Cleft Lip and Palate

See the Cleft Lip and Palate Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Team Approach to Treatment

Treatment for children with cleft palate (with or without cleft lip) and associated craniofacial or velopharyngeal conditions involves a team approach. The team includes a patient care coordinator or nurse who facilitates team function and efficiency, assists families, and coordinates care for individuals and families. The cleft palate team must have as a minimum core a surgeon, an orthodontist, and an SLP.

Teams may also include or have access to professionals in other fields, such as audiology, general dentistry, genetics, nursing, otolaryngology, pediatrics, psychology, and social work. Additional members vary depending on the individual's developmental, medical, and psychological needs. See Standards for Cleft Palate and Craniofacial Teams (ACPA, 2016) for essential characteristics of quality for team composition and functioning.

See also ASHA's web page, Interprofessional Education/Interprofessional Practice (IPE/IPP).

Components

The primary components of treatment are surgical repair and behavioral intervention (i.e., speech therapy).

  • The goal of surgery is to repair affected structures to establish adequate VP function, facilitate orofacial growth, and improve appearance.
  • The goal of speech therapy is to establish normal articulation behaviors.

Treatment may also include early feeding intervention, dental care and orthodontics, audiologic care and monitoring of hearing status, and psychological services. See Parameters for Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Anomalies [PDF] (ACPA, 2009).

In addition to speech therapy for cleft palate speech deviations, treatment may also address developmental articulation and phonology disorders and language delays or disorders, if present. See the following ASHA Practice Portal Pages, Speech Sound Disorders: Articulation and Phonology, Late Language Emergence, Spoken Language Disorders, and Written Language Disorders.

Approaches to Treating Cleft-Type Speech

Approaches to treatment for articulation disorders associated with cleft palate or VPI will depend on whether or not speech deviations are obligatory (i.e., related to atypical anatomy and/or structural defects) or learned.

  • Obligatory speech deviations that are related to true VPI or other structural deviations such as fistulas are not responsive to speech therapy and will likely require surgical intervention or other physical management.
  • Learned articulation errors (e.g., compensatory errors and phoneme-specific nasal air emission) should be responsive to speech therapy.

Surgical Intervention and Other Physical Management

Surgical intervention or other physical management is needed for speech deviations resulting from

  • resonance disorders (hypernasality or hyponasality);
  • pervasive nasal air emission (and/or weak pressure on oral consonants); and
  • other obligatory errors (e.g., related to dental status/malocclusion).

Presurgical orthopedics may be used to move cleft segments closer together and into better alignment prior to surgical repair. These include

  • lip taping;
  • lip adhesion;
  • nasoalveolar molding (NAM) appliances; and
  • devices attached by pins and screws that force alignment of maxillary segments.

Surgeries can include one or more of the following:

  • Repair of cleft lip (usually performed within the first 6 months of life)
  • Repair of cleft palate (usually by 12 months of age in a child with typical development)
  • Repair of submucous cleft palate
  • Procedures to correct noncleft VPI or to correct postoperative velopharyngeal insufficiency (e.g., pharyngeal flap; sphincter pharyngoplasty; palatal lengthening procedures; posterior pharyngeal wall augmentation)
  • Tonsillectomy and/or adenoidectomy (may be needed prior to pharyngeal flap or other pharyngoplasty)
  • Secondary surgeries to repair palatal fistulae (if symptomatic)
  • Alveolar bone grafting (determined by stage of dental development and in collaboration with orthodontist)
  • Surgical treatment of malocclusion (e.g., maxillary advancement—typically completed in adolescence)

For more information about presurgical and surgical intervention, see Peterson-Falzone et al. (2010), Pearson and Kirschner (2011), and Zajac and Vallino (2017c). See also Parameters for Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Anomalies [PDF] (ACPA, 2009).

Other physical management may include the following:

  • Orthodontics—to correct various malocclusions and other dental alignment deviations
  • Prosthodontics—including palatal obturators, speech bulbs, and palatal lifts

Behavioral Intervention: Speech Therapy for Cleft Palate Speech Errors

Direct speech therapy is appropriate for treatable speech problems (i.e., articulation errors), including compensatory misarticulations and phoneme-specific nasal air emission.

Objectives of therapy are to

  • correct oral placements for consonant misarticulations (e.g., bring backed oral articulations forward, teach correct oral place, and establish oral pressure buildup and release) and
  • establish oral pathway/direction of airflow and appropriate valving of airflow at target place during production of oral sounds (Golding-Kushner, 2001; Ruscello, 2017; Trost-Cardamone, 2013).

Therapy can be diagnostic. Progress can help inform the cleft palate team about VP function and the possible need for (further) surgical intervention (see Guide to Treatment Decision-Making for Cleft-Type Speech [PDF], [Trost-Cardamone, 2013]).

Treatment Strategies

Therapy typically targets the elimination of compensatory misarticulations first, as these tend to have greater impact on intelligibility and VP function than do other types of speech sound errors. Later therapy addresses developmental articulation or phonological errors, if present.

Initial Therapy Targets

Initial therapy targets for children with compensatory misarticulations may include

  • sounds for which the child is stimulable (i.e., can articulate, given a model);
  • nasal and low-pressure consonants, if they are produced or co-produced with glottal stops;
  • high-pressure consonants that are not in the inventory, are age appropriate, or have high impact on intelligibility/understandability; and
  • anterior consonants that are visible (e.g., p, b, t, d, f), given that children often compensate with posterior placement.
Strategies and Techniques

Strategies and techniques used in therapy include

  • Using phonetic placement techniques, typically starting with bilabials and then moving to alveolars.
  • Introducing gentle whispering or using sustained /h/ to break the glottal pattern and to teach easy oral airflow with open glottis.
  • Inserting /h/ after oral stop consonants to discourage use of glottal stops prior to vowel onset [e.g., p(h)op for "pop"].
  • Teaching auditory discrimination between the correct target and the compensatory error to facilitate self-monitoring.
  • Providing visual cues, including
    • using a lateral diagram or a model of the mouth for visual placement cues;
    • pointing to lips/tongue to cue placement;
    • using visual airflow cues (e.g., using a feather); and
    • using mirrors for observing articulatory positioning—sit side-by-side, so that the child can view the reflection of themselves and the therapist.
  • Providing verbal cues such as instructions for correct placement and manner or airstream.
  • Providing tactile cues, such as
    • feeling one's neck musculature to help identify incorrect placement for glottal stops and for pharyngeal stops and fricatives;
    • feeling a released puff of air on one's hand during the production of plosives;
    • using one's finger to feel bilabial closure and oral air pressure on plosives; and
    • using nose plugging/pinching (nasal occlusion) to provide the individual with the sensation of oral pressure and to discourage nasal airflow errors.
  • Using established speech therapy procedures and techniques (e.g., minimal pairs, traditional shaping hierarchy). See ASHA's Practice Portal page, Speech Sound Disorders: Articulation and Phonology.

(Golding-Kushner, 2001; Peterson-Falzone et al., 2016; Trost-Cardamone, 2013)

Use of Technology in Speech Therapy

A number of technologies can be used in speech therapy to provide real-time feedback. However, with the exception of the low-tech tools listed below, many are not available to SLPs in early intervention, early childhood, or school-based programs.

Technologies for real-time feedback include the following:

  • Low-tech tools for targeting PSNE:
    • Dental mirror placed under the nose
    • See-Scape™
    • Stethoscope (placed against side of nose)
    • Plastic tubing or drinking straw for self-monitoring one's own productions (one end is placed at patient's/client's nostril entrance, and the other end is placed by the ear)
  • Nasometer to monitor oral versus nasal speech and provide real-time visual feedback; used in cases of phoneme-specific disorders or nasalization errors (not to treat consistent hypernasality).
  • Nasopharyngoscopy to provide visual feedback about the actions of the VP mechanism during speech (Brunner, Stellzig-Eisenhauer, Pröschel, Verres, & Komposch, 2005), which may help individuals improve VP movements when they have the physical ability to achieve VP closure but do not do so because of faulty articulation (e.g., PSNE; Witzel, Tobe, & Sayler, 1988).
  • Electropalatography (EPG)—a computer-based technique for training correct oral articulation placements; EPG provides a visual feedback display of the tongue's contact with the hard palate during speech (Lee, Law, & Gibbon, 2009).

See Kummer (2014b) for a description of various technologies used in speech therapy for cleft-type speech errors.

Early Speech and Language Intervention

Delays in the onset of babbling and the lack of diversity in consonant production during the prelinguistic period have been linked to delays in speech and language development (Stoel-Gammon, 1994). Early speech and language intervention can lessen the impact of these factors on the development of communication skills in infants and toddlers (see, e.g., Scherer, 1999; Scherer & Kaiser, 2007).

The most important goal of early intervention for babies and toddlers with cleft lip and palate is to help them develop oral speech by increasing consonant inventory, increasing expressive vocabulary, and teaching oral airflow for early emerging fricatives (e.g., /h/; Hardin-Jones, Chapman, & Scherer, 2006; Trost-Cardamone, 2013).

Parent education and training are essential in early intervention. SLPs counsel parents about the expected impact of clefting on speech and encourage parents to foster good communication skills in their babies (Peterson-Falzone et al., 2010). Parent-implemented early intervention programs have been shown to facilitate speech and language development in young children with cleft palate (e.g., Scherer, 2003; Scherer, D'Antonio, & McGahey, 2008).

SLPs play a role by teaching parents

  • how to engage in vocal play with their children before surgery;
  • how not to reinforce compensatory productions (e.g., laryngeal growls and nasal fricatives); and
  • how to provide intensive language stimulation (Golding-Kushner, 2001; Hardin-Jones, Chapman, & Scherer, 2015; Kummer, 2014b; Scherer, 2017; Trost-Cardamone, 2013).

Prior to Palatal Repair

Prior to palatal repair, goals include the following:

  • Using vocal play activities to stimulate production of speech sounds least affected by the cleft (e.g., nasals, glides, glottal fricative /h/, and vowels) by
    • modeling varied sounds and encouraging imitation of sounds as well as lip, tongue, and facial movements and
    • reinforcing attempts to produce oral stop consonants and ignoring any obligatory nasal emissions.
  • Modeling alternatives for compensatory productions (e.g., "no no" instead of "uh uh").

After Palatal Repair

After palatal repair, goals include the following:

  • Using sound play and early word productions to increase variety of vocalization.
  • Increasing consonant inventories, especially oral pressure consonants.
  • Increasing communication opportunities.
  • Increasing vocabulary, with a focus on functional words.
  • Increasing awareness of oral airflow for speech.
  • Monitoring persistent nasal substitutions and glottal stops.
    • If present after surgery, this might indicate learned behaviors (emerging compensatory misarticulations) despite a potentially adequate VP mechanism.

(Hardin-Jones et al., 2006, 2015; Peterson-Falzone et al., 2016; Scherer, 2017)

Feeding and Swallowing

Feeding issues are among the first concerns following the birth of a child with cleft lip and palate. The goal of feeding intervention is to ensure adequate and efficient intake for appropriate hydration and nutrition, for growth and development, and for adequate medical status prior to surgery.

An important additional goal is to ensure that feeding is a low-stress experience for infant and family (Reid, 2004). Health care providers (e.g., SLPs, nurses, or lactation consultants) instruct mothers in feeding techniques and reassure them that successful feeding can be accomplished with the least amount of stress for the infant and family (Goyal, Chopra, Bansal, & Marwaha, 2014).

Prior to Surgery

A number of strategies and techniques can be used to facilitate feeding success prior to surgery, including

  • placing the baby in an upright position while feeding to help prevent nasal regurgitation;
  • providing jaw and cheek support as needed;
  • using the appropriate nipple size;
  • positioning the nipple optimally (e.g., away from the side of cleft, if unilateral);
  • pacing flow rate and providing fluid in rhythm with baby's cues (e.g., movements and reactions);
  • burping frequently to counter excessive air intake; and
  • limiting feeding time (e.g., no more than 30 minutes) to avoid fatigue (Dailey, 2013; Peterson-Falzone et al., 2010, 2016).

Nasoalveolar molding (NAM) appliances are used prior to surgery to align maxillary segments; however, a secondary benefit is that the appliance can function as a feeding plate. Some parents report improved feeding with a NAM appliance (Zajac & Vallino, 2017a).

Bottle Feeding

Most babies who have cleft palate with or without cleft lip will need a modified bottle in order to feed successfully. Nipples can vary in shape, size, and pliability to accommodate each baby's unique needs. For example, a nipple with a wide base may be sufficient for some babies to achieve adequate lip seal despite a wide cleft lip.

Other frequently used modifications include the following:

  • Nipples with a one-way valve at the base. This valve allows milk to flow into the nipple but not back into the bottle when the nipple is compressed; milk in the nipple flows into the baby's mouth on compression (e.g., Special Needs Feeder, Pigeon Bottle, and Dr. Brown's Standard Specialty Feeding System).
  • Soft, squeezable bottles that allow the feeder to express milk into the baby's mouth by compressing the bottle in sync with each sucking motion (e.g., Mead Johnson Cleft Palate Nurser).
  • Nipples with enlarged (e.g., cross-cut) holes that allow milk to flow into the baby's mouth via force of gravity; the feeder must monitor the baby's cues and control the rate of flow to avoid compromising the baby's suck–swallow–breathe coordination.

See the Cleft Palate Foundation video, "Feeding Your Baby," for demonstrations of feeding using various bottle and nipple types.

Breastfeeding

Mothers interested in breastfeeding should be supported and given all necessary guidance in their efforts. Consultation with a lactation consultant or feeding specialist is often recommended, and the baby's weight gain should be closely monitored. If breastfeeding is not sustainable for maintaining adequate nutrition and hydration, mothers who are interested in bonding with their babies during nonnutritive times at the breast after feeding should be supported.

The type and severity of the cleft can affect the degree of success with breastfeeding. For example, babies with isolated cleft lip, small soft palate clefts, or submucous clefts will have less difficulty than babies with larger clefts of the lip and/or palate (see, e.g., Arvedson & Brodsky, 2001; Clarren, Anderson, & Wolf, 1987; Garcez & Giugliani, 2005; Grady, 1977; Mei, Morgan, & Reilly, 2009; Miller, 2011).

As with bottle feeding, making modifications in feeding position and providing cheek and lip support can help make breastfeeding successful. Often, the baby is unable to completely empty the breast; however, milk can be expressed and placed into a bottle to complete the feeding or to store for a later feeding.

After Surgery

Decisions about the timing and methods of feeding after surgical cleft repair vary and depend on a number of factors, including

  • the type (e.g., lip or palate; unilateral or bilateral) and size of the original cleft;
  • the particular surgical procedure (e.g., primary lip repair or primary palate repair); and
  • the preferences of the surgeon and the cleft-craniofacial team.

Some babies are allowed to feed from bottle or breast immediately after surgery, while others will use alternate methods (e.g., syringe or spoon feeding) for the first month or so following surgery (see, e.g., Cohen, Marschall, & Schafer, 1992; Darzi, Chowdri, & Bhat, 1996; Peterson-Falzone et al., 2016).

Feeding Considerations: Babies With Clefts Related to Craniofacial and Genetic Sequences or Syndromes

Clefting is sometimes one of several anomalies in children with craniofacial and genetic sequences or syndromes. Some anomalies associated with these conditions may place the child at risk for airway compromise during feeding. These anomalies may include differences that are both structural (e.g., anatomically smaller airway) and neurological (e.g., weakened muscles due to hypotonia).

Careful assessment is conducted, with particular consideration for potential airway compromise during feeding. The infant's nutritional needs might necessitate alternate feeding methods (e.g., tube feeding).

See ASHA's Practice Portal Page, Pediatric Dysphagia, for assessment and treatment considerations.

Audiologic Care

Early audiologic assessment and ongoing monitoring of hearing status by an audiologist are essential for children with cleft lip and palate, especially because of the potential impact of hearing loss on speech and language development (Holm & Kunze, 1969; Yoshinaga-Itano, Coulter, & Thomson, 2000).

Audiologic assessment and management depend on the type and degree of hearing loss and will include

  • diagnostic auditory brainstem response (ABR) testing shortly after birth;
  • frequent monitoring of hearing status and middle ear function, especially from birth to age 5–6 years old;
  • referral and ongoing monitoring of middle ear health and ventilation tube function by the otolaryngologist; and
  • consideration for amplification and personal FM or Bluetooth system for educational settings when a persistent or permanent hearing loss is identified.

Teachers and other school personnel should be informed of any necessary services and accommodations for school-age children with fluctuating or permanent hearing loss (ACPA, 2009).

See ASHA's Practice Portal pages— Hearing Loss – Beyond Early Childhood and Permanent Childhood Hearing Loss—for information related to audiologic management. Will also link to the Practice Portal page on otitis media when available.

Role of the Community-Based SLP in Treatment

Collaboration

Successful speech therapy involves a partnership between the community-based SLP (e.g., school, private clinic, etc.), the cleft palate team, and the child's parents and caregivers.

Collaboration between the community-based SLP and the SLP on the cleft palate team is essential to ensure optimal speech outcomes (Golding-Kushner, 2001; Peterson-Falzone et al., 2016).

Models of collaboration vary and may change over the course of treatment, based on the needs of the individual and the availability of resources (Dailey & Wilson, 2015; Grames, 2004). Models include informal consultation, formal consultation, parallel service delivery, and co-provision of care (Lorenz, Mauksch, & Gawinski, 1999).

See Ruscello (2017) for a discussion of how the school SLP can use various models of collaboration in treatment. See also ASHA's resource on collaboration and teaming.

Education and Training

Community-based SLPs involved in speech intervention must be familiar with the timeline for surgical and orthodontic intervention, the impact of oral and pharyngeal structures on speech, and the types of errors related to clefts and VPI (Dailey & Wilson, 2015).

Adequate preparation at the graduate school level as well as continuing education and training opportunities are essential for providing the community-based SLP with the knowledge and skills necessary to treat this population (Bedwinek, Kummer, Rice, & Grames, 2010; Grames, 2008).

School-based SLPs report that information in several areas would be helpful. These areas include specific speech treatment techniques, assessment and treatment of articulation disorders related to VPI, treatment of resonance disorders, and language problems of children with cleft lip and palate (Bedwinek et al., 2010).

Persisting Speech Difficulties

Speech difficulties associated with cleft lip and palate can persist into adolescence and adulthood and can have an impact on self-esteem and ease of communication in educational, social, and vocational settings.

Speech difficulties can persist for a number of reasons, including

  • lack of access to adequate speech services when the child was younger, resulting in habituated speech patterns (compensatory articulations) that may be more difficult to change;
  • persistent anatomic obstacles to normal speech, such as severe malocclusion or untreated VPI;
  • expectations of failure;
  • poorly developed self-monitoring skills; and
  • lack of motivation.

Some of the speech errors that persist into adolescence are related to past or ongoing dental and occlusal problems. Some surgical procedures (e.g., maxillary advancement) are done in adolescence, and treatment of related errors or distortions may have been deferred until then. Speech is reevaluated after the surgical procedure to check for articulation and resonance and to ensure that no new or worsening symptoms are present. Additional speech therapy may be appropriate for these individuals. They will need to be highly motivated to improve speech in order to overcome learned misarticulations that have increased in habit strength over time (see, e.g., Kummer, 2014b; Peterson-Falzone et al., 2010).

Transitioning to Adult Services

Individuals transitioning from child-centered multidisciplinary care to adult-centered care may face a number of challenges, including difficulties locating appropriate services on their own. Barriers associated with the transition may have a negative impact on quality of care and on the individual's quality of life. A model of adult care that incorporates a team approach would likely facilitate this transition (Zajac & Vallino, 2017e).

See ASHA's resource on transitioning youth for general information related to transition planning and available services.

Cultural Considerations

Cultural sensitivity is essential when discussing potential treatment recommendations and outcomes. Careful consideration of the family's beliefs and values are also important factors when designing treatment goals. The clinician must consider the individual's linguistic environment to ensure that goals will meet the linguistic demands of daily life for the individual and his or her family. For additional information, see ASHA's Practice Portal page on Cultural Competence.

Service Delivery

See the Cleft Lip and Palate Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives related to service delivery.

In addition to determining the type of speech and language treatment that is optimal for individuals with cleft lip and palate, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

  • Format — whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group; the format of service delivery for this population can include in-office and telepractice models (Golding-Kushner, 2015)
  • Provider — the person providing treatment (e.g., SLP, trained volunteer, caregiver)
  • Dosage — the frequency, intensity, and duration of service
  • Timing — the timing of intervention relative to the diagnosis—this includes timing of behavioral intervention in relation to surgical/physical management  
  • Setting — the location of treatment (e.g., home, community-based, school)

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.