CLEFT LIP AND CLEFT PALATE

Incomplete closure of the lip and palate or root of the mouth.

Etiology: The exact cause of the lip and palatal clefting is not known, but most experts feel that it is due to both genetic and environmental factors.

Related Causes: Genetic; Folic acid deficiency; steroid, exposure to TORCH.

Common problems:

• feeding difficulty

• infections - upper respiratory and ear

• speech defect (cleft palate)

• dental defect (nasal twang)

• altered normal body image

• respiratory distress

Treatment: Surgery

1. Cleft Lip: CHEILOPLASTY

2. Cleft palate: PALATOPLASTY - done before speech development.

Preoperative care:

• proper positioning especially during and after feeding - upright positioned

• burp or bubble the newborn more often

• feed the baby with the use cross cut large holed nipple or Breck feeder technique

• observe for signs of complication: Otitis Media

• For dental defects: Orthodontic exercise and surgery

• speech therapy

Postoperative care:

• Proper positioning: CL- supine or side lying; CP: prone

• Apply elbow restraint and release every 2 hours

• Give feeding with rubber tipped medicine dropper for cleft lip and paper cups and soup spoons for cleft palate

• Cleanse the wound with hydrogen peroxide

• Give post operative medications which include analgesic and antibiotic

• Avoid sucking, suctioning, blowing, pointed and sharp objects (spoon, fork, and straw)

• Make sure baby does not suck the LOGAN’S BAR OR BOW

Feeding an Infant with a Cleft:

Feeding an infant is important not only in providing nourishment, it also provides an intimacy and closeness for both the parent and the child. Infants with a cleft lip seldom have problems either by bottle or breast.

In babies with clefts of the hard palate, the opening in the roof of the mouth often causes difficulty in creating adequate pressure on the nipple, thus creating an inability to suck well enough to get adequate nourishment. Feeding the infant takes patience and practice.

During my school days, we recommended the use of soft squeezable plastic bottle like Mead Johnson with an orthodontic nipple such as Nuk. You can increase the flow by gently squeezing or putting pressure on the bottle. It is important to feed the infant before he/she becomes too hungry. Position the infant in an upright position with the head tilted back slightly. This position allows the milk to flow down into the throat and less into the nose. Infants with clefts do swallow more air and need to be burped frequently. At first, it may take extra time, but this will steadily decrease. Feeding time of the newborn varies from 20-30 minutes. When feeding takes longer than 45 minutes, the infant may be burning up calories necessary to gain weight.

Breast feeding the newborn with a cleft palate is often unsuccessful. Generally the infant cannot produce enough negative pressure to obtain ample breast milk to provide adequate nourishment. Using a breast pump to extract the milk and feeding the infant breast milk from squeezable bottle is recommended.

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Human Chorionic Gonadotropin

Source: Trophoblast of placenta

Function:

• Maintains the corpus luteum for the 1^st trimester because it acts like LH but is not susceptible to feedback regulation from estrogen and progesterone. In the 2^nd and 3^rd trimester, the placenta synthesizes its own estrogen and progesterone. As a result, the corpus luteum degenerates.
• Used to detect the pregnancy because it appears in the urine 8 days after successful fertilization (blood and urine tests available). But the presence of hCG in pregnancy test will still be classified as probably sign of pregnancy. (Read number 3 for another reason why it’s considered to as probably sign.
• Elevated hCG in women with hydatidiform mole or choriocarcinoma.
• It is used medically to induce ovulation and to treat male hypogonadism and cryptorchidism, and is produced in certain cancers (as of the testes). The fact that exogenous HCG has characteristics almost identical to those of the luteinizing hormone (LH) which, as mentioned, is produced in the hypophysis, makes HCG so very interesting for athletes. In a man the luteinizing hormone stimulates the Leydig’s cells in the testes; this in turn stimulates production of androgenic hormones (testosterone). For this reason athletes use injectable HCG to increase the testosterone production.

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Bottlefeeding

A. Advantages
1. Provides an alternative to breastfeeding
2. Less restrictive than breastfeeding; may meet needs of working mothers
3. Allows a more accurate assessment of intake
4. May be indicated in the presence of a congenital anomaly such as cleft palate
5. May be necessary for infants who require special formulas because of allergies or inborn errors of metabolism

B. Types of formulas
1. Commercial liquid or powdered formulas
2. Special formulas
3. Unmodified regular cow’s milk, liquid or reconstituted; not appropriate for infants before 12 months of age; cow’s milk contains more protein, more calcium, less vitamin C, less iron, and less carbohydrate

C. Contraindications
1. Inadequate intelligence to prepare formula
2. Poor storage and refrigeration practices
3. Contaminated water supply
4. Cost of formula and equipment
5. Lack of equipment to adequately prepare bottles

Nursing Care of the Mother Who Is Bottlefeeding

A. Assessment
1. Desire to bottlefeed
2. Sucking ability of infant
3. Knowledge of formulas and formula preparation (more…)

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Breastfeeding Mnemonics:

Breast feeding: benefits ABCDEFGH:
• Infant:
Allergic condition reduced
Best food for infant
Close relationship with mother
Development of IQ, jaws, mouth
• Mother:
Econmical
Fitness: quick return to pre-pregnancy body shape
Guards against cancer: breast, ovary, uterus
Hemorrhage (postpartum) reduced

A. Advantages
a. Psychologic value of closeness and satisfaction in beginning of mother-child relationship
b. Optimum nutritional value for infant
c. Economic and readily accessible (more…)

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Caput succedaneum:

is caused by the mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. Edema of the soft tissue over bone (crosses over suture line); subsides within few days

A caput succedaneum is more likely to form during a prolonged or difficult delivery. This is especially true after the membranes have ruptured, thus removing the protective cushion of the amniotic sac. Vacuum extraction can also increase the chances of a caput succedaneum.

However, a caput succedaneum is sometimes identified by prenatal ultrasound even before labor or delivery begins. It has been found as early as 31 weeks of gestation. More often than not, this is associated with either premature rupture of the membranes or too little amniotic fluid (oligohydramnios). All other things being equal, the longer the membranes are intact, the less likely a caput is to form. (more…)

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Gravida
: The number of pregnancies a woman has had regardless of the outcome of pregnancy.

Nulligravida
: a woman who has never been pregnant.

Primigravida
: a woman experiencing her first pregnancy.

Multigravida
: a woman who has previously had more than one pregnancy.

Gravid
: a pregnant woman

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