Hare lip and Cleft Palate

Hare lip and cleft palate is a defect in the upper lip of the baby also termed as hare lip. It may be unilateral or bilateral and may or may not be associated with a cleft palate. It may vary from a small notch to a complete extending into the base of the nose and is common in female children.

Cleft palate is the abnormal opening in the roof of the mouth resulting from a failure of fusion of the soft palate as weak as the hard palate growing from both sides right and left the side of the body during the embryonic period.

Causes of Hare lip and cleft palate 

The exact cause of the malformation is unknown, nevertheless there are some the common causes;

• Multifactorial inheritance
• Environmental factor
• Familial occurrence
• Medicine such as phenytoin during pregnancy
• Expose to teratogens such as alcohol, smoking, X-ray during pregnancy.

Pathophysiology

During the 6th week of gestation of the fetal development period, the maxillary process needs to fuse with the nasal elevations on the frontal prominence and merging of the upper lip at the midline is completed between the 7th and 8th weeks of gestation. But if the process is failed to fuse with nasal elevation then a cleft lip will develop. And the palate tissues forming the soft and hard palate fuse between 8-12 weeks of gestation. A Cleft palate results from failure to fuse the bone and soft tissue from two sides.

Symptoms of Pathophysiology

• In bilateral defect of the upper lip is unattached on both sides and may be displaced forward.
• In severe case nostril on the affected side is low as well as the presence of deviated nose.
• Missing teeth, malposition of teeth, or deformed teeth on the cleft side.
• Feeding difficulties may present.
• Aspiration during feeding in CP
• The problem is respiration, speech, and hearing in CP.
• Absence of nasal septum development

Diagnosis process 

Most cases of cleft lip and cleft palate are noticed right away at birth and don't require special tests for diagnosis. Increasingly, cleft lip and cleft palate are seen on ultrasound before the baby is born.

Ultrasound before birth

• A prenatal ultrasound is a test that uses sound waves to create pictures of the developing fetus. When analyzing the pictures, a doctor may detect a difference in the facial structures.
• A cleft lip may be detected with ultrasound beginning around the 13th week of pregnancy. As the fetus continues developing, it may be easier to accurately diagnose a cleft lip. A cleft palate that occurs alone is more difficult to see using ultrasound.
• If the prenatal ultrasound shows a cleft, a doctor may offer a procedure to take a sample of amniotic fluid from the uterus (amniocentesis). The fluid test may indicate that the fetus has inherited a genetic syndrome that may cause other birth defects. However, most often the cause of cleft lip and cleft palate is unknown.

Management of cleft palate

Surgical requirement (palatoplasty) is mandatory and it is done at about 9 to 18 months

Management of hare lip

Surgical correction of cleft lip is done in the first few weeks of life if the baby does not have a respiratory, oral, or systemic infection. The name of the surgery is Z- plastic to minimize notching of the lip from retraction of scar tissue and to lengthen the lip.

General nursing management

• Reassurance to the parents: emotional support to the parents of immense importance to overcome the shock of the physical defect. So the parents should be encouraged to care for the baby and express their feeling toward the child's condition.
• Feeding care
• The parents are taught to feed their baby successfully.
• The baby is best fed in the upright position to minimize regurgitation of feeds through the nose.
• A baby requires special types of feeding devices like a squeezable plastic bottle and crosscut nipple.
• Frequent burping after each feeding.
• Breastfeeding is also an option but a breast pump may be useful before nursing to stimulate the letdown reflex.

Preoperative care

• Routine care
• Informed consent
• Preoperative medication
• Position of the baby
• Feeding before surgery and following the same technique postoperatively.
• Parents are advised postoperative care, and restraints to be used after surgery.

Post-operative care

• Use a lip protection device to prevent trauma on the suture side (by use of hand, elbow, or body restraint).
• Pain management by giving painkillers.
• Start feeding 4-6hours after surgery with clear liquids and progress toward breast or bottle as tolerated by a baby.
• Administration of medicine as pre-prescribed.
• Avoid introducing of small feeder or spoon in the oral cavity.
• Clean the site after each feeding.
• Close observation of the suture site for signs and symptoms of infection and bleeding.
• Positioned baby to prevent airway obstruction.
• The gentle suction of mouth and nasopharynx.

In the case of Cleft palate

• Allowed baby to lie on the abdomen to prevent aspiration of blood from the suture side.
• Start feeding by the bottle or cut 4-6 hours after surgery with clear liquids.
• Avoid introducing a feeder or spoon in the oral cavity.
• Take care of the pack in the oral cavity.
• Advise the parents to avoid hard food like cookies, fruits, and apples.
• Arrange a sitting position during feeding.
• Teaching for long-term home care: feeding, testing for speech and hearing problems, and their treatment by the concerned specialist.
• Psychological support to parent family.