Speech Production of Preschoolers with Cleft Palate

Speech and Resonance Disorders in Children With Cleft Palate: Diagnostic Evaluation and Current Speech Therapy Modalities

This article will provide an overview of how speech and resonance can be impacted in children with cleft palate. The authors will outline evidence-based assessment and treatment approaches commonly used for children with cleft palate and provide information on current initiatives to provide speech therapy. The methods discussed will be the use of telehealth to provide access to speech therapy for patients in areas without speech-language pathologists and the use of speech therapy camps to offer intensive, limited-duration speech therapy for groups of children due to the lack of trained providers in certain geographical regions.

Exploring the relationship between cleft type and speech outcome in 4-to-6-year-olds with non-syndromic cleft palate using different measures: A preliminary report

Cleft type affects speech outcomes, but exact relationships remain unclear as outcome measures vary. The primary aim was to investigate the relationship between cleft type and speech outcome using different measures in 4-to-6-year-olds with non-syndromic clefts. Secondary aims were to explore the relationships between (i) speech measures used; and (ii) parent perception of speech intelligibility and listener familiarity. Twenty-two pre-schoolers with clefts, plus one parent for each child, were recruited through a hospital outpatient clinic. Children with cleft lip and palate (CLP; n = 11) and those with cleft palate only (CP; n  = 11), matched on age and time of palate repair, were compared on Percentage Consonants Correct (PCC), clinician-reported speech intelligibility, and parent rating on the Intelligibility-in-Context Scale (ICS). Children with CLP had significantly lower PCC scores than children with CP (p = .020), but had no significant differences in their clinician- or parent-reported speech intelligibility. Clinician-reported speech intelligibility correlated significantly with both PCC (τ = .594, p < 0.01) and ICS (τ = .424, p  = 0.009). No significant correlation was found between PCC and ICS (τ =.197, p = 0.113). Overall, parents rated their child's intelligibility higher for familiar compared to unfamiliar communication partners (τ  = 2.325, p = 0.001, r  = .76). Cleft type is crucial for intervention planning when objective measures are employed. Speech outcomes should be evaluated at impairment, activity, and participation levels, and by different communication partners, to comprehensively evaluate communicative effectiveness.

Evaluating the Impact of a Global Cleft Speech Mentorship Program on Expanding Practitioner Competency in low- and middle-income countries

A primary challenge in global cleft care lies in the limited opportunities for cleft-specific training and mentorship available to speech practitioners worldwide, particularly in low-income and middle-income countries (LMICs). In addition, the limited number of speech therapists with cleft experience in LMICs creates a significant barrier to access to care for individuals with cleft lip and palate globally. The inaccessibility of cleft-specific clinical instruction and cleft-trained speech therapists impacts the effectiveness of intervention and, subsequently, the speech-language development of cleft-affected individuals worldwide. A structured virtual clinical mentorship program targeting speech practitioners of all skill levels in LMICs was established to address this gap in comprehensive cleft care provision. This article will examine the effectiveness of a structured cleft speech mentorship program in expanding practitioner competency in LMIC communities and, as a result, building capacity for cleft speech care globally. The authors will outline various aspects of the development and implementation of this cleft speech mentorship program, including rationale, participant recruitment, program requirements, and impact assessment tools utilized. An analysis of pre-program and post-program data will be conducted to evaluate the degree to which clinical skills were improved, identify persistent areas of weakness, and examine the effectiveness of the program in expanding speech practitioner competency.

Impact of an International Training on Interventionists' Expertise in Cleft Palate Speech: Results From Oaxaca, Mexico

PURPOSE

International cleft lip and palate surgical charities recognize that speech therapy is essential for successful care of individuals after palate repair. The challenge is how to ensure that cleft speech interventionists (i.e., speech-language pathologists and other speech therapy providers) provide quality care. This exploratory study investigated effects of a two-stage cleft training in Oaxaca, Mexico, aimed at preparing speech interventionists to provide research-based services to individuals born with cleft palate. Changes in the interventionists' content knowledge and clinical skills were examined.

METHOD

Twenty-three cleft speech interventionists from Mexico, Guatemala, and Nicaragua participated in a hybrid two-stage training, completing an online Spanish cleft speech course and a 5-day in-person training in Oaxaca. In-person training included a didactic component and supervised clinical practice with 14 individuals with repaired cleft palates. Testing of interventionists' content knowledge and clinical skills via questionnaires occurred before the online course (Test 1), immediately before in-person training (Test 2), and immediately after in-person training (Test 3). Qualitative data on experience/practice were also collected.

RESULTS

Significant increases in interventionists' overall content knowledge and clinical skills were found posttraining. Knowledge and clinical skills increased significantly between Tests 1 and 2. Clinical skills, but not knowledge, showed further significant increases between Tests 2 and 3. Posttraining, interventionists demonstrated greater expertise in research-based treatment, and fewer reported they would use nonspeech oral motor exercises (NSOME).

CONCLUSIONS

Findings provide preliminary support for such two-stage international trainings in preparing local speech interventionists to deliver high-quality speech services to individuals born with cleft palate. While content knowledge appears to be acquired primarily from the online course, the two-stage training incorporating in-person supervised practice working with individuals born with cleft palate may best enhance continued clinical skill development, including replacement of NSOME with evidence-based speech treatment. Such trainings contribute to building capacity for sustainable quality services for this population in underresourced regions.

Enhanced milieu teaching with phonological emphasis: A pilot, telepractice study for parent training in early intervention

PURPOSE

This pilot study evaluated enhanced milieu teaching with phonological emphasis (EMT + PE) parent training intervention delivered through telepractice and its impact on parent implementation, child speech outcomes, and child language outcomes.

METHOD

A multiple baseline design across behaviours was used to assess response to parent training and child outcomes. The intervention was delivered to four parents and their young children with repaired cleft palate. Speech production, receptive language, and expressive language were assessed prior to intervention. EMT + PE strategies including matched turns, modelling and expansions, and prompting/speech recasting were taught to parents using the teach-model-coach-review model. Social validity questionnaires were administered pre- and post-intervention to assess parents' rating of competence and confidence for managing their child's early development. Reliability and procedural fidelity were conducted.

RESULT

All parents increased their use of modelling and expansions, and prompting and speech recasting in response to training, as evidenced by large effect sizes. Children also responded positively to these strategies by increasing percentage of consonants correct (PCC) and target vocabulary, although PCC gains were less than observed in a prior hybrid telepractice and face-to-face intervention. Social validity measures indicated parents increased their confidence to provide intervention for their children.

CONCLUSION

This pilot study indicated that effective parent training in EMT + PE strategies can be delivered through telepractice.

The Association of Speech/Language Risk With Phonological Awareness, Rapid Naming, and Reading Ability in Children With Cleft Lip and/or Palate

Children with cleft lip and/or palate were assessed for speech, language, phonological awareness (PA), rapid naming (RN) and reading ability using standardized instruments at baseline (T1; N = 142, Mage = 6.14 years, 51% males) and 2-year follow-up (T2; 89% retention, Mage = 8.38). Children with no speech or language risk scored higher for T1 and T2 PA, RN, and reading than children with both speech and language risk [Adjusted Mean Difference (AMD) ranged from 11.79 to 21.25]; language risk (AMD 8.37 to 13.58); and speech risk (0.51 to 6.87). No significant differences by cleft type or child sex.

Harnessing the Power of Artificial Intelligence in Cleft Lip and Palate: An In-Depth Analysis from Diagnosis to Treatment, a Comprehensive Review

Cleft lip and palate (CLP) is the most common craniofacial malformation, with a range of physical, psychological, and aesthetic consequences. In this comprehensive review, our main objective is to thoroughly examine the relationship between CLP anomalies and the use of artificial intelligence (AI) in children. Additionally, we aim to explore how the integration of AI technology can bring about significant advancements in the fields of diagnosis, treatment methods, and predictive outcomes. By analyzing the existing evidence, we will highlight state-of-the-art algorithms and predictive AI models that play a crucial role in achieving precise diagnosis, susceptibility assessment, and treatment planning for children with CLP anomalies. Our focus will specifically be on the efficacy of alveolar bone graft and orthodontic interventions. The findings of this review showed that deep learning (DL) models revolutionize the diagnostic process, predict susceptibility to CLP, and enhance alveolar bone grafts and orthodontic treatment. DL models surpass human capabilities in terms of precision, and AI algorithms applied to large datasets can uncover the intricate genetic and environmental factors contributing to CLP. Additionally, Machine learning aids in preoperative planning for alveolar bone grafts and provides personalized treatment plans in orthodontic treatment. In conclusion, these advancements inspire optimism for a future where AI seamlessly integrates with CLP management, augmenting its analytical capabilities.

Speech Outcomes in 5-Year-Old Korean Children with Bilateral Cleft Lip and Palate

Background  Among the cleft types, bilateral cleft lip and palate (BCLP) generally requires multiple surgical procedures and extended speech therapy to achieve normal speech development. This study aimed to describe speech outcomes in 5-year-old Korean children with BCLP and examine whether normal speech could be achieved before starting school. Methods  The retrospective study analyzed 52 children with complete BCLP who underwent primary palatal surgery at a tertiary medical center. Three speech-language pathologists made perceptual judgments on recordings from a speech follow-up assessment of 5-year-old children. They assessed the children's speech in terms of articulation, speech intelligibility, resonance, and voice using the Cleft Audit Protocol for Speech-Augmented-Korean Modification. Results  The results indicated that at the age of five, 65 to 70% of children with BCLP presented articulation and resonance within normal or acceptable ranges. Further, seven children with BCLP (13.5%) needed both additional speech therapy and palatal surgery for persistent velopharyngeal insufficiency and speech problems even at the age of five. Conclusion  This study confirmed that routine follow-up speech assessments are essential as a substantial number of children with BCLP require secondary surgical procedures and extended speech therapy to achieve normal speech development.

Investigating the Impact of Patient-Related Factors on Speech Outcomes at 5 Years of Age in Children With a Cleft Palate

To investigate the relationship between patient-related factors (sex, cleft type, cleft extent, and Robin Sequence [RS]) and speech outcome at 5 years of age for children born with a cleft palate ±  lip (CP ± L).

3157 Children (1426 female:1731 male) with a nonsyndromic CP ± L, born between 2006 and 2014 in England, Wales, and Northern Ireland.

Perceptual speech analysis utilized the Cleft Audit Protocol for Speech-Augmented (CAPS-A) rating and UK National Speech Outcome Standards: Speech Standard 1 (SS1)-speech within the normal range, SS2a-no structurally related speech difficulties or history of speech surgery, and SS3-speech without significant cleft-related articulation difficulties.

Odds of achieving SS1 were lower among boys (aOR 0.771 [CI 0.660-0.901]), those with clefts involving the lip and palate (vs palate only) (UCLP-aOR 0.719 [CI 0.591-0.875]; BCLP-aOR 0.360 [CI 0.279-0.463]), and clefts involving the hard palate (incomplete-aOR 0.701 [CI 0.540-0.909]; complete-aOR 0.393 [CI 0.308-0.501]). Similar relationships with these patient factors were observed for SS3. SS2 was affected by the extent of hard palate involvement (complete; aOR 0.449 [CI 0.348-0.580]). Although those with CP and RS were less likely to meet all 3 standards than those without RS, odds ratios were not significant when adjusting for sex and cleft extent.

Sex, cleft type, and extent of hard palate involvement have a significant impact on speech outcome at 5 years of age. Incorporating these factors into risk-adjustment models for service-level outcome reporting is recommended.

Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience

BACKGROUND

Measurements of postoperative velopharyngeal dysfunction (VPD) can be used to determine the efficacy of a palatoplasty operation. Hypernasality and audible nasal air emission are typical manifestations of VPD during speech. We aimed to longitudinally compare VPD outcomes in postpalatoplasty patients who underwent Furlow repair versus straight line repair with intravelar veloplasty (IVVP). Additionally, we examined the relationship between VPD outcomes and select pre-existing patient characteristics.

METHODS

Retrospective chart review was performed to identify primary palatoplasty patients treated from April 2012 to March 2021. Variables collected included gender, syndromic status, primary language, Veau cleft type, type of speech assessment, age at time of surgery, degree of hypernasality, presence of audible nasal air emission, and overall adequacy of velopharyngeal function. Pearson χ2 test and multivariable t tests were used to analyze variables. Logistic regression was used to control for statistically significant variables.

RESULTS

Of the 118 patients included, 38 received a Furlow procedure and 80 received a straight line with IVVP procedure. Audible nasal air emission was present in 57.3% of straight line with IVVP patients and 42.9% of Furlow patients, with no statistically significant difference between groups. Clinically significant hypernasality was present in 42.1% of straight line with IVVP patients and 22.9% of Furlow patients (P=0.05). Velopharyngeal function was classified as adequate in 63.5% of straight line with IVVP patients and 83.3% of Furlow patients (P=0.03). However, after stratifying by syndromic versus nonsyndromic status, there was no statistically significant difference between straight line with IVVP and Furlow patients for postoperative hypernasality and velopharyngeal function.

CONCLUSIONS

This study suggests that there are no statistically significant differences between straight line with IVVP and Furlow palatoplasty techniques regarding speech outcomes including hypernasality, audible nasal air emission, and overall VP function. Furthermore, select patient characteristics such as gender, primary language, syndromic status, age at repair, and Veau cleft type do not significantly impact postoperative speech outcomes.

Where is the Care? Identifying the Impact of Rurality on SLP Caseloads and Treatment Decisions for Children with Cleft Palate

Challenges providing cleft/craniofacial care in rural communities are often reported, leading to disparities in resources available to clinicians. The purpose of this study was to identify the impact of rurality on caseloads and practice patterns of speech-language pathologists (SLPs) regarding speech and velopharyngeal function for children with cleft lip and/or palate (CL/P).

A national, survey of US-based SLPs (N = 359 respondents) investigated resources, comfort level, caseloads, and practice patterns for children with CL/P. Sub-county classifications that delineated levels of rurality were utilized. Descriptive statistics and chi-square analyses were conducted to determine the impact of population density on assessment and referral decisions.

Nearly 83% of SLPs reported providing care for a child with CL/P and 41.4% of these SLPs reported five or more children with CL/P on caseload throughout their career. There were no significant differences in rurality of practice setting and the likelihood of treating a child with CL/P. Significant differences were present between rural, town, suburban, and metropolitan-based SLPs regarding available resources (p = 0.035). SLPs in rural settings reported feeling uncomfortable treating children with CL/P compared to those in metropolitan settings (p = 0.02). Distance to the cleft/craniofacial team and comfort levels impacted referral decisions.

Most SLPs report having children with CL/P on caseload regardless of practice location. Rurality impacted assessment and referral decisions, especially surrounding access to resources and comfort levels engaging in team care. Findings have implications for developing support systems and reducing barriers for rural SLPs working with children born with CL/P.

Thematic Analysis of Coping Strategies Used by Parents of Children with Cleft Lip and Palate in El Salvador

OBJECTIVE

The aim of this study was to describe coping strategies used by parents of children with cleft palate with or without a cleft (CP ± L) during the early development of their children in El Salvador.

DESIGN

Qualitative interviews were completed with 16 parents of children born with CP ± L who were 6 months to 6 years old. Parents were questioned about their emotions and coping during eight time periods: prenatal, birth, social interaction before the first surgery, the beginning of surgeries, social interaction after the first surgery, early childhood education (ECE), speech-language therapy, and formal education. Thematic analysis (TA) was used to identify coping strategies as conceptualized by Lazarus and Folkman (1984).

RESULTS

Four major themes emerged: (a) experienced emotions related to diagnosis, (b) interpretations related to the birth of a child with a cleft, (c) seeking and experiencing cleft treatment, and (d) social interaction of the children. During prenatal and birth stages, parents used emotion-focused strategies. A few hours to a week after birth, they used problem-focused strategies, which led them in search of treatment. Some parents used avoidance strategies during periods of social interaction before surgery, ECE, and formal education. Socioeconomic challenges impacted access to speech-language therapy. Sociocultural factors, such as discrimination, religion, and folk beliefs, appeared to influence some of the coping strategies used by parents.

CONCLUSIONS

Problem-focused strategies appear to be helpful in seeking surgical treatments. The emotion-focused strategy of avoidance seemed to have adverse effects in minimizing opportunities for social interaction prior to surgery and early education.

Treatment of Speech Sound Errors in Cleft Palate: A Tutorial for Speech-Language Pathology Assistants

PURPOSE

Cleft palate is one of the most common birth defects in the United States. Most of these children receive speech therapy by preschool and school-based clinicians. The purpose of this article is to provide a comprehensive tutorial for speech-language pathology assistants (SLPAs) regarding treatment techniques and principles for children with cleft palate.

METHOD

It has been reported that 68% of preschoolers with repaired cleft palate received speech therapy. Preschool and school-based speech-language pathologists (SLPs) have reported a strong desire for practical professional development and continuing education resources regarding treatment of children with cleft palate. Thus, it seems likely that SLPAs may feel similarly unequipped to provide effective treatment for children with cleft palate. Obligatory and learned speech errors commonly found in children with cleft palate are described. Elicitation strategies for compensatory articulations are detailed. The implementation of evidence-based articulation and phonological treatment approaches is described in a step-by-step manner. "Red flags" that may arise during treatment and require input from the supervising SLP are highlighted.

RESULTS

SLPAs will learn elicitation techniques for compensatory articulations and implement evidence-based treatment approaches to improve the speech accuracy of children with cleft palate.

CONCLUSION

It is important for all school-based clinicians to be familiar with speech therapy for individuals with cleft palate.

Speech Intervention for Children With Cleft Palate Using Principles of Motor Learning

PURPOSE

This is a pilot study to apply an articulatory kinematic speech intervention that uses the principles of motor learning (PML) to improve speech and resonance outcomes for children with cleft palate. It is hypothesized that (a) treatment that applies select PML during practice will improve production of treated phonemes, representing both active and inconsistent passive errors, at word level in children with cleft palate; (b) effects of practice on phonemes with active or inconsistent passive errors will generalize to untreated exemplars of treated phonemes; and (c) learning will be retained for at least 1-month posttreatment.

METHOD

A multiple-baseline design across participants combined with a crossover single-case experimental model was used. Participants attended two 8-week blocks of twice-weekly face-to-face speech therapy (40-50 min/treatment) to treat active and inconsistent passive cleft speech errors using articulatory kinematic speech intervention that applied PML. The participants were four children with cleft-type speech errors. The primary dependent variable measured was percentage of words correct across treatment items, generalization items, and control items. Perceptual accuracy of target words was scored. Effect sizes were calculated to quantify the magnitude of treatment effect.

RESULTS

For three children with active and inconsistent passive cleft speech errors and one child with active cleft speech errors and developmental phonological speech errors, this approach resulted in improvements to their treated items and generalization to their untreated items. Inconsistent passive cleft speech errors were particularly responsive to the treatment in the three children who presented with these errors.

CONCLUSION

This Phase I study has shown that articulatory kinematic speech intervention that applies the PML is effective in improving the speech outcomes for children with cleft palate and that there is validity in pursuing further research into this approach.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21644831.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

Phonological Profile of Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

This purpose of this study was to assess the frequency and types of phonological process errors in patients with velopharyngeal dysfunction (VPD) and the different types of palatal anomalies.

METHOD

A total of 808 nonsyndromic patients with VPD, who underwent follow-up at the Center for Cleft Palate and Craniofacial Anomalies, from 2000 to 2016 were included. Patients were stratified into four age groups and five subphenotypes of palatal anomalies: cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP. Phonological processes were compared among groups.

RESULTS

The 808 patients ranged in age from 3 to 29 years, and 439 (54.3%) were male. Overall, 262/808 patients (32.4%) had phonological process errors; 80 (59.7%) ages 3-4 years, 98 (40, 0%) ages 4.1-6 years, 48 (24.7%) 6.1-9 years, and 36 (15.3%) 9.1-29 years. Devoicing was the most prevalent phonological process error, found in 97 patients (12%), followed by cluster reduction in 82 (10.1%), fronting in 66 (8.2%), stopping in 45 (5.6%), final consonant deletion in 43 (5.3%), backing in 30 (3.7%), and syllable deletion and onset deletion in 13 (1.6%) patients. No differences were found in devoicing errors between palatal anomalies, even with increasing age. Phonological processes were found in 61/138 (44.20%) with CP, 46/118 (38.1%) with SMCP, 61/188 (32.4%) with non-CP, 70/268 (26.1%) with OSMCP, and 25/96 (26.2%) with CLP. Phonological process errors were most frequent with CP and least with OSMCP (p = .001).

CONCLUSIONS

Phonological process errors in nonsyndromic VPD patients remained relatively high in all age groups up to adulthood, regardless of the type of palatal anomaly. Our findings regarding the phonological skills of patients with palatal anomalies can help clarify the etiology of speech and sound disorders in VPD patients, and contribute to general phonetic and phonological studies.

Utilization of part C early intervention services for patients with cleft palate

OBJECTIVES

To investigate the utilization of early intervention services under Part C of the 2004 Individuals with Disabilities Educational Act for children with cleft palate and to better understand barriers these patients encounter when receiving services.

METHODS

A retrospective chart review was performed on children under the age of 18 who were treated for cleft palate at a single tertiary care center and referred to Tennessee's Early Intervention System (TEIS) between January 2007 and December 2018.

RESULTS

For the 61 patients included, developmental therapy was the most common TEIS referral made (n = 408, 28%), followed by speech therapy (n = 371, 26%). Most of these services were delivered as scheduled (n = 513, 80%); some families missed appointments without notifying the provider (i.e., family no-show)(n = 101, 2%). Children referred at a younger age were more likely to receive developmental therapy (p = 0.012) and to attend their services (p = 0.027). Patients with Medicaid were more likely to have absences with prior notification (p = 0.05) and without prior notification (i.e., family no-show)(p = 0.009) than patients with other types of health insurance.

CONCLUSIONS

Patients with cleft palate often have complex needs; earlier referral to ancillary services may improve attendance at appointments and impact the services they receive. Socioeconomic factors may hinder patients from accessing these services even once they are referred.

Parents' perceptions on speech therapy delivery models in children with a cleft palate: A mixed methods study

PURPOSE

This study investigated parents' perceptions on two different speech therapy delivery models in children with a CP ± L, namely an innovative high intensity speech intervention (i.e. HISI: 10 1-h sessions divided over 2 weeks) and a low intensity speech intervention (i.e. LISI: 10 1-h sessions divided over 10 weeks).

METHOD

Twelve parents of 12 children who received HISI (n = 6) or LISI (n = 6) were contacted with the request to participate to this study to review their opinion on the received therapy. Participation included the completion of a questionnaire containing items related to satisfaction, speech progress, intervention intensity and frequency, transfer, and need for further speech therapy. Additionally, semi-structured interviews were carried out. The interviews were analyzed using an inductive thematic approach.

RESULTS

There were no significant differences between the two groups in satisfaction with the "general speech therapy, "duration of one speech therapy session", "total intervention duration" and "degree of improvement of speech intelligibility". Following HISI, parents perceived more improvement in terms of spontaneous speech and better resolution of the speech disorders. The interviews revealed 3 themes of importance to the parents: (1) treatment-related expectations, (2) treatment-related burden, and (3) patient-therapist relationship. Parents in the HISI group reported two concerns: (1) the lack of variation when receiving daily intervention, and (2) the emotional burden when the child is confronted with his/her speech disorder on a daily basis.

CONCLUSIONS

Parents were equally satisfied with the provided intervention. Parents in the HISI group perceived more speech progress following the intervention compared to parents in the LISI group. The intensive contact with the speech pathologist enhanced the patient-therapist relationship. To support a cultural shift away from low intensity therapy delivery models, it will be important to counsel and inform parents of the benefits of HISI and to counterbalance concerns.

The Panorama of Cleft Lip and Palate Live Birth in Brazil: Follow-up of a 10-Year Period and Inequalities in the Health System

OBJECTIVE

To provide the prevalence and an overview of cleft lip and palate (CL/P) in the period of 2008 to 2017, as well as the profile of care provided for this condition in Brazil.

DESIGN

Cross-sectional study of epidemiological character.

SETTING

Brazilian government website.

PARTICIPANTS

National Live Birth and Hospital Information System.

INTERVENTION

Organization of the end databases and performance-based statistical analysis.

MAIN OUTCOME MEASURE(S)

Analysis of the prevalence of CL/P in newborns, sociodemographic condition of the mothers, surgical procedures and hospitalizations, and specialized hospitals in Brazil within a 10-year period.

RESULTS

The average prevalence of CL/P in Brazil was ∼52 children per 100 000 live births in the covered period, corresponding to 1 per 1924 newborns. The presence of cleft was associated with preterm birth, being underweight, and the male gender. The highest prevalence was found in the South region, while the lowest was found in the Northeast region, with increasing rates in the North region of Brazil. The states with the highest prevalence were not those with a great number of hospitalizations and surgical procedures for live births with CL/P.

CONCLUSION

In the 10-year study period, the prevalence of CL/P was 0.52 newborns per 1000 live births, a result which differs among the states of Brazil. The need to reinforce the national monitoring of the prevalence and surgical procedures of cleft patients have also emphasized the need to improve public medical care for CL/P subjects.

Barriers and Resources to Cleft Lip and Palate Speech Services Globally: A Descriptive Study

BACKGROUND

Although a number of international cleft organizations and cleft professionals in low- and middle-income countries (LMICs) have built and supported comprehensive cleft care and speech therapy models to address the shortage of speech services in LMICs, the specific speech needs of individuals with cleft lip and palate (CLP) in such countries remain unknown. The objective of this study was to evaluate the barriers to accessing speech services for patients with CLP as well as the resources and models of speech services that are currently available for individuals with CLP in LMICs, with the goal of better understanding the needs of this population.

METHODS

Qualitative and quantitative methods consisted of Smile Train partner surveys that were distributed June 25th to July 31st, 2018 worldwide. Surveys were distributed through Smile Train's online medical database, Smile Train Express, which every Smile Train partner uses to report their Smile Train sponsored treatment outcomes. A total of 658 Smile Train partners responded to the surveys. Respondents included surgeons, speech therapists, orthodontists, administrators and nurses who represented non-governmental organizations, hospitals (private or public), hospital groups, and private clinics.

RESULTS

Results indicated that lack of resources, including access to local speech providers and language materials, as well as financial constraints such as patient travel and speech treatment costs, are the most commonly reported barriers to accessing speech services across all geographic regions surveyed.

CONCLUSIONS

Improving access to CLP speech services in LMICs may require strategies that address lack of speech providers, language materials, and financial constraints.

A Deep Learning Algorithm for Objective Assessment of Hypernasality in Children With Cleft Palate

OBJECTIVES

Evaluation of hypernasality requires extensive perceptual training by clinicians and extending this training on a large scale internationally is untenable; this compounds the health disparities that already exist among children with cleft. In this work, we present the objective hypernasality measure (OHM), a speech-based algorithm that automatically measures hypernasality in speech, and validate it relative to a group of trained clinicians.

METHODS

We trained a deep neural network (DNN) on approximately 100 hours of a publicly-available healthy speech corpus to detect the presence of nasal acoustic cues generated through the production of nasal consonants and nasalized phonemes in speech. Importantly, this model does not require any clinical data for training. The posterior probabilities of the deep learning model were aggregated at the sentence and speaker-levels to compute the OHM.

RESULTS

The results showed that the OHM was significantly correlated with perceptual hypernasality ratings from the Americleft database (r = 0.797, p < 0.001) and the New Mexico Cleft Palate Center (NMCPC) database (r = 0.713, p < 0.001). In addition, we evaluated the relationship between the OHM and articulation errors; the sensitivity of the OHM in detecting the presence of very mild hypernasality; and established the internal reliability of the metric. Further, the performance of the OHM was compared with a DNN regression algorithm directly trained on the hypernasal speech samples.

SIGNIFICANCE

The results indicate that the OHM is able to measure the severity of hypernasality on par with Americleft-trained clinicians on thisdataset.

Speech in a consecutive series of children born with cleft lip and palate with and without syndromes and/or additional malformations

Background

When evaluating speech in children with cleft palate with or without cleft lip (CP/L), children with known syndromes and/or additional malformations (CP/L+) are usually excluded. The aim of this study was to present speech outcome of a consecutive series of 5-year-olds born with CP/L, and to compare speech results of children with CP/L + and children with CP/L without known syndromes and/or additional malformations (CP/L-).

Methods

One hundred 5-year-olds (20 with CP/L+; 80 with CP/L-) participated. All children were treated with primary palatal surgery in one stage with the same procedure for muscle reconstruction. Three independent judges performed phonetic transcriptions and rated perceived velopharyngeal competence from audio recordings. Based on phonetic transcriptions, percent consonants correct (PCC) and percent non-oral errors were investigated. Group comparisons were performed.

Results

In the total group, mean PCC was 88.2 and mean percent non-oral errors 1.5. The group with bilateral cleft lip and palate (BCLP) had poorer results on both measures compared to groups with other cleft types. The average results of PCC and percent non-oral errors in the CP/L + group indicated somewhat poorer speech, but no significant differences were observed. In the CP/L + group, 25 % were judged as having incompetent velopharyngeal competence, compared to 15 % in the CP/L- group.

Conclusions

The results indicated relatively good speech compared to speech of children with CP/L in previous studies. Speech was poorer in many children with more extensive clefts. No significant differences in speech outcomes were observed between CP/L + and CP/L- groups.

From excitement to self-doubt and insecurity: Speech-language pathologists' perceptions and experiences when treating children with a cleft palate

BACKGROUND

Speech disorders in children with a cleft palate with or without a cleft lip (CP±L) are complex given the magnitude of influencing factors. Providing intervention to eliminate these speech errors is often challenging. Speech-language pathologists (SLPs) might have negative perceptions of the treatment of children with a CP±L.

AIMS

To explore how community SLPs perceive and experience the provision of speech intervention to children with a CP±L.

METHODS & PROCEDURES

A total of 18 female community SLPs, aged between 23 and 62 years, were included in this study. Semi-structured interviews were conducted. The interviews were analysed using an inductive thematic approach aiming to identify themes driven by the data. Trustworthiness of the data was achieved by including researcher triangulation (involving three researchers with different research backgrounds) and deviant case analysis of two cases.

OUTCOMES & RESULTS

Initial responses demonstrated that the community SLPs were excited and enthusiastic to treat children with a CP±L. Expanding on these initial reports, however, they revealed that their excitement turned into professional self-doubt and insecurity when confronted with the treatment challenges inherent with this population. To cope with this self-doubt, they outlined several responsibilities for the cleft team SLPs. They expressed a strong desire to receive confirmation and approval on their treatment practices from more experienced SLPs (i.e., the cleft team SLPs). Their perceptions were dominated by a polarized thinking pattern. Treatment approaches were divided in categories as 'right' or 'wrong' and 'good' or 'bad'.

CONCLUSIONS & IMPLICATIONS

The community SLPs are lacking professional confidence when treating children with a CP±L. They put themselves in a subordinate position towards the cleft team SLPs and expect the latter to provide ready-made answers to problems and questions. This expectation can perhaps be explained by their fear of making mistakes during therapy preventing treatment progress. If they handle in accordance with the experts' advice, they cannot blame themselves in cases where no treatment progress is seen. Educational programmes need to pay more attention to gaining professional confidence (in the search for the most optimal treatment approach for each individual patient) rather than merely focusing on competency-based learning tools.

WHAT THIS PAPER ADDS

What is already known on the subject Speech disorders in children with a cleft palate with or without a cleft lip (CP±L) are complex given the magnitude of influencing factors. Providing intervention to eliminate these speech errors is often challenging. What this paper adds to existing knowledge This study explored how community SLPs' perceive and experience the provision of speech intervention to children with a CP±L. The perceptions of community SLPs are dominated by a polarized thinking pattern. Treatment approaches are divided into categories as "right" or "wrong" and "good" or "bad". They lack professional confidence when they treat children with a CP±L. The community SLPs put themselves in a subordinate position towards the cleft team SLPs and expect the latter to provide ready-made answers to problems and questions. What are the potential or actual clinical implications of this work? Educational programs in speech-language pathology need to pay more attention to gaining professional confidence rather than merely focusing on competency-based learning tools.

Non-Oral Compensatory Misarticulations Revisited

Non-oral compensatory misarticulation patterns are often associated with the speech of children with cleft palate. Despite their saliency, the etiology, frequency, and treatment of these misarticulations have not been studied extensively. The purpose of this commentary is to review what we know about these atypical patterns of articulation and address clinical assumptions regarding their etiology and treatment.

Determination of Ethnic Variation in Infant Nasolabial Anthropometry Using 3D Photographs: Implications for Bilateral Cleft Lip Nasal Correction

OBJECTIVE

We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients.

METHODS

Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05.

RESULTS

Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures.

CONCLUSIONS

African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.

English-Only Treatment of Compensatory Speech Errors in a Bilingual Adoptee With Repaired Cleft Palate: A Descriptive Case Study

Purpose The purpose of this clinical focus article is to provide a descriptive case study of a late-adopted, bilingual adolescent with cleft palate speech errors. Specifically, we examined the cross-linguistic generalization of remediated compensatory cleft errors, following treatment in English (second language) only. The overarching goal of this study is to gain insights into the complexity of speech intervention for the adopted population with delayed cleft palate repair. Method A 14-year-old female adopted from China with a repaired unilateral cleft lip and palate and maladaptive articulation errors underwent 55 one-hour sessions of a motor-based, speech therapy approach over a 15-month span, targeting English phonemes only. Pre-, mid-, and posttreatment evaluation included perceptual and instrumental assessment of speech and resonance. Outcome measures at each time point included perceptual speech and resonance ratings, nasometry scores, and percent consonants correct (PCC) in both English and Mandarin. Results PCC in English improved from 60% in single words and 35% in sentences pretreatment to 100% in single words and sentences during posttreatment assessment. Without direct treatment in Mandarin, PCC in Mandarin improved from 56% in single words and 50% in sentences pretreatment to 100% in single words and 99% in sentences during posttreatment assessment. Posttreatment nasometry scores decreased by 20% for the nasal sample and 17% for the oral sample compared to pretreatment. Conclusions This descriptive case study demonstrated successful remediation of cleft palate speech errors, following 15 months of treatment in a late-adopted bilingual adolescent using a motor-based therapy approach. Treatment of errors in English (second language) led to generalization of correct productions in Mandarin (first language). This study presents the potential for bilingual late adoptees to achieve intelligible speech in both languages when motor-based therapy principles are applied to intervention.

Identifying associations between dental arch relationship scores, relative deprivation and other cleft audit outcomes. Part 1

OBJECTIVES

To assess whether dental arch relationship scores are associated with speech, audiological and psychology outcomes in patients with complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP).

SETTING AND SAMPLE POPULATION

One hundred 5-year-old children with non-syndromic complete UCLP and forty-two 5-year-olds with non-syndromic complete BCLP from the United Kingdom.

MATERIAL AND METHODS

Data were collected from five-year audit clinics for dental arch relationships, speech, hearing and psychology outcomes. Associations were assessed between ordinal prognostic covariates and the dental arch relationship outcome using a Cochrane-Armitage test for trend and comparisons with binary prognostic covariates using chi-square/Fisher's exact test. This was extended to assess associations between five-year audit outcomes and a measure of deprivation.

RESULTS

There was no evidence of associations between dental arch relationships and outcomes for audiology and speech. Individual domain analysis of the psychology outcomes within the UCLP cohort reported a poor outcome for Pro-social score to be associated with a poor 5-year-old index score (P = .018). For the BCLP sample, a good outcome for the BCLP Deciduous Dentition Yardstick was associated with a good conduct score (P = .01).

CONCLUSION

There was no association with the 5-year-old index/BCLP Deciduous Dentition Yardstick score and outcomes reported for audiology and speech. For the UCLP and BCLP cohorts, a poor dental arch relationship outcome may be associated with issues with some aspects of psychological well-being, associated with peer interactions and conduct. The deprivation index of samples had no association with the outcomes assessed.

Evaluation of Discipline-Specific Outcomes Through a Multidisciplinary Team Clinic for Patients With Isolated Cleft Palate

OBJECTIVE

To describe the incidence and timing of provider-specific interventions for children with isolated cleft palate.

DESIGN

This was a retrospective cohort study involving review of medical records.

SETTING

Multidisciplinary team care clinic at a tertiary academic children's hospital between January 2000 and July 2019.

PATIENTS

Patients with isolated nonsyndromic cleft palate seen by an American Cleft Palate-Craniofacial Association-approved team; 138 children were included.

MAIN OUTCOME MEASURES

Study outcomes included incidence of secondary velopharyngeal management, tympanostomy tube insertion, speech therapy, hearing loss, dental/orthodontic treatment, and psychology interventions. Provider-specific outcomes were calculated for patients at ages 0 to 3, 3 to 5, and >5 years.

RESULTS

Median follow-up time was 7.0 years (interquartile range: 3.3-11.8 years). At their last team assessment, 42% of patients still had conductive hearing loss. The rate of tympanostomy tube insertions not done alongside a palatoplasty was highest for ages 3 to 5 and dropped after new American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines in 2013 (P = .015); 54% of patients received speech-language therapy during follow-up. Palatoplasty, psychology, and dental/orthodontic treatment were all less common than speech or ENT treatment (P < .01). Secondary palatoplasty was performed in 31 patients (22%). Patients who received speech, dental/orthodontic, or psychology intervention followed up longer than those who did not (9.8 vs 2.1 years, P < .001).

CONCLUSION

Half of the patients terminated team follow-up by age 7, suggesting that burden of care outweighed perceived benefits of continued follow-up for many families. These results can be used to adjust protocols for children with isolated cleft palate.

Intelligibility in 3-Year-Olds With Cleft Lip and/or Palate Using the Intelligibility in Context Scale: Findings from the Cleft Collective Cohort Study

Objective:

To provide comparison data on the Intelligibility in Context Scale (ICS) for a sample of 3-year-old English-speaking children born with any cleft type.

Design:

Questionnaire data from the Cleft Collective Cohort Study were used. Descriptive and inferential statistics were carried out to determine difference according to children’s cleft type and syndromic status.

Participants:

A total of 412 children born with cleft lip and/or palate whose mothers had completed the ICS when their child was 3 years old.

Main Outcome Measure(s):

Mothers’ rating of their children’s intelligibility using the ICS.

Results:

The average ICS score for the total sample was 3.75 ( sometimes-usually intelligible; standard deviation [SD] = 0.76, 95% CIs = 3.68-3.83) of a possible score of 5 ( always intelligible). Children’s speech was reported to be most intelligible to their mothers (mean = 4.33, SD = 0.61, 95% CIs = 4.27-4.39) and least intelligible to strangers (mean = 3.36, SD = 1.00, 95% CIs = 3.26-3.45). There was strong evidence ( P < .001) for a difference in intelligibility between children with cleft lip only (n = 104, mean = 4.13, SD = 0.62, 95% CIs = 4.01-4.25) and children with any form of cleft palate (n = 308, mean = 3.63, SD = 0.76, 95% CIs = 3.52-3.71). Children born with cleft palate with or without cleft lip and an identified syndrome were rated as less intelligible (n = 63, mean = 3.28, SD = 0.85, 95% CIs = 3.06-3.49) compared to children who did not have a syndrome (n = 245, mean = 3.72, SD = 0.71, 95% CIs = 3.63-3.81).

Conclusions:

These results provide preliminary comparative data for clinical services using the outcome measures recommended by the International Consortium for Health Outcomes Measurement.

Perceptual Speech Outcomes After Early Primary Palatal Repair in Ugandan Patients With Cleft Palate

OBJECTIVE

To provide speech outcomes of English-speaking Ugandan patients with a cleft palate with or without cleft lip (CP±L).

DESIGN

Prospective case-control study.

SETTING

Referral hospital for patients with cleft lip and palate in Uganda.

PARTICIPANTS

Twenty-four English-speaking Ugandan children with a CP±L (15 boys, 9 girls, mean 8.4 years) who received palatal closure prior to 6 months of age and an age- and gender-matched control group of Ugandan children without cleft palate.

INTERVENTIONS

Comparison of speech outcomes of the patient and control group.

MAIN OUTCOME MEASURES

Perceptual speech outcomes including articulation, resonance, speech understandability and acceptability, and velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary surgery.

RESULTS

Normal speech understandability was observed in 42% of the patients, and 38% were judged with normal speech acceptability. Only 16% showed compensatory articulation. Acceptable resonance was found in 71%, and 75% of the patients were judged perceptually to present with competent velopharyngeal function based on the VPC-sum. Additional speech intervention was recommended in 25% of the patients. Statistically significant differences for all these variables were still observed with the control children (P < .05).

CONCLUSIONS

Overall, acceptable speech outcomes were found after early primary palatal closure. Comparable or even better results were found in comparison with international benchmarks, especially regarding the presence of compensatory articulation. Whether this approach is transferable to Western countries is the subject for further research.

Effectiveness of Speech Intervention in Patients With a Cleft Palate: Comparison of Motor-Phonetic Versus Linguistic-Phonological Speech Approaches

Purpose The purpose of this study was to compare the effect of two different speech therapy approaches, a traditional motor-phonetic approach and a linguistic-phonological approach, on the speech and health-related quality of life in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years old. Method A block-randomized, sham-controlled design was used. Fourteen children with a CP ± L (M _age = 7.71 years) were divided into two groups using block randomization stratified by age and gender: one receiving motor-phonetic intervention (n = 7) and one receiving linguistic-phonological intervention (n = 7). Each group received 10 hr of speech therapy divided over 2 weeks. Perceptual speech assessments were performed on several baseline and posttreatment data points. The psychosocial effects of the intervention were assessed using the patient-reported Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire. Both groups were compared over time using (generalized) linear mixed models. Within-group effects of time were determined using pairwise comparisons with post hoc Bonferroni correction. Results Significant Time × Group interactions with large effect sizes were revealed in terms of consonant proficiency, indicating significant differences in evolution over time among the two groups. Only in the group receiving linguistic-phonological intervention, percentage of correctly produced consonants and places significantly improved after the treatment. Total Velopharyngeal Insufficiency Effects on Life Outcomes scores of the parents significantly improved in both groups after the intervention. Conclusions Both motor-phonetic and linguistic-phonological speech interventions can have a positive impact on the occurrence of cleft speech characteristics and consonant proficiency in children with a CP ± L. A linguistic-phonological approach, however, was observed to be more effective in terms of improving these speech outcomes compared with a motor-phonetic approach. Speech intervention, irrespective of the used approach, significantly improved the participant's health-related quality of life.

Speech outcomes after palatal closure in 3-7-year-old children

Introduction

One of the main goals of the team approach in management of oro-facial clefts is to help the children with cleft palate have adequate speech development.

Objective

The present study aimed to investigate the prevalence of articulation and resonance disorders following palate closure in children who were visited for routine examination by the Isfahan Cleft Care Team between 2011 and 2015, and to study the impact of cleft type and age at the time of palatoplasty on speech outcomes.

Methods

Clinical records of 180 preschool children with repaired cleft palate were reviewed. The percentage of children demonstrating hypernasality, nasal emission, nasal turbulence, and compensatory misarticulations was calculated. The relationship between cleft type and age at the time of palatal surgery, as independent variables, and speech outcomes were examined.

Results

67.7 and 64.5 percent of the children demonstrated respectively moderate/severe hypernasality and nasal emission, and 71.1 percent produced compensatory misarticulations. Age at the time of palatal repair was significantly associated with compensatory misarticulations and also with moderate/severe hypernasality. The prevalence of compensatory misarticulations, significant hypernasality, nasal emission and also nasal turbulence was not significantly different in various types of cleft.

Conclusions

We observed a high prevalence of different speech disorders in preschool children with repaired cleft palate compared to other studies. This can be partly due to late palatal repair in the studied population. Despite many advances in cleft palate management programs in Iran, there are still many children who do not access the interdisciplinary team cares in their early childhood. We should, therefore, try to increase accessibility of appropriate and timely management services to all Iranian children with cleft lip/palate.

The Method of Surgical Lip Repair Affects Speech Outcomes in Children With Bilateral Cleft Lip and Palate

OBJECTIVE

It was hypothesized that lip repair protocols in children with bilateral cleft lip and palate (BCLP) would affect development of bilabial consonants /m/ /b/ /p/. This study compared speech outcomes in 2 surgical groups.

DESIGN

A retrospective case note investigation.

SETTING

UK Cleft Centre (2000-2009).

PATIENTS

Forty-nine children with complete BCLP, of whom 26 had a 1-stage and 23 a 2-stage bilateral cleft lip repair.

INTERVENTIONS

One-stage cleft lip repair versus a 2-staged cleft lip repair.

MAIN OUTCOME MEASURES

Bilabial consonant production at 18 months, 3 and 5 years of age. Cleft Speech Characteristics (CSCs) at age 5.

RESULTS

At age 18 months, 81% of the 1-stage lip repair group and 4% of the 2-stage lip repair group produced bilabial consonants (P <·0001, Fisher test). At age 3 years, 81% of the 1-stage and 26% of the 2-stage lip repair groups produced bilabial consonants (P =·0133, Fisher test). At age 5 years, both groups had similar bilabial consonant production, but children in the 2-stage lip repair group had more frequent and severe CSCs (P = ·0037, χ²).

CONCLUSION

A 1-stage lip repair for children with complete BCLP resulted in better bilabial consonant production at 18 months and 3 years of age than a 2-stage lip repair. At age 5 years both groups had bilabial consonants but children in the 2-stage lip repair group had worse CSCs. The surgical protocol for bilateral cleft lip repair affected speech outcome in children with BCLP.

An Exploratory Study of Speech and Language Therapy Intervention for Children Born With Cleft Palate ± Lip

INTRODUCTION

Children born with a cleft palate ± lip are at risk of developing speech and language difficulties, which may require intervention from a speech and language therapist (SLT). To date, there is no strong evidence to support one approach to intervention over another, neither is it clear which approaches or methods of provision are commonly used.

OBJECTIVES

To describe the range of speech and language therapy interventions being used with children born with cleft palate in the United Kingdom up to 5 years of age. To explore the different ways, interventions are being delivered.

DESIGN

A prospective study to conduct 9 semi-structured focus groups. Iterative content analysis was completed.

SETTING

Regional Cleft Lip and Palate Centers in the United Kingdom.

PARTICIPANTS

Sixty-two speech and language therapy professionals from specialist cleft teams and community services.

RESULTS

Four main codes were identified: "intervention approaches," "service delivery models," "decision-making and rationale," and "patient-centered care." Participants frequently discussed how they adopt an eclectic style when delivering intervention, the importance of an individualized approach for each child and service delivery constraints, such as a lack of resources.

CONCLUSION

Insight into the multitude of intervention approaches used by SLTs, aspects which influence their decision-making and the variability of service delivery models were gained. Uncertainty regarding which intervention approaches and methods for delivery are most effective provides rationale for future research, to improve the effectiveness of speech and language intervention for children with cleft palate ± lip.

Randomized controlled trial comparing Parent Led Therapist Supervised Articulation Therapy (PLAT) with routine intervention for children with speech disorders associated with cleft palate

BACKGROUND

A total of 68% of pre-school children with cleft palate have speech problems requiring speech therapy. There is a lack of access to regular targeted therapy. Parent training leads to positive outcomes in early communication skills in cleft palate and non-cleft speech disorders. Connected health has been used to address inadequate access to therapy, providing intervention to those who would not otherwise receive therapy.

AIMS

To evaluate the speech, activity and participation outcomes of Parent Led, Therapist Supervised, Articulation Therapy (PLAT) compared with routine speech therapy intervention in parent-child dyads.

METHODS & PROCEDURES

A total of 44 children, aged 2.9-7.5 years, were included in a two-centre, two-phase randomized controlled trial. Informed consent and assent were obtained. Participants and speech and language therapists (SLTs) were unblinded to the groups. Parents, in the parent-trained group (n = 23), attended 2 days' training, received a detailed speech therapy programme, and undertook intervention over 12 weeks supported by the cleft specialist SLT using FaceTime and one face-to-face session. In the control arm (n = 21), parent-child dyads received six therapy sessions over 12 weeks with a research SLT, comparable with usual care. Speech recordings were undertaken pre- and post-intervention. Percent consonant correct (PCC) was analysed by external SLTs blinded to the time and group. Activity and participation were measured using the Intelligibility in Context Scale (ICS) and Focus on Outcomes for Children Under Six (FOCUS) questionnaire.

OUTCOMES & RESULTS

There was no evidence of an interaction between Time and Group or an overall statistical difference between groups for PCC scores. There was a statistically significant difference over time for both groups (words: p < 0.002; confidence interval (CI) = 9.38-16.27; d = 0.57; sentences: p < 0.002; CI = 16.04-25.97; d = 0.23). Effect sizes were medium for words and small for sentences. For intelligibility and participation, there was no evidence of an interaction between Time and Group or an overall statistical difference between groups. A statistically significant difference over time was found for intelligibility (F = 29.97, d.f. = 1, 42, p < 0.001, 95 % CI = 1.45-3.15 d = 0.46) and for participation (F = 14.19, d.f. = 1, 41, p < 0.001 95% CI = 7.63-25.03; d = 0.36) with FOCUS results indicating clinically meaningful (parent-led group) and significant (control group) change in participation.

CONCLUSIONS & IMPLICATIONS

PLAT can be as effective as routine care in changing speech, activity and participation outcomes for children with cleft palate, when supported by a specialist cleft SLT using connected health. What this paper adds What is already known on this subject Over 50% of children with cleft palate require speech therapy. However, there is a lack of timely, accessible speech therapy services in the UK and Ireland. Previous studies have shown that parents can deliver therapy effectively, and that connected health can support the delivery of speech therapy. This study aims to provide evidence that parent-led therapy with the supervision of a specialist cleft therapist using FaceTime is effective. What this paper adds to existing knowledge This randomized controlled trial indicates that parents can be trained to deliver therapy for children with cleft palate speech disorders, under the supervision of an SLT. This approach results in improved speech, activity and participation outcomes similar to routine care. What are the potential or actual clinical implications of this work? This study indicates that both parent-led articulation therapy and routine care showed meaningful gains in speech, activity and participation, and that parent-led articulation therapy when supported by a cleft SLT using connected health could be an additional service delivery model for children with cleft palate speech disorders.

Crowdsourcing to Assess Speech Quality Associated With Velopharyngeal Dysfunction

OBJECTIVE

To assess crowdsourced responses in the evaluation of speech outcomes in children with velopharyngeal dysfunction (VPD).

DESIGN

Fifty deidentified speech samples were compiled. Multiple pairwise comparisons obtained by crowdsourcing were used to produce a rank order of speech quality. Ratings of overall and specific speech characteristics were also collected. Twelve speech-language pathologists (SLPs) who specialize in VPD were asked to complete the same tasks. Crowds and experts completed each task on 2 separate occasions at least 1 week apart.

SETTING

On-line crowdsourcing platform.

PARTICIPANTS

Crowdsource raters were anonymous and at least 18 years of age, North American English speakers with self-reported normal hearing. Speech-language pathologists were recruited from multiple cleft/craniofacial teams.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Correlation of repeated assessments and comparison of crowd and SLP assessments.

RESULTS

We obtained 6331 lay person assessments that met inclusion criteria via crowdsourcing within 8 hours. The crowds provided reproducible Elo rankings of speech quality, ρ(48) = .89; P <.0001, and consistent ratings of intelligibility and acceptability (intraclass correlation coefficient [ICC] = .87 and .92) on repeated assessments. There was a significant correlation of those crowd rankings, ρ(10) = .86; P = .0003, and ratings (ICC = .75 and .79) with those of SLPs. The correlation of more specific speech characteristics by the crowds and SLPs was moderate to weak (ICC < 0.65).

CONCLUSIONS

Crowdsourcing shows promise as a rapid way to obtain large numbers of speech assessments. Reliability of repeated assessments was acceptable. Large groups of naive raters yield comparable evaluations of overall speech acceptability, intelligibility, and quality, but are not consistent with expert raters for specific speech characteristics such as resonance and nasal air emission.

Sociodemographic Predictors of Patient Age at Time of Cleft Lip and Palate Repair

Objective:

To identify the impact of sociodemographic and health variables on the age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Design:

A retrospective, noninterventional quality assessment, and quality improvement study was designed.

Setting:

This institutional study was performed at Michigan Medicine in Ann Arbor, MI.

Patients:

All patients born between 2011 and 2014 who received surgical cleft repair, excluded those who were adopted (n = 165).

Main Outcome Measure:

The age at which patients undergo cleft lip repair, cleft palate repair, and primary speech evaluation.

Results:

Cleft lip repair was performed significantly later for patients identifying as Asian (18 weeks, P = .01), patients with Child Protective Services contact (19 weeks, P = .01), patients with a significant comorbidity (14 weeks, P = .02), and patients who underwent preliminary lip adhesion surgery (19 weeks, P < .01). Cleft palate repair was performed significantly later for patients identifying racially as Asian (19 weeks, P = .03) and other (22 weeks, P = .03). Preliminary speech and language evaluation were performed significantly later for patients identifying as black (55 weeks, P = .03) and patients diagnosed with an isolated cleft lip (71 weeks, P < .01).

Conclusions:

Timing of cleft lip, cleft palate repair, and primary speech and language evaluation are subject to variation which may be predicted by clinically accessible factors. By identifying race, Child Protective Services contact, and care variables as significant predictors of increased patient age at time of intervention, multidisciplinary cleft care teams can proactively allocate patient support resources.

Holistic Communication Assessment for Young Children With Cleft Palate Using the International Classification of Functioning, Disability and Health:Children and Youth

Purpose Children with a cleft palate (± cleft lip; CP±L) can have difficulties communicating and participating in daily life, yet speech-language pathologists typically focus on speech production during routine assessments. The International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY; World Health Organization, 2007) provides a framework for holistic assessment. This tutorial describes holistic assessment of children with CP±L illustrated by data collected from a nonclinical sample of seven 2- to 3-year-old children, 13 parents, and 12 significant others (e.g., educators and grandparents). Method Data were collected during visits to participants' homes and early childhood education and care centers. Assessment tools applicable to domains of the ICF-CY were used to collect and analyze data. Child participants' Body Functions including speech, language, and cognitive development were assessed using screening and standardized assessments. Participants' Body Structures were assessed via oral motor examination, case history questionnaires, and observation. Participants' Activities and Participation as well as Environmental and Personal Factors were examined through case history questionnaires, interviews with significant others, parent report measures, and observations. Results Valuable insights can be gained from undertaking holistic speech-language pathology assessments with children with CP±L. Using multiple tools allowed for triangulation of data and privileging different viewpoints, to better understand the children and their contexts. Several children demonstrated speech error patterns outside of what are considered cleft speech characteristics, which underscores the importance of a broader assessment. Conclusion Speech-language pathologists can consider incorporating evaluation of all components and contextual factors of the ICF-CY when assessing and working with young children with CP±L to inform intervention and management practices.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip

OBJECTIVE

To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols.

SETTING

An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital.

DESIGN

Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018.

PATIENTS, PARTICIPANTS

Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92).

RESULTS

Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon.

CONCLUSIONS

Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.

The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study

Objective:

To determine whether timing of palatoplasty (early, standard, or late) is associated with speech and language outcomes in children with cleft palate.

Design:

Retrospective case series.

Setting:

Tertiary care children’s hospital.

Participants:

Records from 733 children born between 2005 and 2015 and treated at the Cleft Craniofacial Clinic of a tertiary children’s hospital were retrospectively reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, syndromes, staged palatoplasty, and introduction to clinic after 12 months of age. Data from 232 children with cleft palate ± cleft lip were analyzed.

Interventions:

Palatoplasty.

Main Outcome Measures:

Speech/language delays and disorders at 20 months and 5 years of age based on formal hospital or community-based testing or screening evaluation in the Cleft Craniofacial Clinic; additional speech surgery.

Results:

Median age at palatoplasty was 12.6 months (range: 8.8-21.9 months). Age at palatoplasty was classified as early (<11 months, n = 28), standard (11-13 months, n = 158), or late (>13 months, n = 46). Late palatoplasty was associated with increased odds of speech/language delays and speech therapy at 20 months, and language delays at 5 years, compared with standard or early palatoplasty ( P < .05 for all comparisons). However, speech sound production disorders, velopharyngeal incompetence, tube replacement, and hearing loss were not significantly associated with age at palatoplasty.

Conclusions:

Late palatoplasty may be associated with short- and long-term delays in speech/language development. Future studies with standardized surgical technique/timing and outcome measures are required to more definitively describe the impact of age at palatoplasty on speech/language development.

Effect of neck extension on ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in patients undergoing palatoplasty: A prospective observational study

Palatoplasty is performed with neck extension in patients with a cleft palate. The neck extension required for a better surgical view during palatoplasty can affect intracranial pressure. We evaluated the effect of neck extension on intracranial pressure by measuring the optic nerve sheath diameter using ultrasonography during palatoplasty. The optic nerve sheath diameter was measured in 30 patients at 10 min after anesthetic induction in the supine position (T1), at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4). Hemodynamic and respiratory variables such as systolic blood pressure, heart rate, end-tidal carbon dioxide partial pressure, and peak airway pressure were also measured at the same time points. In comparison with the optic nerve sheath diameter measured at 10 min after anesthetic induction in the supine position (T1), the mean optic nerve sheath diameters were significantly increased at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4; 4.19 ± 0.26, 5.20 ± 0.29, 4.38 ± 0.36, and 4.35 ± 0.30 mm, respectively). However, hemodynamic and respiratory variables were not significantly different at all time points. We found that the optic nerve sheath diameter, an indicator of intracranial pressure, was increased during palatoplasty with neck extension, which suggests that the position may affect the intracranial pressure of patients with a cleft palate.

Velopharyngeal Closure and Resonance in Children Following Early Cleft Palate Repair: Outcome Measurement

Introduction Timing of cleft palate repair and the method of speech outcome measurement in children with cleft lip and palate are much debated topics. The associated problems and quality of life in these children depend on the timing of the surgery.

Aim The aim of this study was to investigate the velopharyngeal (VP) function and resonance parameters in children following early cleft palate repair.

Method A total of 25 Kannada-speaking children with early repaired cleft palate were subjected to speech assessment and videofluoroscopic assessment. Perceptual speech parameters measured were severity of hypernasality and presence of nasal air emission. Videofluoroscopy was interpreted in terms of closure ratios to predict the severity of VP dysfunction.

Results The analysis of videofluoroscopic images indicated that 48% of children had complete VP closure and 52% had perceptually normal resonance. A good correlation was found between the closure ratio and hypernasality.

Conclusion Understanding the perceptual speech parameters and their structural correlates for outcome measurement will give better evidence for refining the existing treatment protocols. Data on a larger population are warranted for establishing predictors of optimum speech outcome.

Intensive speech therapy in Ugandan patients with cleft (lip and) palate: a pilot-study assessing long-term effectiveness

BACKGROUND/AIMS

In resource-limited countries, traditional models for speech therapy delivery are not adequate to reach all patients in need. In those countries, intensive speech therapy might be a solution. Preliminary results of previous research demonstrated that intensive speech therapy can be effective in the short term for patients living in countries with limited access to speech therapy. Questions might arise whether or not intensive treatment results in long-term benefits for these patients. Hence, the present study investigated long-term effectiveness of intensive speech therapy provided to Ugandan patients born with a cleft palate with or without cleft lip (CP ± L) in terms of different speech characteristics.

METHODS

Five Ugandan patients with CP ± L, who received intensive speech therapy in the past, were contacted to participate in this follow-up study. All patients agreed to participate. Perceptual and instrumental speech evaluations were performed identically to the assessments immediately before and after speech therapy, to allow for comparison. Additionally, the Cleft Evaluation Profile, investigating self-perceived satisfaction with cleft-related features was included to compare satisfaction before and after speech therapy.

RESULTS

Long-term improvement in percentage correct consonants was seen in four patients. Furthermore, after speech therapy, decreased presence of resonance disorders was observed in two of the included patients. Before speech therapy, all participants were dissatisfied with speech. Interestingly, after intensive speech therapy, satisfaction with speech was seen in every patient and this satisfaction remained in the long term.

CONCLUSION

In summary, speech improvements after speech therapy varied among the five patients. Nevertheless, present study provided encouraging results to further investigate effectiveness of intensive speech therapy in patients with CP ± L.

Opinions of Speech-Language Pathologists Regarding Speech Management for Children With Cleft Lip and Palate

Objective:

The purpose of the present study was to examine practice patterns and opinions that speech-language pathologists (SLPs) have about speech-language intervention for children with cleft lip and palate.

Methods:

One hundred seven speech-language pathology members of the American Speech-Language-Hearing Association Special Interest Group 5: Craniofacial and Velopharyngeal Disorders Special Interest Group completed a 37-item online survey that examined common practices in early intervention as well as opinions about speech characteristics, assessment, and management strategies for children with cleft lip and palate.

Results:

The overwhelming majority of respondents (96%) agreed that speech-language pathologists (SLPs) should meet with parents before palatal surgery to discuss speech-language issues. Although 90% of the SLPs identified increasing consonant inventory as an early intervention goal, lack of consensus was evident regarding the type of consonant to stimulate. Respondents agreed that while blowing activities are not useful in strengthening labial, lingual, or velopharyngeal movements, they are useful in heightening awareness of oral airflow for children with cleft palate. A large degree of variability was evident in opinions regarding prevalence and treatment of compensatory articulations as well as the effectiveness of treatment strategies designed to reduce perceived hypernasality and audible nasal emission.

Conclusions:

The findings of this study indicate a large degree of variability in opinions of SLP respondents regarding assessment and treatment of children with cleft lip and palate.

Effect of Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) on Compensatory Articulation in Children With Cleft Palate/Lip

Objective. This investigation researched the effectiveness of the PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) method to address compensatory articulation errors in children with cleft palate. Design. Single-subject AB multiple baselines across participants and behaviors. Setting. Pediatric outpatient rehabilitation department in a local hospital in a metropolitan city. Participants. The investigation consisted of 3 participants (ages = 4:4 to 12:8) born with bilateral complete cleft lip and palate. All participants underwent several reconstructive surgeries to repair their lips and palates. Interventions. The PROMPT treatment was provided for 45 minutes 3 times a week for 4 weeks (3 weeks for Participant 2). Main Outcome Measure. Therapy sessions addressed anterior lingual speech motor phonemes across 3 tiers (syllables, words, and phrases). Results. Direct visual observation of data obtained throughout this investigation indicate potential positive effects and significant correlation between improvements in sound production at 3 tiers and the implementation of the PROMPT technique. Speech intelligibility was judged by 3 blinded listeners who were unfamiliar with children with speech disorders or with cleft palate speech. All listeners identified and judged improvement in overall speech intelligibility over the course of this investigation. Listeners examined speech samples selected from sessions 3, 6, 9, and 12. Conclusion. The findings in this investigation provide a potential relationship on the effectiveness of the PROMPT method and attainment of accurate speech productions in children with cleft palate producing compensatory articulation errors, resulting in improvement in overall speech intelligibility.

The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: A retrospective study in Isfahan Cleft Care Team

OBJECTIVES

This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined.

METHODS

A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos.

RESULTS

Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05).

CONCLUSION

Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT.

Child development skills and language in toddlers with cleft lip and palate

INTRODUCTION

Children born with cleft lip and palate (CLP) are exposed to several risk factors for developmental delay.

METHODS

This cross-sectional and descriptive study compared the performance of gross motor, adaptive fine motor, social-personal and language skills in children with non-syndromic cleft lip and palate (age = 36-47 months, n = 30) matched as to chronological age and gender. The evaluation instruments were Denver Developmental Screening Test II and MacArthur Communicative Development Inventory - part D, employed for the receptive and expressive vocabulary checklist. Intergroup comparisons were performed using t tests and Chi-square tests. The Pearson correlation coefficient was used to verify the inter-category correlation (p ≤ 0.05).

RESULTS

There was statistically significant difference in gross motor, adaptive fine motor, and language skills, both in receptive and expressive aspects, in the comparison between groups. In the personal-social area, children with CLP presented performance below the expected, without statistically significant difference between groups.

CONCLUSIONS

Children with CLP are at risk for developmental disorders and should be monitored from early childhood to minimize the deleterious effects of this risk condition.