The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate

Psychological Screening Indicates That 1 in 4 Children With Cleft Lip and Palate Require Psychological Support

Children with cleft lip and/or palate (CL/P) often experience developmental issues, including language delay, learning difficulties, and attention issues. The aim of the study was to assess potential difficulties in children with CL/P and to determine the necessity of ongoing psychological support. Eighty-two children treated for CL/P, 29 5-year-olds and 53 10-year-olds, participated together with their parents in the study. The Strengths and Difficulties Questionnaire (SDQ) was used to assess difficulties and strengths. Proxy reports were used for the 5-year-olds, while self-reports and proxy reports were utilized for the 10-year-olds. Patients who were identified as requiring further support were offered psychological interventions. Parents of 5-year-olds and 10-year-olds with CL/P estimated significantly more difficulties compared with parents of children in the normal population. Thirty-nine percent of the parents estimated that their child had minor, moderate or severe difficulties. However, 10-year-olds with CL/P didn't perceive any difference in difficulties compared with preadolescents in the normal population. The 10-year-olds estimated significantly less emotional difficulties than children in the normal population. Nevertheless, 41% of the 10-year-olds reported that they overall had difficulties, either minor or severe, in one or more areas. There were significantly moderate correlations between parental and child reports on SDQ. According to the results of the standardized psychological screenings, 25.6% of children with CL/P required additional psychological support. One in 4 children with CL/P needs psychological support. Standardized psychological interview-based follow-ups for patients with CL/P can contribute to more information regarding the patient's needs rather than only using a questionnaire.

Administration of Porphyromonas gingivalis in pregnant mice enhances glycolysis and histone lactylation/ADAM17 leading to cleft palate in offspring

Periodontal disease is a risk factor for many systemic diseases such as Alzheimer's disease and adverse pregnancy outcomes. Cleft palate (CP), the most common congenital craniofacial defect, has a multifaceted etiology influenced by complex genetic and environmental risk factors such as maternal bacterial or virus infection. A prior case-control study revealed a surprisingly strong association between maternal periodontal disease and CP in offspring. However, the precise relationship remains unclear. In this study, the relationship between maternal oral pathogen and CP in offspring was studied by sonicated P. gingivalis injected intravenously and orally into pregnant mice. We investigated an obvious increasing CP (12.5%) in sonicated P. gingivalis group which had inhibited osteogenesis in mesenchyme and blocked efferocytosis in epithelium. Then glycolysis and H4K12 lactylation (H4K12la) were detected to elevate in both mouse embryonic palatal mesenchyme (MEPM) cells and macrophages under P. gingivalis exposure which further promoted the transcription of metallopeptidase domain17 (ADAM17), subsequently mediated the shedding of transforming growth factor-beta receptor 1 (TGFBR1) in MEPM cells and mer tyrosine kinase (MerTK) in macrophages and resulted in the suppression of efferocytosis and osteogenesis in palate, eventually caused abnormalities in palate fusion and ossification. The abnormal efferocytosis also led to a predominance of M1 macrophages, which indirectly inhibited palatal osteogenesis via extracellular vesicles. Furthermore, pharmacological ADAM17 inhibition could ameliorate the abnormality of P. gingivalis-induced abnormal palate development. Therefore, our study extends the knowledge of how maternal oral pathogen affects fetal palate development and provides a novel perspective to understand the pathogenesis of CP.

CleftED: A National Collaborative Study of Undergraduate Education and Exposure to Cleft lip and Palate Within the United Kingdom

IntroductionCleft Lip and/or Palate (CLP) are the most common congenital orofacial anomalies. Those involved in CLP care may extend beyond the core members of the Cleft multidisciplinary team (MDT) with a variety of medical healthcare professionals destined to contribute to the management of CLP patients at some point during their respective careers. Therefore, it seems essential that a basic understanding of CLP, CLP-associated problems, and potential avenues for direct or indirect involvement in CLP care be introduced at undergraduate level.AimsTo investigate penultimate and final year undergraduate medical student CLP knowledge and exposure obtained whilst at medical school.MethodologyAn online questionnaire was distributed to penultimate and final year medical students throughout the UK.ResultsA total of 3102 responses were received from 35 medical schools. 44.3% (n  =  1374) of respondents had no exposure to CLP teaching up until their current year of education. 61.3% (n  =  1903) of respondents had never been involved in the care of a CLP patient. 53.6% (n  =  1662) of respondents were not confident in their current knowledge of CLP. 78.5% (n  =  2257) of respondents indicated a desire to be involved in the care of CLP patients in their future career.ConclusionMore than half of the medical student survey respondents were not confident in their current knowledge of CLP and had limited involvement in CLP care. This may translate to a delay in diagnosis when students qualify. Improving CLP education and exposure during undergraduate training can help achieve national CLP standards for early diagnosis.

Glycolysis regulates palatal mesenchyme proliferation through Pten-Glut1 axis via Pten classical and non-classical pathways

Abnormal embryonic development leads to the formation of cleft palate (CP) which is difficult to be detected by genetic screening and needs sequent treatment from infants to adults. There are no interceptive treatment about CP until now. Germline deletion of phosphatase and tensin homolog (Pten) was related to embryonic malformation and regulated tumor cell proliferation through glycolysis. However, the role of Pten in CP and the relationship between CP, Pten, and glycolysis are unknown. In our research, we constructed Pten knockdown models in vitro and in vivo. Our results provided preliminary evidence that blocking Pten by its inhibitor such as VO-OHpic might be an effective interceptive treatment in early period of palate development when pregnant mother expose in harmful environment during the early period of palate development to reducing CP occurring which was related with the crosstalk between Pten, and glycolysis in the process.

Assessment of level of knowledge and satisfaction of website about cleft lip and palate

PURPOSE

To promote orientation about cleft lip and palate and to verify knowledge and satisfaction of an orientation program through a website developed for students and health professionals.

METHODS

This is a cross-sectional study, 13 healthcare professionals and 81 students from the areas of nursing, speech-language pathologist, medicine, nutrition, dentistry, and psychology participated. The research consisted of three stages: filling out a pre-program questionnaire, accessing the website (http://fissuralabiopalatina.unb.br/) developed by the researchers and filling out a post-program questionnaire. For the statistical analyses McNemar's, Chi-square and Fisher's Exact Tests were used.

RESULTS

The majority of students were enrolled in the eighth semester of graduation or above, with little or no prior contact with the CLP. After accessing the website, there was an increase in knowledge for eight questions (p≤0.05). 70.2% consider their satisfaction when accessing the website to be excellent, 24.5% very good and 5.3% good. 44.7% of participants praised the website's design and layout, accessible language and informative content.

CONCLUSION

It was possible to promote the guidelines about cleft lip and palate on the website, observing was an expansion of the topic for students and health professionals.

Tooth Anomalies in Patients With Nonsyndromic Orofacial Cleft: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the frequency of tooth anomalies (TA) in the deciduous and permanent dentition of patients with nonsyndromic orofacial clefts (NSOC), both inside and outside the cleft area.

METHODS

The following databases were searched for the relevant literature: Cochrane, OVID, SciELO, Embase, Livivo, PubMed, Scopus, and Web of Science. The risk of bias was analyzed using the Joanna Briggs Institute. Fixed and random-effects meta-analysis was performed comparing the presence and absence of NSOC subtypes. The certainty of evidence was evaluated using the GRADE approach.

RESULTS

Out of 1939 articles identified, after applying the inclusion and exclusion criteria, a total of 75 articles were included (46 cohort and 29 case-control), including 27,703 patients (16,450 with NSOC and 11,253 healthy controls) from 34 countries. The meta-analyses revealed higher odds for tooth agenesis (ORNSOC: 3.72; p = 0.001) and macrodontia (ORNSOC: 8.04; p = 0.04) across the different cleft subtypes outside the cleft area compared with the control group in the permanent dentition, whereas the frequency of root dilaceration was significantly lower in nonsyndromic cleft lip only (NSCLO) (ORNSCLO: 0.38; p < 0.0001) and in nonsyndromic cleft lip and palate (NSCLP) (ORNSCLP: 0.44; 95% p < 0.0001). The results also demonstrated a higher risk of tooth agenesis (ORNSOC: 16.49; p < 0.0001), microdontia (ORNSOC: 17.14; p < 0.0001), macrodontia (ORNSOC: 10.41; p = 0.02), supernumerary tooth (ORNSOC: 10.03; p < 0.0001), and enamel hypoplasia (ORNSOC: 5.62; p < 0.0001) in the permanent dentition inside the cleft area of patients with NSOC. However, for the deciduous dentition, outside the cleft area, microdontia was the only TA significantly more frequent in patients with NSOC (ORNSOC: 6.24; p = 0.006) and nonsyndromic cleft palate only (NSCPO) (ORNSCPO: 8.45; p = 0.02) compared with the control group. TA associations varied across populations. In Europe, no significant associations were found for NSOC, while in Asia, strong associations were observed for NSCLP and NSCL ± P (ORNSCLP and NSCL±P: 139.19; p < 0.0001). In South America, significant associations were identified for NSCLP (ORNSCLP: 2.16; p < 0.0001), NSCL ± P (ORNSCL±P: 2.48; p < 0.0001), and NSOC (ORNSOC: 2.72; p < 0.0001). In North America, tooth agenesis was more frequent in NSCL ± P (ORNSCL±P: 4.75; p < 0.0001), though no significant associations were found for NSCLP or NSOC. In the cleft area, significant associations were observed in European populations for NSOC, including increased frequencies of tooth agenesis (ORNSOC: 19.57; p = 0.003) and supernumerary teeth (ORNSOC: 9.77; p < 0.0001). Asian populations showed similar patterns (ORNSOC: 19.23; p = 0.002), while no significant associations were noted in South America due to limited data. Root dilaceration remained less frequent in NSCLO (ORNSCLO: 0.38; p < 0.0001) and NSCLP (ORNSCLP: 0.44; p < 0.0001), with no associations identified for microdontia, taurodontism, supernumerary tooth, impacted tooth, or transposition.

CONCLUSION

The results confirm a higher frequency of TA in the permanent dentition of patients with NSOC compared to controls, regardless of cleft subtype. However, significant differences were observed depending on whether the TA occurred inside or outside the cleft area. Although only a limited number of studies were included, microdontia was the only TA significantly more prevalent in the cleft area of patients with NSOC in the deciduous dentition. Variations in the frequency of TA across populations highlight the complex interplay of genetic, environmental, and methodological factors influencing these associations. Despite these findings, the quality of the existing evidence is moderate, with limitations stemming from small sample sizes, methodological variations, and study heterogeneity. These results emphasize the importance of tailored dental management and early intervention strategies for individuals with different cleft subtypes to effectively address and mitigate the impact of these tooth anomalies on oral health and development.

Distribution of Specialties Providing Surgical Management of Cleft-Related Speech Disorders in Children 3 years of Age and Older: 2004 to 2021

Given the overlap in specialties performing secondary correction of velopharyngeal incompetence (VPI), the present study investigated the specialty distribution for surgical providers of cleft care from 2004 to 2021. Data were obtained from 45 hospitals from 2004 to 2021 through the Pediatric Health Information System database. Cases of secondary surgical management of VPI were retrieved, identifying the year of surgery and specialty of the providing surgeon. A total of 7090 procedures were included in this study, of which 36.0% were secondary palatoplasty/lengthening, 34.1% were sphincter pharyngoplasty, and 29.8% were pharyngeal flap. Secondary management of VPI was performed by plastic surgeons (67%), otolaryngologists (31%), and oral and maxillofacial surgeons (OMFS, 12%). Palatal revision and/or lengthening procedures were the most common secondary procedure performed by plastic surgeons (42%) and OMFS (64%), whereas sphincter pharyngoplasty was the most common procedure performed by otolaryngologists (55%; P <0.001). The proportion of sphincter pharyngoplasty performed by plastic surgeons significantly decreased from 2017-2021 ( P <0.05). Plastic surgeons performed most procedures for secondary management of VPI from 2004 to 2021, followed by otolaryngologists and OMFS. The type of procedure selected for secondary management of VPI differed significantly between the provider's specialty, with otolaryngologists more likely to perform sphincter pharyngoplasty.

Exploring the Regulatory Interaction of Differentially Expressed Proteins in Cleft Palate Induced by Retinoic Acid

OBJECTIVE

This study aimed to identify novel proteins involved in retinoic acid (RA)-induced embryonic cleft palate development.

METHODS

The palate tissues of the control and RA-treated E14.5 were dissected and subjected to iTRAQ-based proteomic analysis.

RESULTS

Differential expression analysis identified 196 significantly upregulated and 149 downregulated considerably proteins in RA-induced palate tissues. Comprehensive Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis revealed the significant involvement of cytoplasmic translation, ribosome biogenesis, glycolysis/gluconeogenesis, and glutathione metabolism pathways in cleft palate pathogenesis triggered by RA. In particular, ribosome-related pathways were highly enriched, while glycolysis was disrupted. Protein-protein interaction analysis, facilitated by the STRING database, revealed a tightly interconnected network of differentially expressed proteins. Further analysis using the cytoHubba plugin in Cytoscape identified ten hub proteins, including Eif4a1, Gapdh, Eno1, Imp3, Rps20, Rps27a, Eef2, Hsp90ab1, Rpl19, and Rps16, indicating their potential roles in RA-induced cleft palate development, and thus positioning them as potential biomarkers for cleft palate.

CONCLUSION

These findings provide valuable insights into the proteomic changes associated with RA-induced cleft palate and shed light on key pathways and proteins that can contribute significantly to the pathogenesis of this congenital condition.

Oral and Maxillofacial Manifestations of Kallmann Syndrome: A Systematic Analysis of the Literature

AIMS

Kallmann syndrome (KS) is a rare genetic disorder characterized by congenital hypogonadotropic hypogonadism and varied clinical features. Despite its recognition, the oral and maxillofacial manifestations remain poorly understood. This study synthesized clinical aspects and management of KS-related oral and maxillofacial alterations.

METHODS

Searches were conducted in the PubMed, Web of Science, Scopus, Embase, and LILACS databases, supplemented by manual scrutiny and gray literature. Case series and/or case reports were included. The Joanna Briggs Institute tool was employed for critical appraisal of the studies.

RESULTS

A total of 46 studies comprising 108 cases were included. The mean age of individuals was 19.8 (±12.6) years, and there was a marked predominance of males (79.3%). Cleft lip/palate (32.7%) was the predominant oral condition, followed by high-arched palate (21.7%), and dental agenesis (19.8%). Oral treatment consisted of corrective surgery of the cleft lip and/or palate (n = 9), myoplasty (n = 1), and tooth extraction/orthodontic treatment (n = 1). Hyposmia/anosmia (71.3%) was the most frequently reported manifestation.

CONCLUSION

Early diagnosis and interdisciplinary collaboration are essential for addressing the complex nature of KS-related oral and maxillofacial alterations and improving patient outcomes. The scarcity of data on oral treatment underscores the need for additional research and clinical attention in this field.

The IRF6 rs2013162 and MTHFR A1298C rs1801131 Gene Polymorphisms Related to non-Syndromic Cleft lip and Palate among Deutero-Malay in Indonesia

OBJECTIVE

This study aimed to identify risk factors for NSCLP by analyzing polymorphisms in IRF6 rs2013162 and MTHFR A1298C rs1801131 in the Deutero Malay Population in Indonesia.

SETTING

DNA isolation from venous blood samples was done followed by PCR and PCR-RFLPs method.

PATIENTS/PARTICIPANTS

115 NSCLP subjects and 120 healthy control subjects.

MAIN OUTCOME MEASURE(S)

The odds ratio (OR) determined to evaluate the risk factors is the main outcome measure.

MATERIAL AND METHODS

The study is a case-control design using samples from the venous blood of 115 NSCLP subjects and 120 healthy control subjects. After DNA was extracted, the PCR-RFLPs method was performed using the DdeI restriction enzyme on 100 blood samples of the IRF6 rs2013162 group and Mboll restriction enzyme on 135 blood samples of the MTHFR A1298C rs1801131 group. The Chi-Square test was used with the Exact Fisher alternatives, depending on the expected count value.

RESULTS

The results showed that the T mutant allele (OR = 4.125, P < .05) and GT genotype (OR = 21.00, P < .05) of IRF6 rs2013162 and the C mutant allele (OR = 3.781, P < .05), AC genotype (OR = 5, P < .05) and CC genotype (OR = 9,681, P < .05) of the MTHFR A1298C is associated to a greater risk of NSCLP.

CONCLUSIONS

IRF6 rs2013162 and MTHFR A1298C rs1801131 gene polymorphisms are strongly associated with NSCLP among the Deutero Malay population in the Indonesian population.

Epidemiology of cleft lip and palate in Bhutan, 2015-2022

BACKGROUND

The epidemiology of cleft lip (CL) and cleft palate (CLP) has not previously been described in the context of the Bhutan and Bhutanese populations. Using National Birth Defects Surveillance Data and other vital statistics, we present the comprehensive epidemiology of the cleft lip and palate in Bhutan.

METHODOLOGY

The National Birth Defects Surveillance Data Registry from 2015 to 2022 is reviewed retrospectively, covering 8 years of birth defect surveillance in the country from records maintained with three referral hospitals in the country. The baseline prevalence and incidence of cleft lip and palate have been presented over the years. The incidence of cleft lip and palate was defined as the number of cases per 1000 live births. We used Poisson's regression to compute the incidence of cleft lip and palate. Pearson chi-square tests (χ2) were used to examine the associations of maternal and child characteristics with cleft lip and palate.

RESULTS

A total of 1401 newborns with various birth defects were born among the 89,078 live births from 2015 to 2022 in Bhutan. Of these, 122 (8.7%) constituted orofacial clefts. The prevalence of orofacial clefts tended to increase, with a period prevalence of 1.37 per 1000 live births. There were more cases in males (72) than in females (50). The incidence rate ratio ranged from 1.2 to 2.0 compared with the 2015 baseline year, indicating increased rates over time.

CONCLUSION

Orofacial clefts constituted 8.7% of total birth defects and 1.37 per 1000 live births over the years. The increasing prevalence trends and incidence rate ratios over the years underscore the importance of ongoing surveillance and interventions to address the burden of orofacial clefts in Bhutan.

CLINICAL TRIAL NUMBER

Not applicable.

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.

The Kumagai Method: Feeding Techniques Using the Pigeon Baby Cleft Palate Bottle

BACKGROUND/OBJECTIVES

This study aimed to identify the P-bottle feeding techniques systematically organized by Ms. Kumagai, an expert in nursing care for children with a cleft lip and/or palate (CLP), which were developed as she gained expertise in feeding affected children.

METHODS

We recruited three nurses who had mastered the Kumagai method for feeding with a P-bottle. Through analysis of participants' voices and videos during interviews, we focused on aspects such as dealing with a closed mouth, inserting the nipple in cases of unilateral and bilateral CLP, dealing with the child's movements after insertion, and key considerations when squeezing the bottle.

RESULTS

The interview analyses revealed numerous techniques used by nurses to manage the difficulties encountered while feeding children, ensuring successful provision of nourishment. Specifically, the nurses employed techniques such as placing the nipple along the midline of the child's tongue and varying the application of force on the nipple depending on the cleft type. The nurses reported that the objectives of these techniques were to prevent ulcer formation and encourage the use of the tongue, simulating original feeding movements.

CONCLUSIONS

We explored feeding techniques and the management of associated challenges. Our results suggest that the "Kumagai Method" could be valuable in improving feeding practices.

Proteomic analysis illustrates the potential involvement of motor proteins in cleft palate development

Cleft palate (CP) is a congenital condition characterized by a complex etiology and limited diagnostic and therapeutic options. In this study, we delved into the molecular mechanisms associated with retinoic acid (RA)-induced CP in Kun Ming mice. Proteomic analysis of control and RA-induced CP samples at embryonic day 15.5 revealed 25 upregulated and 19 downregulated proteins. Further analysis identified these differentially expressed proteins (DEPs) as being involved in extracellular matrix organization, actin cytoskeleton, and myosin complex. Moreover, these DEPs were found to be enriched in pathways related to motor protein activity and extracellular matrix-receptor interaction. Protein-protein interaction network analysis identified 10 hub proteins, including motor proteins and ECM-related proteins, which exhibited higher expression levels in CP compared to control tissues. These findings provide insights into the molecular mechanisms underlying CP and highlight potential targets for diagnostic and therapeutic purposes.

Hospitalization Trends for Airway Infections and In-Hospital Complications in Cleft Lip and Palate

Importance

Cleft lip or palate is a prevalent birth defect, occurring in approximately 1 to 2 per 1000 newborns and often necessitating numerous hospitalizations. Specific rates of hospitalization and complication are underexplored.

Objective

To assess the rates of airway infection-associated hospitalization, overall hospital admissions, in-hospital complications, and mortality among children with a cleft lip or palate.

Design, Setting, and Participants

This nationwide, population-based cohort study used in-hospital claims data from the Federal Statistical Office in Switzerland between 2012 and 2021. Participants included newborns with complete birth records born in a Swiss hospital. Data were analyzed from March to November 2023.

Exposure

Prevalent diagnosis of a cleft lip or palate at birth.

Main Outcomes and Measures

Outcomes of interest were monthly hospitalization rates for airway infections and any cause during the first 2 years of life in newborns with cleft lip or palate. In-hospital outcomes and mortality outcomes were also assessed, stratified by age and modality of surgical intervention.

Results

Of 857 806 newborns included, 1197 (0.1%) had a cleft lip and/or palate, including 170 (14.2%) with a cleft lip only, 493 (41.2%) with a cleft palate only, and 534 (44.6%) with cleft lip and palate. Newborns with cleft lip or palate were more likely to be male (55.8% vs 51.4%), with lower birth weight (mean [SD] weight, 3135.6 [650.8] g vs 3284.7 [560.7] g) and height (mean [SD] height, 48.6 [3.8] cm vs 49.3 [3.2] cm). During the 2-year follow-up, children with a cleft lip or palate showed higher incidence rate ratios (IRRs) for hospitalizations due to airway infections (IRR, 2.33 [95% CI, 1.98-2.73]) and for any reason (IRR, 3.72 [95% CI, 3.49-3.97]) compared with controls. Additionally, children with cleft lip or palate had a substantial increase in odds of mortality (odds ratio [OR], 17.97 [95% CI, 11.84-27.29]) and various complications, including the need for intubation (OR, 2.37 [95% CI, 1.95-2.87]), extracorporeal membrane oxygenation (OR, 2.89 [95% CI, 1.81-4.63]), cardiopulmonary resuscitation (OR, 3.25 [95% CI, 2.21-4.78]), and respiratory support (OR, 1.94 [95% CI, 1.64-2.29]).

Conclusions and Relevance

In this nationwide cohort study, the presence of cleft lip or palate was associated with increased hospitalization rates for respiratory infections and other causes, as well as poorer in-hospital outcomes and greater resource use.

Genetic Testing in Craniofacial Care: Development of Algorithms for Testing Patients with Orofacial Clefting, Branchial Arch Anomalies, and Craniosynostosis

OBJECTIVE

To develop consensus-based algorithms for genetic testing in patients with common craniofacial conditions.

DESIGN

An online collaborative consisting of online meetings, independent work, and feedback across groups. Setting/Participants: A collaborative of genetics and pediatrics providers from three regional craniofacial centers (four institutions).

METHODS

Collaborative participants agreed upon a shared initial framework, developed algorithms independently, and presented/tested the algorithms with a national audience. Algorithms were modified based on consensus feedback.

RESULTS

The collaborative group developed final algorithms for genetic testing in patients with orofacial cleft, branchial arch conditions, and craniosynostosis.

CONCLUSIONS

Timely and accurate diagnosis of genetic conditions can support medical management recommendations that result in safer surgical interventions. Algorithms can help guide best-practices for testing, particularly in institutions without easy access to genetics providers.

Better Guidelines and Policies: AAP's Partnership for Policy Implementation

OBJECTIVES

In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs.

METHODS

In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily.

RESULTS

Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers.

CONCLUSIONS

With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.

Reducing delayed detection of isolated cleft palate-related deformity: a call for routine intraoral examination of newborns

OBJECTIVE

To provide healthcare professional-friendly practical recommendations for early detection of cleft palate-related deformities in newborns and offer an overview of managing these high-prevalent congenital abnormalities.

SOURCE OF DATA

PubMed, SciELO, Lilacs, Cochrane, ScienceDirect, and Scopus databases were reviewed for cleft- and diagnosis-related studies.

SUMMARY OF THE FINDINGS

Unfortunately, the global prevalence of delayed detection of cleft palate-related deformities remains unacceptably high, with over a quarter of cleft palates missed at birth. This delayed identification causes physical and psychological distress for patients and families, including feeding challenges and weight faltering. To improve cleft management, it is essential to adopt routine detailed, in-depth intraoral examination immediately after birth. It is recommended not only to finger-assisted palpate the intraoral structures but also to visually inspect the oral cavity from gingiva to uvula using a wooden tongue depressor and light-assisted examination. With timely diagnosis and referral to specialized care, pediatricians, nurses, speech therapists, and plastic surgeons provide life-changing treatments, including health care maintenance, anticipatory guidance, feeding support, primary surgical reconstruction, and age- and condition-specific protocols.

CONCLUSIONS

Encouraging neonatologists and pediatricians, who are the first to examine newborns, to actively investigate the intraoral region for cleft palate-related deformities is instrumental in optimizing therapeutic approaches and prioritizing age-phases in treatment. Their crucial role in early detection and referral can lead to transformative outcomes, impacting not only the future of the newborns by facilitating functional integration into society but also yielding positive effects on families and the health system.

Prenatal Diagnosis and Pregnancy Outcomes of Fetuses With Orofacial Cleft: A Retrospective Cohort Study in Two Centres in Hong Kong

OBJECTIVE

To evaluate the local incidence of orofacial cleft (OFC) encountered in fetal morphology scan and prenatal diagnosis, genetic etiology of fetuses with or without other structural abnormalities, and their pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

Two maternal fetal medicine units, tertiary hospitals, Hong Kong.

PARTICIPANTS

All pregnant women with antenatal diagnosis of fetal OFC between January 2016 and December 2020 (N = 66).

RESULTS

OFC has an incidence of 0.13% among pregnancies in Hong Kong and 28.8% (19/66) were syndromic cleft that exhibited other fetal structural anomalies. There were 55 cases (84.6%) who opted for invasive prenatal diagnostic testing. Genetic defects were identified in 25.8% (17/66) of this cohort, including 14 pathogenic variants. The detection rate in the syndromic cases is 68.4% (13/19) which was significantly higher than 8.5% (4/47) among non-syndromic cases. Aneuploidies would be the most common cause, accounting for 9.1% (6/66). Chromosomal microarray analysis (CMA) provided an incremental diagnostic yield of 6.1% compared to conventional karyotyping. A total of 29 live births including 3 cases of a variant of uncertain significance and 26 cases without genetic abnormalities detected have continued pregnancy to birth. There were 87.5% (21/24) without detectable pathogenic genetic abnormality reported good long-term outcomes. The chance of OFC fetuses having a good long-term outcome was significantly higher if no genomic variant was detected (P < .001).

CONCLUSIONS

Invasive prenatal tests with CMA should be offered to pregnancies with OFC regardless of the type. It has provided incremental diagnostic yield over conventional karyotyping and helped in prenatal and genetic counseling. A negative result in non-syndromic OFC favors couples to keep the pregnancy.

Cleft Lip and/or Palate Repair in Children With Hypopituitarism: Analysis of the Kids' Inpatient Database

OBJECTIVE

Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP).

DESIGN

A retrospective cross-sectional analysis.

SETTING

The 1997 to 2019 Kids' Inpatient Databases (KID).

PATIENTS

Children 3 years old and younger who underwent CL/P repair.

MAIN OUTCOME MEASURE(S)

Complications and mortality.

RESULTS

A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P < .001) and higher rates of complications and mortality (12.8% vs 2.9%, P < .001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P < .001).

CONCLUSIONS

CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality.

MicroRNAs in Small Extracellular Vesicles from Amniotic Fluid and Maternal Plasma Associated with Fetal Palate Development in Mice

Cleft palate (CP) is a common congenital birth defect. Cellular and morphological processes change dynamically during palatogenesis, and any disturbance in this process could result in CP. However, the molecular mechanisms steering this fundamental phase remain unclear. One study suggesting a role for miRNAs in palate development via maternal small extracellular vesicles (SEVs) drew our attention to their potential involvement in palatogenesis. In this study, we used an in vitro model to determine how SEVs derived from amniotic fluid (ASVs) and maternal plasma (MSVs) influence the biological behaviors of mouse embryonic palatal mesenchyme (MEPM) cells and medial edge epithelial (MEE) cells; we also compared time-dependent differential expression (DE) miRNAs in ASVs and MSVs with the DE mRNAs in palate tissue from E13.5 to E15.5 to study the dynamic co-regulation of miRNAs and mRNAs during palatogenesis in vivo. Our results demonstrate that some pivotal biological activities, such as MEPM proliferation, migration, osteogenesis, and MEE apoptosis, might be directed, in part, by stage-specific MSVs and ASVs. We further identified interconnected networks and key miRNAs such as miR-744-5p, miR-323-5p, and miR-3102-5p, offering a roadmap for mechanistic investigations and the identification of early CP biomarkers.

Impact of Syndromes on Sleep-Disordered Breathing in Children After Cleft Palate Repair

OBJECTIVE

Prior research suggests that children with cleft palate (CP) are at increased risk of obstructive sleep-disordered breathing (SDB). However, few studies differentiate the effects of CP repair on SDB based on syndrome status. The goal of this study was to evaluate differences in SDB after palatoplasty among children with nonsyndromic CP, syndromic CP, and isolated Robin sequence (RS).

DESIGN

Retrospective chart review.

SETTING

Tertiary academic children's hospital.

PATIENTS/PARTICIPANTS

A total of 145 children who underwent primary CP repair from 2014 to 2021.

MAIN OUTCOME MEASURE

Post-palatoplasty SDB is defined as parent-reported symptoms and/or evidence of obstructive sleep apnea (OSA).

RESULTS

Median age at palatoplasty was 11.1 [IQR 10.2-13.6] months. Most patients (61.4%) had nonsyndromic CP, 26.9% had a syndrome, and 11.7% had RS. Children with syndromic CP and RS had more post-palatoplasty SDB symptoms (56.4% vs 58.8% vs 30.3%, P = .006) and higher rates of OSA (25.6% vs 29.4% vs 5.6%, P = .001) compared to children with nonsyndromic CP after palatoplasty. Children with syndromic CP and RS had nearly 3 to 4 higher odds of post-palatoplasty SDB than children with nonsyndromic CP (adjusted odds ratio [aOR] 2.88, 95% CI 1.29-6.47, P = .010; aOR 3.73, 95% CI 1.19-11.70, P = .024).

CONCLUSION

This study showed that children with CP experience higher rates of SDB after palatoplasty than the general pediatric population. Within the cohort, children with syndromic CP and isolated RS were more likely to have obstructive sleep disorders than nonsyndromic children after palatoplasty. Clinicians should counsel caregivers accordingly and closely monitor these groups for SDB after palate repair.

Prenatal Consultation Outcomes for Infants With Cleft Lip With and Without Cleft Palate

To assess the clinical impacts of prenatal consultation with a multidisciplinary cleft team on infants with cleft lip with or without cleft palate (CL ± P).

Retrospective cases series.

Tertiary pediatric hospital.

Infants with CL ± P whose mothers received prenatal consultation with a pediatric otolaryngology team from June 2005 to December 2019 were identified. A random sample of infants with CL ± P without prenatal consultation from June 2005 to December 2019 was also identified.

The primary outcomes were the length of hospitalization during the first 12 weeks of life, timing of surgical repair, length of postsurgical hospitalization, and number of unplanned clinic visits and phone calls for feeding evaluation.

Time to cleft lip repair differed significantly between the 2 groups with repair performed at 13.4 (±0.9) weeks for the prenatal consultation group (n = 73) and 15.3 (±2.1) weeks for the control group (n = 80), (P < .05). If hospitalization was required for feeding difficulties during the first 12 weeks of life, length of stay was 4.9 (± 1.7) days for infants with prenatal consultation and 11.5 (± 7.2) days for control infants (P < .05). Unplanned clinic visits with a speech-language pathologist (SLP) for feeding difficulties were needed for 2.7% of prenatal consultation infants and 11.3% of control infants (P < .05).

Prenatal consultation regarding CL ± P resulted in infants with decreased duration of early hospitalizations, earlier cleft lip repair, and decreased engagement with the SLP feeding clinic for feeding difficulties when compared with infants without prenatal consultation.

Associated medical conditions among 10-year-old children with oral clefts - a retrospective review across three cleft centres: Part 2

Introduction In many cases, children with oral clefts present with accompanying medical conditions. These associated conditions can add complexity to the patient's dental management, both in terms of their treatment need and risk. Recognition and careful consideration of associated medical conditions is therefore crucial in providing safe and effective care for these patients.Aim This paper is the second in a two-part three-centre series. It investigates the prevalence of medical conditions affecting cleft lip and/or palate patients attending three cleft units within the UK.Method Retrospective review was undertaken within three cleft units: South Wales (SW), Cleft NET East (CNE) and West Midlands (WM). This was completed via assessment of the 10-year audit record appointment clinical notes for the year 2016/2017.Results In total, 144 cases were reviewed (SW = 42; CNE = 52; WM = 50). Of these, 38.9% of patients (n = 56) had associated medical conditions recorded.Discussion The review highlights the variety and impact of medical conditions affecting UK cleft patients providing insight into the consequent complexity of their dental care.Conclusion An awareness of cleft lip and/or palate patients' associated medical conditions is important for all health care professionals involved in their care. Indeed, understanding of the patient's medical needs by multidisciplinary cleft teams is essential for effective planning and completion of holistic care. Involvement of specialists in paediatric dentistry sharing care with general dental practitioners is vital in providing appropriate oral health care and preventive support.

Cleft Palate in a Newborn With Trisomy 21: A Case Report

Trisomy 21, or Down syndrome (DS), is neonates' most common chromosomal abnormality. In addition, children born with DS have an increased risk of congenital anomalies such as congenital heart defects, gastrointestinal abnormalities, and, rarely, cleft palate. Cleft lip and palate are among the most common congenital anomalies associated with many congenital syndromes; however, Trisomy 21 is the least common congenital anomaly associated with orofacial clefts. We present a case of cleft palate, duodenal stenosis, persistent pulmonary hypertension of the newborn, patent ductus arteriosus, and atrial septal defect in a newborn with classical clinical features of Down syndrome. This report discusses the uncommon presentation of trisomy 21 and concomitant cleft palate in a neonate, including its recognition and treatment, as no standard of care treatment exists.

Current Concepts and Challenges in the Treatment of Cleft Lip and Palate Patients-A Comprehensive Review

Cleft lip and cleft palate has one of the highest incidences in the malformations of the oral cavity, that varies between populations. The background underlying the issue of cleft lip and palate is multifactorial and greatly depends on the genetic factors and environmental factors. The aim of this nonsystematic narrative review is to present the cleft palate and or lip pediatric population as target for interdisciplinary treatment. The purpose of this narrative review is to sum up the modern knowledge on the treatment of patients with clefts, as well as to highlight the importance of the great need for cooperation between different dental specialists along with medical professionals such as oral surgeons, prosthodontists, orthodontists along with medical professions such as pediatricians, speech therapists and phoniatrics, and laryngologist.

Autophagy triggered by the ROS/ERK signaling pathway protects mouse embryonic palatal cells from apoptosis induced by nicotine

Maternal cigarette smoking during pregnancy is a known high-risk factor for having a child with a cleft lip and/or palate (CLP), a common congenital malformation. Nicotine is the major teratogen component of cigarettes and e-cigarettes, and nicotine plays an important role in the development of CLP. However, the mechanism underlying nicotine's effect on CLP remains unclear. Here, we aimed to determine the role and molecular mechanisms of nicotine-induced autophagy, an important process involved in regulating the cellular stress response in mouse embryonic palatal cells (MEPCs). First, we found that nicotine promoted MEPCs proliferation and inhibited their apoptosis from 0 to 12 h. After 12 h, the proliferation was inhibited, and apoptosis was promoted. The migration of MEPCs was also inhibited by nicotine. Simultaneously, long-term nicotine stimulation inhibited the osteogenic differentiation of MEPCs. We then found that nicotine significantly increased autophagy flux in MEPCs at 12 h by increasing the expression of microtubule-associated protein light chain 3 (LC3) and reducing P62 expression levels. After nicotine exposure, intracellular reactive oxygen species (ROS) and extracellular signal-regulated kinase-1/2 (ERK1/2) expression significantly increased, and the expression of ERK1/2 was reversed by the ROS scavenging agent N-acetylcysteine (NAC). Moreover, the autophagy induced by nicotine was reversed by SCH772984, a specific inhibitor of ERK1/2, and the autophagy inhibitor chloroquine (CQ). These results suggest that in the early stage of nicotine exposure, MEPCs may trigger autophagy through the ROS/ERK1/2 signaling pathway to avoid cell damage caused by nicotine.

Cleft Palate and Aortic Dilatation as Clues for Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is a rare autosomal-dominant disorder of the connective tissue with some typical vascular findings, skeletal manifestations, craniofacial features, and cutaneous findings with a wide phenotypic spectrum. Six different genes are involved in LDS and the diagnosis is based on the identification of a heterozygous pathogenic variant in TGFBR1, TGFBR2, SMAD3, TGFB2, TGFB3, or SMAD2 in children with suggestive findings. These genes distinguish LDS into six classes (LDS1-LDS6, respectively). Delay in diagnosis of Loeys-Dietz syndrome may be associated with an adverse prognosis due to a very high augmented risk of early complications such as aortic or vascular rupture. The present report describes a case of an early diagnosis of LDS in a neonate with cleft soft palate and aortic root dilatation.

Targeted re-sequencing on 1p22 among non-syndromic orofacial clefts from Han Chinese population

Rs560426 at 1p22 was proved to be associated with NSCL/P (non-syndromic cleft lip with or without the palate) in several populations, including Han Chinese population. Here, we conducted a deep sequencing around rs560426 to locate more susceptibility variants in this region. In total, 2,293 NSCL/P cases and 3,235 normal controls were recruited. After sequencing, association analysis was performed. Western blot, RT-qPCR, HE, immunofluorescence staining, and RNA sequencing were conducted for functional analyses of the selected variants. Association analysis indicated that rs77179923 was the only SNP associated with NSCLP specifically (p = 4.70E-04, OR = 1.84), and rs12071152 was uniquely associated with LCLO (p = 4.00E-04, OR = 1.30, 95%CI: 1.12–1.51). Moreover, de novo harmful rare variant NM_004815.3, NP_004806.3; c.1652G>C, p.R551T in ARHGAP29 resulted in a decreased expression level of ARHGAP29, which in turn affected NSCL/P-related biological processes; however, no overt cleft palate (CP) phenotype was observed. In conclusion, rs12071152 was a new susceptible variant, which is specifically associated with LCLO among the Han Chinese population. Allele A of it could increase the risk of having a cleft baby. Rs77179923 and rare variant NM_004815.3, NP_004806.3; c.1652G>C, p.R551T at 1p22 were both associated with NSCLP among the Han Chinese population. However, this missense variation contributes to no overt CP phenotype due to dosage insufficiency or compensation from other genes.

Systematic Review of Clinical Practice Guidelines for Oral Health in Children With Cleft Lip and Palate

OBJECTIVE

Clinical practice guidelines (CPGs) exist to present recommendations and policies aimed at optimizing the oral health of children and adolescents born with cleft lip and/or palate. The aim of this review is to identify and assess the scope, quality, adequacy, and consistency of CPGs related to oral health in children and adolescents with clefts, along with reporting any differences and shortcomings.

METHODS

A systematic review of the literature of CPGs following Preferred Reporting Items for Systematic Reviews guidelines was conducted. Assessment of selected CPGs was performed using the Appraisal of Guidelines for Research & Evaluation II methodological quality instrument.

RESULTS

Only 7 CPGs fulfilled the criteria. Of these, 4 were from the American Cleft Palate-Craniofacial Association, and 1 each from the American Academy of Pediatrics, the Academy of Breastfeeding Medicine, and the American Academy of Pediatric Dentistry. The lowest overall mean scores were in the domain "Rigor of Development" (mean 29.58%, SD 17.11), revealing lower quality in methodology of the guideline. The domain "Clarity of Presentation" (mean 73.80%, SD 7.87) revealed the best score.

CONCLUSIONS

Our review results reveal a lack of integrated high-quality CPGs that can be used as universal guidelines by health workers in a range of disciplines for improving oral health in children and adolescents with cleft problems.

Cleft lip and palate: the psychological burden of affected parents during the first three years of their children's lives

The surgical treatment of cleft lip and palate (CLP) has been well described in the literature. Nevertheless, little is known about the psychological burden of affected parents. The aim of this study was to investigate the psychological burden in parents of children with CLP within the first 3 years of the children's lives. A standardized questionnaire (Parenting Stress Index, PSI) was administered to 33 parents of children with CLP to evaluate their psychological burden. The corresponding interview was conducted independent of any operative procedure during the yearly routine CLP consultation. Each participant's stress profile was assessed and compared with the average values of parents with non-cleft children. Psychological stress was substantially increased in all participants when compared to the parents of healthy children. This result was highly significant (P < 0.001). Parent depression (P < 0.001) and child-related requirements (P < 0.001) were the most critical subscales in the stress profile. Overall, the child-related burden was greater than the parent-related burden. These results indicate that parents of children with CLP have a higher level of psychological stress than parents of non-cleft children. This psychological stress might be reduced if addressed by specialist clinical psychologists in cleft-treating centres.

Obstructive sleep apnea in children with non-syndromic cleft palate: a systematic review

STUDY OBJECTIVES

To characterize obstructive sleep apnea (OSA) in children with non-syndromic cleft palate based on polysomnographic parameters relative to primary palatoplasty.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Scopus, CINAHL, and Cochrane. Studies were only considered for inclusion if they examined exclusively non-syndromic cleft palate patients and reported polysomnogram data.

RESULTS

Seven studies met inclusion criteria, providing information on a total of 151 patients with a weighted mean age of 5.2 ± 5.0 years old (range 0.1- 12 years). Five studies presented data from either the pre- or post-operative period. Two studies investigated both pre- and post-palatoplasty polysomnogram data, and neither observed a significant change in apnea hypopnea index (AHI) values following surgery (mean pre-operative AHI of 2.7, mean improvement of 0.6 events/hour). The entire cohort had a pre-palatoplasty weighted mean AHI of 11.4 (range 1.5 -16.1) and post-palatoplasty AHI of 1.5 (range 0.2 - 5.2). Interpretation of polysomnographic data was limited by heterogeneity; however, the AHI values of children with non-syndromic cleft palate largely demonstrated mild to moderate OSA following palatoplasty.

CONCLUSIONS

The full effect of cleft palate repair on OSA in children with non-syndromic cleft palate remains understudied. While published data are heterogenous, few studies support the worsening of obstructive AHI after palatoplasty in children with non-syndromic cleft palate. Further studies with standardized polysomnographic parameters are needed to provide guidance for management of this population.

Long-term safety of facilitated subcutaneous immunoglobulin treatment in pregnant women with primary immunodeficiency diseases: results from a registry study

Aim: Clinical outcomes of women who become pregnant during/after facilitated subcutaneous immunoglobulin (fSCIG) treatment are not well characterized. Materials & methods: This noninterventional, prospective, open-label, post authorization, pregnancy registry study assessed safety outcomes in mothers with primary immunodeficiency diseases who had ever received fSCIG before/during pregnancy and their infants (n = 7). Enrolled women received alternative treatment (arm 1: n = 2) or continued fSCIG (arm 2: n = 7) during pregnancy. Results: No treatment-related adverse events (AEs)/serious AEs (SAEs) were reported. 13 AEs occurred in mothers, including two SAEs (thrombocytopenia, pre-eclampsia; arm 2). A total of 17 AEs occurred in infants, including two SAEs (cleft lip, talipes calcaneovalgus; arm 2) with normal growth/development. Conclusion: Findings provide limited but useful safety data regarding women who received fSCIG before/during pregnancy and the growth/development of their infants. Clinical Trial registration: NCT02556775 (ClinicalTrials.gov); EUPAS5798.

Impact of Insurance Status on Initiation of Breast Milk Feeding Among Infants With CL ± P

To evaluate rates of breast milk feeding among infants with cleft lip with or without cleft palate (CL ± P) enrolled in Medicaid compared to Private Insurance/Self-Pay.

This was a population-based retrospective cohort study.

The 2018 US National Vital Statistics System-Natality component (NVSS-N) was used to examine nationwide birth certificate data.

Infants with cleft lip with or without cleft palate and either Medicaid or Private Insurance/Self-Pay were included.

Breast milk feeding rates among infants with CL ± P, as a function of insurance status.

Chi-square tests of independence revealed that of 896 infants with CL ± P and insured by Medicaid, 527 (58.8%) were breast milk fed at discharge. Of 865 infants with CL ± P and insured by Private Insurance/Self-Pay, 621 (71.8%) were breast milk fed at discharge. Using logistic regression models and controlling for baseline demographic differences, results indicated that infants with CL ± P in the Medicaid group had reduced odds of breast milk feeding compared to the Private Insurance/Self-Pay group (OR = 0.08; 95% CI 0.56, 0.96).

Breast milk support services are often necessary for the initiation of breast milk feeding among infants with CL ± P. However, these resources are likely not as readily available for those enrolled in Medicaid. These results suggest that infants with CL ± P, enrolled in Medicaid, may experience reduced breast milk feeding rates due to limited resources to initiate breast milk feeding. Factors that may promote breast milk feeding among this population are discussed.

Impact of Cleft Palate Anastomosis in Cleft Lip and Palate Patients with Coexisting Cleft Lip Anastomosis Scar Based on Cephalometric Measurements

(1) Background: This article focuses on examining components affecting the overbite, overjet, and the effect of palate surgery on craniofacial morphology with a concomitant cleft lip fusion scar, and a comparison of patients who had only a cleft lip fusion scar. Patients with unilateral cleft lip (UCL) and patients with unilateral cleft lip and palate (UCLP) were included in the study. We aimed to find if cephalometric parameters were significantly different in these groups. (2) Material and methods: The study group consisted of a lateral cranial radiograph of patients with UCLP (n = 30) and UCL (n = 30). Cephalometric radiographs were saved electronically, and cephalometric analysis was performed using a computer program. (3) Results: We observed that a statistically significant higher degree of maxillary prognathism occurred in the UCL than in the UCLP. We observed the anterior position of the upper lip in relation to E-line in patients with cleft lip. (4) Conclusions: The results present the effect of cleft palate surgery on further forward growth of the maxilla. There was a decreased ANB angle present in the skeletal class II in patients with UCL and UCLP. The SNB angle was not increased, and the reverse overjet was due to the rectroclination of the upper incisors and protruded lower incisors.

Dental caries and periodontitis risk factors in cleft lip and palate patients

Cleft lip and palate (CLP) is the most common congenital facial malformation and has a significant developmental, physical, and psychological impact on those with the deformity and their families. Risk factors contributing to CLP may conclude as genetic factors and environmental factors. The anatomical and morphological abnormalities related to CLP are favorable for dental plaque accumulation on the tooth surface. Therefore, patients with CLP undergo poorer oral hygiene and higher susceptibility to dental caries and periodontitis. In this review, we aim to conclude and update probable causes underlying the association between CLP and poor oral health and provide novel ideas of targeted early prevention for such oral diseases.

Clinical Practice Guidelines for the Management of Patients With Cleft Lip and Palate: A Systematic Quality Appraisal Using the Appraisal of Guidelines for Research and Evaluation II Instrument

ABSTRACT

Patients with cleft lip and/or palate require complex and longitudinal care by a multidisciplinary cleft team. Unfortunately, delivery of cleft care is often fragmented, and care practices can vary significantly. Multiple clinical practice guidelines (CPGs) have been proposed to provide a standardized framework for cleft care delivery. As CPGs have gained popularity, there has been increasing demand to maintain the quality of existing guidelines. A comprehensive search of EMBASE, MEDLINE via PubMed, Scopus, Cochrane and grey literature sources published from January 1, 1990 to December 31, 2020 was conducted to identify CPGs for the care of cleft patients. The Appraisal of Guidelines for Research and Evaluation, 2nd edition II tool was used to assess the quality of selected CPGs. Intraclass coefficients were calculated to assess agreement among appraisers. Eleven guidelines were identified for study inclusion. One guideline was classified as "high" quality by Appraisal of Guidelines for Research and Evaluation II criteria, and the remaining guidelines were classified as "average" or "low" quality. The "Clarity of Presentation" domain achieved the highest mean score (76.9% ± 11.7%) across CPGs, whereas the "Rigor of Development" domain scored the lowest (35.6% ± 21.2%). Intraclass coefficients analysis reflected very good inter-rater reliability across all domains (0.853-0.987). These findings highlight significant variability in the quality of existing CPGs for the global management of patients with cleft lip and/or palate. The "Rigor of Development" domain reflects the greatest opportunity for improvement. Given these findings, future guidelines may prioritize incorporating a systematic review of existing evidence into recommendations.

The Term Newborn: Delivery Room Triage and Transitions of Care

Term newborn infants without significant medical problems usually transition from fetal to newborn life without medical assistance. Infants requiring therapy often need care in a neonatal intensive care unit as opposed to a well-baby unit. Infants with unclear physiologic status or disease that may require therapies in the immediate newborn period may benefit from a period of observation with close monitoring before admission to a well-baby unit. Whenever possible, providing care for a newborn infant in an area that provides care for the newborn and mother together in the same room facilitates adaptation to normal breastfeeding and family bonding.

Assessing Adherence to Audiologic Parameters of Care for Children With Cleft Palate: A Quality Improvement Initiative

OBJECTIVE

To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate.

DESIGN

Prospective, multidisciplinary quality improvement initiative.

SETTING

Tertiary pediatric hospital.

PATIENTS, PARTICIPANTS

Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205).

INTERVENTIONS

A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication.

MAIN OUTCOME MEASURE(S)

Completion of recommended audiologic assessment at 5 separate care milestones.

RESULTS

After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes.

CONCLUSIONS

Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.

2020 edition of the Rourke Baby Record: What is new in preventive care of children up to 5 years of age?

OBJECTIVE

To update primary care providers practising well-child and well-baby clinical care on the evidence that contributed to the recommendations of the 2020 edition of the Rourke Baby Record (RBR).

QUALITY OF EVIDENCE

Pediatric preventive care literature was searched from June 2016 to May 2019, primary research studies were reviewed and critically appraised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and recommendations were updated where there was support from the literature.

MAIN MESSAGE

Notable changes in the 2020 edition of the RBR include the recommendations to limit or avoid consumption of highly processed foods high in dietary sodium, to ensure safe sleep (healthy infants should sleep on their backs and on a firm surface for every sleep, and should sleep in a crib, cradle, or bassinette in the parents' room for the first 6 months of life), to not swaddle infants after they attempt to roll, to inquire about food insecurity, to encourage parents to read and sing to infants and children, to limit screen time for children younger than 2 years of age (although it is accepted for videocalling), to educate parents on risks and harms associated with e-cigarettes and cannabis, to avoid pesticide use, to wash all fruits and vegetables that cannot be peeled, to be aware of the new Canadian Caries Risk Assessment Tool, to note new red flags for cerebral palsy and neurodevelopmental problems, and to pay attention to updated high-risk groups for lead and anemia screening.

CONCLUSION

The RBR endeavours to guide clinicians in providing evidence-informed primary care to Canadian children. The revisions are rigorously considered and are based on appraisal of a growing, albeit still limited, evidence base for pediatric preventive care.

Temporal oral microbiome changes with brushing in children with cleft lip and palate

This cohort study aimed to characterize the oral microbiome of children with CLP, from two different age groups, and evaluate the effect of supervised or unsupervised toothbrushing on the microbiome of the cleft over time. Swab samples were collected from the cleft area at three different time points (A; no brushing, B; after 15 days and C; after 30 days) and were analyzed using next-generation sequencing to determine the microbial composition and diversity in these time points. Overall, brushing significantly decreased the abundance of the genera Alloprevotella and Leptotrichia in the two age groups examined, and for Alloprevotella this decrease was more evident for children (2-6 years old). In the preteen group (7-12 years old), a significant relative increase of the genus Rothia was observed after brushing. In this study, the systematic brushing over a period of thirty days also resulted in differences at the intra-individual bacterial richness.

An overview of cleft lip and palate

Cleft lip and palate are types of craniofacial birth defects that affect thousands of children worldwide each year. These conditions are sensitive topics of conversations, often affected by the stigma of physical birth deformities and cultural myths. This article reviews the pathophysiology of cleft lip and palate, and describes the traditional management of patients with oral-facial clefts, including the extensive supportive care and an interprofessional team or cleft team approach that extends beyond the surgical correction.

Problemas de Salud Mental en Niños con Fisura Labiopalatina

Los niños que padecen enfermedades genéticas son una población vulnerable para desarrollar problemas de salud mental. La fisura labiopalatina (FLAP) es una anomalía congénita de tipo estructural. Objetivo: Estudiar el impacto a nivel familiar del diagnóstico de FLAP. Metodología: Alcance descriptivo, de diseño mixto y corte transversal. Se construyó un cuestionario autoadministrado compuesto por un consentimiento informado, un cuestionario de datos sociodemográficos, el Child Behavior CheckList y preguntas abiertas. El muestreo fue intencional y la muestra fue de 42 casos. Resultados: El diagnóstico de una fisura labio palatina es una experiencia difícil en los padres, quienes viven este momento de manera negativa, con tristeza y miedo.  Los niños en edad preescolar con diagnóstico de fisura labiopalatina son una población en riesgo de desarrollar trastornos psicopatológicos, mayormente de tipo externalizantes.

Proposed Federal Bill to Mandate Insurance Coverage for Children With Congenital Anomalies

The Ensuring Lasting Smiles Act was reintroduced in United States Congress in March 2019. If enacted, the bill will substantially limit private insurers' ability to deny coverage for the medically necessary treatment of congenital anomalies, including cleft palate and craniofacial anomalies. Coverage denials are currently a barrier to care for these individuals, especially for patients residing in states lacking coverage mandates. The purpose of this article is to describe the issues underlying the proposed federal legislation and provide a policy discussion to better inform cleft and craniofacial providers about pending legislation relevant to their practice.

Descriptive Overview of Primary Cleft Palate Surgeries in the Low- and Middle-Income Countries

OBJECTIVE

To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO.

DESIGN

The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States.

PARTICIPANTS

Patient records of those undergoing primary cleft palate surgeries only.

MAIN OUTCOME MEASURES

Region, age, sex, type of cleft, laterality of cleft.

RESULTS

Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region.

CONCLUSIONS

Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission.

Teeth: Small but Mighty and Mighty Important. A Comprehensive Review of Children's Dental Health for Primary Care Clinicians

Healthy teeth allow us to eat and stay well-nourished. Although primary care clinicians receive limited training about teeth, given the common nature of dental problems, it is important that they understand and recognize normal and abnormal dental conditions and can implement primary and secondary prevention of dental conditions in their practice. PubMed has been used to search the scientific literature for evidence on the following topics: normal dental development, dental abnormalities, malocclusion, teething, dental caries and related epidemiology and prevention, fluoride, dental injury and its management and prevention; and identification, prevention and treatment of gingivitis and periodontal disease. Literature review relied on randomized controlled trials, meta-analyses, systematic reviews, and Cochrane reviews when relevant and available. Other sources of evidence included cohort and case-control studies. Consensus statements and expert opinion were used when there was a paucity of high-quality research studies. The literature has been synthesized on these topics to make them relevant to pediatric primary care clinicians, and as available, the strength of evidence has been characterized when making clinical recommendations.

The Densitometric Analysis of Protein Pattern in Cleft Lip and Palate Patients

Objectives

Cleft lip and palate (CLP) belongs to the congenital anomaly that is clinically seen as cleft in lip, alveolar bone, palate, and nasal septum. The patients suffer from esthetic and various functional defects. CLP is resulted from impaired palatogenesis during the embryonic phase. The etiology of CLP is influenced by genetic, environmental, and combination of both. According to the literature, CLP is highly associated with defect in interferon regulatory factor 6 (IRF6) and poliovirus receptor-like (PVRL1) genes. The present study aimed to investigate the total protein profile and to identify protein IRF6 and PVRL1 in plasma of CLP patients.

Materials and Methods

Dot-Blot analysis was performed to identify protein target of IRF6 and PVRL1. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis was performed in gel concentration 12% using plasma of CLP patients, their parents, and control population. The gels were stained by Coomassie blue afterward. Gels were analyzed through ImageLab 5.2.1 software.

Results

The intensity of major bands in CLP patients was darker than control group, but remains similar to the parents group. The target protein IRF6 and PVRL1 were positively identified through Dot-Blot. Retardation factor value was significantly different in major bands of CLP patients compared to control group.

Conclusion

There pattern of protein profile in CLP patients was different compared to non-CLP.