies and used bar charts and a map.

RESULTS

Out of 208 search results, 36 were duplicates, and 25 eventually fit the inclusion criteria, with 52% retrieved from Google Scholar. About 80% of the studies were from four countries: Nigeria, South Africa, Ghana, and Uganda; 72% were hospital-based and 52% were cross-sectional. The most frequent data collection method was clinical examination and questionnaires. Most studies focused on feeding problems in children with OFCs (44%) and the impact of OFCs on malnutrition (32%). International collaboration was observed in six studies, with one study showing South-South collaboration. Only two studies were funded.

CONCLUSIONS

There is a predominance of under-funded descriptive research not indexed by international databases. Minimal research has been directed to population-level OFC preventive programs in primary healthcare settings and assessing interventions supporting children with OFCs. A research agenda is needed to prioritize research needs and secure funds to support South-South collaboration to address the nutrition and feeding-related problems associated with OFCs.

Three-Dimensional Anthropometric Analysis of the Effect of Lip Reconstructive Surgery on Children with Cleft Lip and Palate at Three Different Times

OBJECTIVES

This investigation aimed to assess the optimal timing for lip repair in children with cleft lip and palate via 3D anthropometric analysis to evaluate their maxillofacial structures.

METHODS

The sample comprised 252 digitized dental models, divided into groups according to the following timing of lip repair: G1 (n = 50): 3 months; G2 (n = 50): 5 and 6 months; G3 (n = 26): 8 and 10 months. Models were evaluated at two-time points: T1: before lip repair; T2: at 5 years of age. Linear measurements, area, and Atack index were analyzed.

RESULTS

At T1, the intergroup analysis revealed that G1 had statistically significant lower means of I-C', I-C, C-C', and the sum of the segment areas compared to G2 (p = 0.0140, p = 0.0082, p = 0.0004, p < 0.0001, respectively). In addition, there was a statistically significant difference when comparing the cleft area between G2 and G3 (p = 0.0346). At T2, the intergroup analysis revealed that G1 presented a statistically significant mean I-C' compared to G3 (p = 0.0461). In the I-CC' length analysis, G1 and G3 showed higher means when compared to G2 (p = 0.0039). The I-T' measurement was statistically higher in G1 than in G2 (p = 0.0251). In the intergroup growth rate analysis, G1 and G2 showed statistically significant differences in the I-C' measurement compared to G3 (p = 0.0003). In the analysis of the Atack index, there was a statistically significant difference between G1 and the other sample sets (p < 0.0001).

CONCLUSION

Children who underwent surgery later showed better results in terms of the growth and development of the dental arches.

The Pattern and Profile of Orofacial Clefts in Somaliland: A Review of 40 Consecutive Cleft Lip and Palate Surgical Camps

INTRODUCTION

Somaliland is an autonomously run country that is not internationally recognized. As such, it has been largely excluded by global health development programs despite being the world's fourth poorest country. The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate from this nation.

METHODS

The authors performed a retrospective chart review on all patients who received cleft lip and palate repair by a single surgeon in 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland, between 2011 and 2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. Descriptive statistical analysis was performed.

RESULTS

A total of 767 patients (495 male, 64.5%) received 787 surgical procedures. The average age of primary surgery was 73.7 months. The most common chief complaint was left cleft lip with cleft palate (316, 41.2%). Males received primary surgery 19.2 months later than did females (73.7 and 54.6 mo, respectively, P <0.001). Patients residing in Hargeisa received their initial procedure an average of 17.8 months younger than those who lived elsewhere in Somaliland (62.9 and 80.7 mo, respectively, P =0.004).

CONCLUSIONS

In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural sex expectations. Patients from rural locations were especially vulnerable to receiving delayed treatment. Further efforts to decrease the burden of craniofacial deformities in Somaliland should be pursued in earnest.

Age at primary surgery among orofacial cleft individuals in Indonesia

OBJECTIVES

To observe the age at primary cleft surgery among charity organizations such as Smile Train in helping Indonesia manage patients with OFC.

MATERIALS AND METHODS

A retrospective analysis of medical records was conducted to identify patients with orofacial clefts who underwent primary surgery between 2001 and 2021. The age at the time of surgery was recorded for each patient. Descriptive statistics were used to analyse the data and determine the average age at primary surgery.

RESULTS

In the period between 2001 and 2021, a total of 34 239 individuals in Indonesia underwent primary lip surgery, while 16 768 individuals received primary palatal surgery, as recorded in the Smile Train database. Notably, a significant proportion of these surgeries were classified as delayed primary repairs. Approximately 65.3% of primary lip surgeries were performed beyond the recommended timeline of 6 months of age, indicating a delay in the surgical intervention. Similarly, 67% of primary palatal surgeries were also delayed, occurring after the recommended timeline of 18 months of life.

CONCLUSIONS

This study provides insights into the age at primary surgery among individuals with orofacial clefts in Indonesia. The findings highlight the need for timely intervention and the importance of considering individualized treatment plans based on the specific type of orofacial cleft. Further research is warranted to explore factors influencing the age at primary surgery and their impact on treatment outcomes and long-term functional outcomes in this population.

Travel Distance and Spanish-Speaking are Associated with Delays in the Treatment of Cleft Palate

OBJECTIVE

Delayed repair of cleft palate is associated with worse speech outcomes. Social determinants of health may influence the timing of surgery; however, there are no population health investigations to evaluate factors such as travel distance, language barriers, and payer. This study sought to identify factors that may interfere with timely cleft palate repair.

DESIGN

Retrospective cohort.

SETTING

National/multi-center.

PATIENTS/PARTICIPANTS

All cleft palate repairs within California were extracted from 2000-2021.

MAIN OUTCOMES MEASURES

The primary outcome was age at surgical repair, which was modeled with linear regression. Covariates included race, primary language, distance from patient home to hospital, socioeconomic status, primary payer, and managed care enrollment status.

RESULTS

11 260 patients underwent surgical repair of a cleft palate. Black race was associated with delayed repair (22 additional days, P = .004, 95% CI 67.00-37.7) along with Asian/Pacific-Islander race (11 additional days, P = .006, 95% CI 3.26-18.9) compared to white race. Spanish-speaking patients had significantly later cleft palate repairs by 19 days, (P < .001, 95% CI 10.8-27.7) compared with English-speaking. Further distances from the hospital were significantly associated with later cleft surgeries with out-of-state patients undergoing surgery 52 days later (P < .001, 95% CI 11.3-24.3). Managed care plans and Medi-Cal were significantly associated with earlier surgical repair compared with private insurance.

CONCLUSION

Black, Asian Pacific Islander, and Spanish-speaking patients and greater distance traveled to hospital were associated with delayed cleft palate repairs. These results underscore the importance of addressing structural and social barriers to care to improve outcomes and reduce health disparities for patients with cleft palate.

Barriers in Cleft Service Access in Sub-Saharan Africa: A Thematic Analysis of Practical Needs of Rural Families

OBJECTIVE

To explore the experiences and perceptions of barriers of parents and family members of patients with cleft lip and palate in accessing cleft services in remote northwest Nigeria.

DESIGN

Face-to-face semi-structured audio recorded interviews were used to obtained qualitative textual data. Thematic analysis using interpretative descriptive techniques was employed to understand the participants' lived experiences with barriers and accessibility to cleft services.

SETTING

Participants were from Sokoto, Kebbi and Zamfara states in remote northwest, Nigeria.

PARTICIPANTS

Consisted of 22 caregivers (17 parents and 5 extended family members) were purposively sampled between 2017 and 2020.

MAIN OUTCOME MEASURES

Barriers experienced while accessing cleft services were identified during thematic analysis.

RESULT

Over three quarter of the respondents had patients with both cleft lip and palate and without any previous family history (n = 20). About two-thirds of the participants (n = 15) were females. Most of the interviews were conducted before the surgeries (n = 15).

FIVE THEMES EMERGED

lack of information, financial difficulty, misrepresentation from health workers, multiple transportation and previous disappointment.

CONCLUSIONS

Areas of poor awareness, misinformation from primary health care workers, financial hurdles, multiple transportation logistics and others were identified. Aggressive broadcasting of information through radio, timely treatment and collaboration with influential religious leaders were emphasized. Support, grants and subsidies from government and voluntary agencies are encouraged to mitigate the huge out of pocket cost of cleft care in the region.