Children with cleft lip/palate and mental retardation: a subpopulation of cleft-craniofacial team patients

Clinical and Descriptive Study of Orofacial Clefts in Colombia: 2069 Patients From Operation Smile Foundation

OBJECTIVE

To describe the population of patients with cleft lip and/or palate (CL/P) in terms of cleft phenotypes, gender, age, ethnic group, family history, clinical presentation (syndromic vs nonsyndromic), some environmental and behavioral factors, and some clinical features.

DESIGN

Descriptive retrospective study.

SETTING

Patients attending the genetics counseling practice in Operation Smile Foundation, Bogotá, Colombia, for over 8 years.

PARTICIPANTS

No screening was conducted. All patients requiring clinical genetics assessment in Operation Smile Foundation were included in the study.

RESULTS

Left cleft lip and palate (CLP) and nonsyndromic forms were the most frequent types of malformations in this population. Psychomotor retardation and heart disease were the most frequent comorbidities in these patients. A low proportion of mothers exposed to passive smoking during pregnancy was observed and low birth weight accounted for an important number of cases. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CLP in this population.

CONCLUSIONS

In this study, the most frequent type of CL/P was the nonsyndromic complete left CLP. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CL/P in this population.

Specialist hospital treatment and care as reported by children with intellectual disabilities and a cleft lip and/or palate, their parents and healthcare professionals

BACKGROUND

Research into hospital treatment and care of children with intellectual disabilities is extremely limited, but available literature points to difficulties. Some children have a co-occurring condition alongside an intellectual disability which requires ongoing treatment, such as a cleft lip/palate. To date, their experiences remain untapped.

METHOD

Semi-structured interviews with 23 participants; five children with intellectual disabilities (aged 11-16), their parents (n = 9) and nine healthcare professionals working in cleft care. Thematic analysis determined patterns across the data.

RESULTS

Three key themes were found: struggles (stress and distress, and power imbalance), tensions (perceived levels of choice and control in decision making, lack of training around intellectual disability assumptions and jargon) and good practice (appropriate communication and information, and tailored treatment).

CONCLUSION

Good practice was evident, but was ad hoc. Individualized treatment and communication based upon children's needs are required as is further investigation into general anaesthetic induction for children with intellectual disabilities.

Academic outcomes of children with isolated orofacial clefts compared with children without a major birth defect

OBJECTIVE

To compare academic outcomes between children with orofacial cleft (OFC) and children without major birth defects.

DESIGN AND SETTING

In 2007-2008, we mailed questionnaires to a random sample of mothers of school-aged children with OFC and mothers of children without major birth defects (comparison group). The questionnaire included Likert-scale, closed-ended, and open-ended questions from validated instruments. We conducted bivariate and multivariable analyses on parent-reported educational outcomes and bivariate analyses on parent-reported presence of related medical conditions between children with isolated OFC and unaffected children.

PATIENTS/PARTICIPANTS

A random sample of 504 parents of children with OFCs born 1996-2002 (age 5-12 years) were identified by the North Carolina Birth Defects Monitoring Program. A random sample of 504 parents of children without birth defects born 1996-2002 was selected from North Carolina birth certificates. Of the 289 (28.7%) respondents, we analyzed 112 children with isolated OFC and 138 unaffected children.

MAIN OUTCOME MEASURES

Letter grades, school days missed, and grade retention.

RESULTS

Parents of children with isolated OFC reported more developmental disabilities and hearing and speech problems among their children than comparison parents. Children with isolated OFC were more likely to receive lower grades and miss more school days than unaffected children. Because of the low response rate, results should be interpreted cautiously.

CONCLUSION

Children with isolated OFC may have poorer academic outcomes during elementary school than their unaffected peers. Future studies are needed to confirm these results and determine whether these differences persist in later grades.

Bridging the Gap: Addressing Challenges toward Improvement of Cleft Teamwork in a Tertiary Care Center in North India: A Pilot Study

Aim

The aim of this study was the initiation of systematic data collection so as to improve the capacity for outcome measurement after cleft repair. Also, a clinical audit was done for evaluation of the process and assessment of outcomes of cleft care.

Design and Setting

A questionnaire-based survey and outcome assessment was carried out over a 1-year period from March 2008 to February 2009 at the combined outpatient cleft clinic of a tertiary care center in India.

Patients and Participants

Data collection (basic demographic and environmental information) was done twice a week throughout the year by students from the Department of Pediatric Dentistry, at the outpatient cleft clinic.

Results

A total of 68 completed cleft lip and palate registry forms, from which all the information was available, were analyzed. There was a skewed sex ratio, with a higher preponderance of boys seeking treatment. Of affected males, 19.1% were between 2 and 5 years of age when they first reported to the cleft clinic. Surprisingly, no bilateral clefts of lip, unilateral cleft lip (right) and unilateral cleft lip and palate (right) were observed in girls. Oral health was poor in 74% of patients; among the dental referrals only 26% could be recruited for orthodontics with a reasonably good prognosis.

Conclusions

Poverty, illiteracy, and superstitions prevent an average patient from India from receiving multidisciplinary cleft care. This emphasizes the need to create systems that suit the needs of our target patients.

Implementing the brazilian database on orofacial clefts

Background. High-quality clinical and genetic descriptions are crucial to improve knowledge of orofacial clefts and support specific healthcare polices. The objective of this study is to discuss the potential and perspectives of the Brazilian Database on Orofacial Clefts. Methods. From 2008 to 2010, clinical and familial information on 370 subjects was collected by geneticists in eight different services. Data was centrally processed using an international system for case classification and coding. Results. Cleft lip with cleft palate amounted to 198 (53.5%), cleft palate to 99 (26.8%), and cleft lip to 73 (19.7%) cases. Parental consanguinity was present in 5.7% and familial history of cleft was present in 26.3% subjects. Rate of associated major plus minor defects was 48% and syndromic cases amounted to 25% of the samples. Conclusions. Overall results corroborate the literature. Adopted tools are user friendly and could be incorporated into routine patient care. The BDOC exemplifies a network for clinical and genetic research. The data may be useful to develop and improve personalized treatment, family planning, and healthcare policies. This experience should be of interest for geneticists, laboratory-based researchers, and clinicians entrusted with OC worldwide.

Amygdala volume correlates positively with fearfulness in normal healthy girls

Research into the neural underpinnings of fear and fear-related pathology has highlighted the role of the amygdala. For instance, bilateral damage to the amygdaloid complex is associated with decreased appreciation of danger and recognition of fear in humans, whereas enlarged amygdala volume is associated with internalizing syndromes. It is unknown whether amygdala volume and fearfulness are related in the absence of pathology. We examined the correlation between normal fearfulness and amygdala morphology in 116 healthy children and adolescents (60 boys, 56 girls, age 7-17 years). Fearfulness was measured using the parent ratings on the Pediatric Behavior Scale and amygdala volumes were determined by manual tracing. We found a positive correlation between right amygdala volume in girls (r = 0.29). This relationship was more robust and present bilaterally when analyses were limited to girls with a positive nuclear family history of depression (for left r = 0.63; for right r = 0.58). In boys there was no significant relationship which may suggest that biological mechanisms differ between sexes. Given the role of enlarged amygdala volume in pathology, these findings may indicate that variation in amygdala morphology marks susceptibility to internalizing disorders.

Evaluation of Craniofacial Care outside the Brazilian Reference Network for Craniofacial Treatment

Objective:

To describe health care provided outside the Brazilian Reference Network for Craniofacial Treatment, and to inform the debate about craniofacial health care policy in Brazil.

Design:

Observational, retrospective cohort.

Methods:

Craniofacial care providers completed the same questionnaire previously used to evaluate the Brazilian Reference Network for Craniofacial Treatment (RRTDCF).

Results:

Units outside the RRTDCF are mainly located in the southeast region of Brazil and in universities. They comprise 56 independent clinics, 22 combined clinics, and four parental associations. Services provided are variable from unit to unit and just six of them meet the American Cleft Palate-Craniofacial Association minimum team standard. Genetic evaluation and counseling is provided by clinical geneticists in 35 units; whereas, in 30 units, it is undertaken by untrained professionals.

Conclusion:

A significant number of craniofacial units work in parallel and overlap the RRTDCF. They are funded by the government but not recognized as craniofacial teams. Regional disparities and lack of coordination within and between cleft lip and/or cleft palate (CL/P) teams are unsolved problems. Non-RRTDCF units are heterogeneous concerning configuration, service provided, areas of treatment, and composition of the teams. A nationwide and voluntary database on orofacial clefts is a proposed strategy to address some of these problems. Anticipated benefits include strengthening the collaboration within and between healthcare teams and supplying health authorities with a comprehensive and population-specific source of information on this prevalent and potentially preventable group of birth defects.

CHERI: time to identify the syndrome?

Chiari I malformations are congenital abnormalities that are etiologically heterogeneous. Some studies recognize a probable association between Chiari 1 malformation, delayed language or motor development, and mental retardation with or without epilepsy. The present patient appeared to have an isolated cleft palate and Chiari 1 malformation with co-existing functional and behavioral disorders (i.e., speech delay, mental retardation, and deviant electroencephalography [EEG]). In consideration of the cleft palate population, the implication of the present case study is that more attention should be paid to the developmental milestones in children with cleft palate. Because several cases of Chiari I anomaly co-occurring with mental retardation and deviant EEG or epilepsy have been recognized, it appears justified to identify a syndrome, which is here called CHERI (Chiari 1 malformation with or without cleft palate, deviant EEG or epilepsy, and retarded intelligence with delayed language development). It will be important in the future to describe those cases identified to delineate the clinical picture and to estimate the frequency of the occurrence of various characteristics.

Social Response in Children with Severe Cognitive Impairments: Factors in Craniofacial Surgery Decision-Making

BACKGROUND

The controversy over whether certain pediatric craniofacial operations primarily address "functional" versus "aesthetic" goals has fostered tensions among insurance companies, patients and families, and treatment teams. The authors posit that such operations have objectives and outcomes that can be categorized as "functionally aesthetic" and describe the empirical basis for this assertion. Furthermore, the authors apply this concept to the difficult surgical decision-making process associated with treating children with severe cognitive impairments.

METHODS

When patients have severe cognitive impairments, the social benefits of treatment may be less clear than for other patients, increasing the complexity of surgery decision-making. The authors discuss the nature of cognitive impairment, its prevalence in patients with craniofacial anomalies, links between social functioning and both cognitive development and appearance, and the importance of social integration for psychological and cognitive functioning. Special issues involved in working with cognitively impaired children are covered, including parent and patient expectations for surgical outcome and the difficulties involved in pain assessment and control. Potential linkages are described for craniofacial surgery, appearance, social functioning, and cognitive development.

CONCLUSIONS

A craniofacial operation directed at reconstruction of a congenital defect in a child should not be dismissed as simply and purely cosmetic. The authors document and outline the potential ethical issues and social and cognitive benefits that should be considered by insurance companies, patients and families, and treatment teams when determining treatment options for cognitively impaired children with craniofacial anomalies.

Mental development in infants with cleft lip and/or palate

OBJECTIVE

Investigated mental development in infants and toddlers with cleft lip and/or palate (CLP).

DESIGN

This was a retrospective analysis of developmental scores on qualified children between 4 and 36 months of age. Cross-sectional analysis included children in four age groups (6, 12, 18, and 24 months); longitudinal analysis included children at mean age 9.1 (range = 4 to 15) months at Time 1 and 24 months (range = 16 to 36) at Time 2.

PARTICIPANTS

Cross-sectional analysis included 180 children (59% male participants) in four diagnostic groups (cleft lip only [CL], cleft lip and palate [CLP], cleft palate only [CP], and Pierre Robin). The longitudinal sample included 85 children (64% male children) in the same diagnostic groups.

MAIN OUTCOME MEASURES

Mental Scale (MDI) of the Bayley Scales of Infant Development.

RESULTS

Mean MDIs were in the average range but decreased significantly between youngest and oldest groups in both cross-sectional (F(3,179) = 4.9, p<.01) and longitudinal samples (F(1,84) = 6.87, p<.01). There was a significant difference among cleft types (F(3,179) = 3.5, p<.025). Infants with CL obtained the highest scores, and infants with Pierre Robin Sequence obtained the lowest. Perceptual-motor development in the first year of life was predictive of developmental status at age 2.

CONCLUSIONS

The number of children with CLP who may be at risk for developmental problems during the second year of life is greater than would be expected. Children at greatest risk may demonstrate early delays in acquisition of perceptual-motor skills during the first year of life.

Psychological issues in craniofacial care: state of the art

This article is an extensive review of the psychological literature on cleft lip and palate and other craniofacial anomalies. Issues of parental acceptance, social competence, self-concept, emotional adjustment, and cognitive functioning are examined. Cumulative research suggests that many children with craniofacial conditions develop in a typical manner and do not experience psychological problems. However, a significant number of children (30% to 40% in most studies) experience difficulties with internalizing and/or externalizing problems, learning disorders, and social competence. A multifactorial model for examining the domains that are related to both psychological risk and protection is recommended. The need for multicenter studies that are prospective and clinically relevant is emphasized.