Clinical Practice Guideline on Treatment of Patients with Clefts of the Lip and Palate
Netherlands Association for Plastic Surgery (NVPC). (2018).
Utrecht (Netherlands): Netherlands Association for Plastic Surgery (NVPC), 1-358.
This clinical practice guideline provides recommendations for the treatment of individuals with a cleft lip and/or cleft palate without additional craniofacial differences or other disorders.
Netherlands Association for Plastic Surgery (NVPC; Netherlands)
ERN CRANIO (European Reference Networks)
When developing a feeding plan for a baby with a cleft lip, cleft lip and alveolar arch, and/or cleft palate, parents should be included in the decision-making process of finding a comfortable, individualized feeding method keeping "the wellbeing of the child and the quality of the feeding session ... paramount" (Chapter 4; p. 41). The feeding method (e.g., breastfed, bottle-fed, feeding posture) should be considered in relation to the growth of the child, feeding parameters (e.g., intake quantity, flow, feeding time), feeding difficulties (e.g., swallowing air, choking, nasal regurgitation), and parent confidence and capabilities. Oral intake should be prioritized when possible. Parents should be offered prenatal preparation and support with potential feeding difficulties. Parents should make the decision between breast milk or formula.
Cleft teams should include speech therapists "with knowledge about and experience in the normal development of drinking and eating and the effect of clefts of the lip and palate on these processes" (Chapter 4; p. 40). The speech therapist should participate in special interest groups or national societies related to craniofacial differences.
"Start oral feeding as soon as possible in both the postnatal and postoperative phase. Tube feeding (as only feeding method) is not recommended" (Chapter 4; p. 40).
All children with a cleft lip, cleft lip and alveolar arch, and/or cleft palate should have their hearing assessed thoroughly on a periodic basis up to 3-4 years old. Children who receive tympanostomy tubes should have their hearing assessed at least once post-operatively.
A multi-disciplinary team, including at least a speech therapist, a surgeon, and an ENT physician, should diagnose velopharyngeal insufficiency. The speech therapist conducting a speech therapy examination for velopharyngeal insufficiency should participate in the national task force for orofacial cleft speech therapists or a similar professional organization.
After primary palate closure and 6 months of specialized speech therapy with inadequate treatment outcomes, velopharyngeal insufficiency may be diagnosed in children with cleft palate.<br /><br />One year post-speech-improvement surgery, all pre-operative assessments should be repeated to assess the effect of surgery. After 6 months of specialized speech therapy post-surgery, nasoendoscopy/videofluoroscopy may be repeated.
Assessment for velopharyngeal insufficiency should include an oral inspection, acoustic nasometry, mirror tests, and nasoendoscopy with a photo or video recording. Videofluoroscopy may be performed as an alternative to nasal endoscopy or to provide additional information regarding velum function. Magnetic resonance imaging should not be included in a standard assessment for velopharyngeal insufficiency.
