Craniofacial conditions, including cleft lip and palate, are congenital structural anomalies caused by atypical embryological development. Craniofacial differences are a result of interruption in embryologic growth between the 4th and 10th week of the developing embryo or fetus (Peterson-Falzone, Hardin-Jones, & Karnell, 2010).
Clefts are described based on the structures involved (lip, alveolus, hard palate, soft palate), laterality (unilateral left, unilateral right, or bilateral), and severity (width and extent of structures involved). Clefts can be isolated (cleft lip only or cleft palate only), or they can occur in combination. They can be unilateral or bilateral, and they can be complete or incomplete.
Figure 1 contains images of the most common types of cleft affecting the palate, along with a labeled image of intact structures. The primary palate is the triangular area of the hard palate anterior to the incisive foramen and includes a portion of the alveolar ridge. The secondary palate consists of the remaining hard palate and all of the soft palate.
Figure 1: Representation of the most common types of cleft affecting the palate. (a) Unilateral cleft lip with alveolar involvement; (b) bilateral cleft lip with alveolar involvement; (c) unilateral cleft lip associated with cleft palate; (d) bilateral cleft lip and palate; (e) cleft palate only (© Copyright Brito, Meira, Kobayashi, & Passos-Bueno, 2012).
Palatal clefts can be overt or submucous. An overt palatal cleft is visibly open and can be observed on intraoral inspection. In a submucous cleft palate (SMCP), oral mucosa is intact, but the underlying velar musculature has failed to attach at midline. The cleft is not visibly open and often is not obvious on intraoral inspection. There are three signs of an SMCP: (a) zona pellucida—a blue discoloration due to levator veli palatini muscle diastasis (i.e., separation in the midline); (b) a bifid uvula; and (c) a palpable bony notch at the edge of the hard palate.
Another type of SMCP, referred to as an occult (hidden) submucous cleft palate (OSMCP) has no visual oral manifestations and can be diagnosed only by direct observation during surgery or by magnetic resonance imaging (MRI). Nasendoscopy may demonstrate a concave or flattened nasal surface of the palate, indicating possible diastasis and/or absence of the musculus uvulae muscle.
Cleft lip and cleft palate can be associated with a large number of craniofacial and genetic sequences or syndromes, some of which are rare. Some examples include the following:
Incidence is the number of new cases of a disorder or condition identified in a specific time period. Prevalence is the number of individuals who are living with the disorder or condition in a given time period.
Epidemiological estimates of orofacial clefts vary substantially on the basis of a variety of factors, including the sample population, the surveillance methodology, and the clinical classification (International Perinatal Database of Typical Oral Clefts [IPDTOC] Working Group, 2011).
Worldwide, oral clefts in any form (i.e., cleft lip, cleft lip and palate, or isolated cleft palate) occur in about one in every 700 live births (World Health Organization [WHO], 2001). International estimates that are limited to cleft lip with or without cleft palate range from 7.94 to 9.92 per 10,000 live births (IPDTOC, 2011; Tanaka, Mahabir, Jupiter, & Menezes, 2012).
Cleft lip with or without cleft palate is the second most common birth defect in the United States, affecting one in every 940 births and resulting in 4,437 cases every year (Parker et al., 2010). Reported prevalence estimates range from 7.75 to 10.63 per 10,000 live births (Parker et al., 2010; Tanaka et al., 2012). Isolated cleft palate is less common, presenting in one in every 1574 births (Parker et al., 2010).
The occurrence rate of orofacial clefts varies by population. Overall, higher rates have been reported in Asians and American Indians (one in 500 births), and lower rates have been reported in African-derived populations (one in 2,500 births; Dixon, Marazita, Beaty, & Murray, 2011). Isolated cleft palate is more frequently found in females than in males, at a ratio of 2:1. In contrast, there is a 2:1 male-to-female ratio for cleft lip with or without cleft palate (Mossey, Little, Munger, Dixon, & Shaw, 2009).
The signs and symptoms associated with clefting depend on a variety of factors, including type and severity and whether both lip and palate are involved. Individuals with cleft lip and palate may experience difficulties in one or more of the areas listed below.
Normal velopharyngeal (VP) closure separates the nasal and oral cavities and allows for speech to be produced with a balance between oral and nasal resonance. VP closure allows for (a) oral resonance of vowels, liquids, and glides and (b) the buildup of intraoral pressure and facilitation of orally directed airflow required for production of the oral pressure consonants (stops, fricatives, and affricates). With normal resonance balance, nasal consonants /m/, /n/, and "ng" have nasal energy enhancement.
Velopharyngeal dysfunction (VPD; also referred to as velopharyngeal inadequacy [VPI]) may result from palatal clefting or from other noncleft causes such as mechanical interference (e.g., large tonsils), neurogenic etiologies, or velopharyngeal mislearning (see Classification of Velopharyngeal Dysfunction [PDF] [Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones, 2006; Trost-Cardamone, 1989]).
During speech production, VPD can cause hypernasality (a resonance disorder), nasal air emission, or both. Hypernasality and nasal air emission that result from an anatomical or physiological inability to close the VP port are considered obligatory (see "obligatory errors" in the Articulation subsection below).
(See e.g., Kummer, 2011, 2014a; Trost-Cardamone, 2013; Zajac & Vallino, 2017a.)
The resulting impact of VPD on articulation can be described as "cleft palate speech" or "cleft-type speech" and may include obligatory errors and/or compensatory (learned) errors.
Obligatory errors exist due to structural abnormalities that result in velopharyngeal insufficiency and oral structural deviations (e.g., oronasal fistulas, dental deviations, or malocclusions).
They are not likely to improve until the structural cause is addressed though physical management (e.g., surgery or prosthetic intervention).
Obligatory errors include the following:
Compensatory errors are learned articulation errors. They are, for the most part, errors in place of articulation or direction of airflow.
These errors are thought to develop for a number of reasons, including the inability to generate adequate intraoral air pressure for consonant production, the presence of anterior structural anomalies, abnormal auditory–perceptual learning, or other factors.
Compensatory errors that developed due to anatomical inability to close the VP port can persist even after successful physical management of the VP mechanism.
Learned nasal emission can be realized as nasal fricative substitutions or nasal emission that is co-produced with the target sound and may be associated with nasal turbulence or snorting.
The following two patterns may be see:
(See e.g., Golding-Kushner, 2001, 2015; Golding-Kushner & Shprintzen, 2011; Morgan & O'Gara, 2014; Peterson-Falzone, Trost-Cardamone, Karnell, &Hardin-Jones, 2016; Trost-Cardamone, 2013; Zajac & Vallino, 2017d)
Children may also present with articulation and/or phonological errors that are unrelated to cleft palate. See ASHA's Practice Portal page, Speech Sound Disorders: Articulation and Phonology, for a description of these error types and for detailed information on assessment and treatment.
When compared with age-matched peers without cleft palate, babies with cleft palate often show both quantitative and qualitative differences in their early prelinguistic and linguistic development.
Speech and language development in children with clefts depends on a number of factors, including hearing status, type and severity of the cleft, and the presence of a syndrome.
(See e.g., Chapman, 1991; Chapman & Hardin, 1992; Chapman, Hardin-Jones, Schulte, & Halter, 2001; Estrem & Broen, 1989; Hardin-Jones & Chapman, 2014; O'Gara & Logemann, 1988; O'Gara, Logemann, & Rademaker, 1994; Olson, 1965; Peterson-Falzone et al., 2010; Scherer, Williams, & Proctor-Williams, 2008; Shprintzen, 2000; Trost-Cardamone, 2013)
Voice problems in children with cleft palate may include the following:
Syndromic conditions associated with cleft palate may be associated with organic laryngeal disorders that affect voice. Examples include calcification of the larynx in Apert syndrome and vocal fold paralysis and glottic webbing in 22q11.2 deletion syndrome (Cavalli, 2011; Shprintzen, 2000; Shprintzen & Golding-Kushner, 2008).
Feeding problems can vary considerably in infants with clefting, depending on the type and severity of the cleft. In most cases, infants with clefts who are otherwise typically developing have normal pharyngeal swallowing function; once the milk reaches the oropharynx, the swallow is initiated with normal airway protection (Miller & Kummer, 2014; Shprintzen & Bardach, 1995).
Babies with cleft lip only typically have little feeding difficulty. Once the nipple is positioned in the baby's mouth, he or she can usually achieve sufficient compression of the nipple against the intact palate.
Babies with cleft palate—with or without cleft lip—may have more significant feeding difficulty. They are unable to separate the nasal cavity from the oral cavity and therefore cannot create the negative pressure necessary for sucking. In addition, they may have difficulty compressing the nipple to express milk because the palatal surface is not intact.
Potential problems associated with feeding difficulties include
Infants with cleft palate and other craniofacial anomalies associated with genetic syndromes or sequences may have more significant feeding and swallowing difficulties (Cooper-Brown et al., 2008; Dailey, 2013). For example, children with Pierre Robin sequence are at increased risk for airway obstruction, dysphagia, and aspiration due to micrognathia and glossoptosis, which position the tongue toward or even against the posterior pharyngeal wall (Monasterio et al., 2004; Nassar, Marques, Trindale, & Bettiol, 2006; Shprintzen & Singer, 1992). In infants with 22q11.2 deletion syndrome, laryngeal, neurologic, or cardiac abnormalities may exacerbate feeding difficulties (e.g., Cuneo, 2001; Golding-Kushner & Shprintzen, 2011) and may contribute to fatigue (Cuneo, 2001).
Infants with cleft lip and palate who are preterm may have feeding and swallowing problems, which, in addition to those problems associated with clefting, place these infants at high risk for aspiration and poor nutritional intake.
More significant feeding and swallowing difficulties seen in these populations may be signaled by the following:
For more information, see ASHA's Practice Portal page, Pediatric Dysphagia.
Dental deviations and malocclusion can affect articulatory placement.
Dental deviations include the following:
Malocclusions include the following:
Children with cleft palate with or without cleft lip may be at high risk for middle ear effusions and associated conductive hearing loss because of eustachian tube malfunction (Flynn, Möller, Jönsson, & Lohmander, 2009). The prevalence of middle ear fluid in children with unrepaired cleft palate has been estimated at more than 90% (Paradise, Bluestone, & Felder, 1969; Stool & Randall, 1967). Middle ear fluid is also seen in children with isolated cleft lip, although the prevalence is lower than in children with cleft palate (Deedler et al., 2011; Ruegg et al., 2015; Vallino, Zuker, & Napoli, 2008).
Other potential causes of conductive hearing loss include anomalies of the outer ear (e.g., stenotic or narrow external auditory canal) and anomalies of the middle ear (e.g., malformation of the ossicles; Zajac & Vallino, 2017b).
Fluctuating and long-standing conductive hearing loss is the primary concern for children with cleft palate. However, sensorineural hearing loss (e.g., due to inner ear anomalies), or mixed hearing loss may also be present, especially in children with syndromes (e.g., Stickler syndrome; Nowak, 1998; Zajac & Vallino, 2017b).
See ASHA's Practice Portal pages, Permanent Childhood Hearing Loss and Hearing Loss Beyond Early Childhood, for more detailed information about hearing loss. Will link to Practice Portal page on otitis media, currently under development.
Cleft lip and palate can have an impact on the individual's psychological and social well-being; this impact can vary on the basis of cultural beliefs.
Potential psychosocial impact can include the following:
See Hunt, Burden, Hepper, and Johnston (2005) and Peterson-Falzone et al. (2010) for more detailed discussions of the psychosocial impact of cleft lip and palate.
Earlier theories suggested that craniofacial conditions may negatively affect mother–infant interaction and attachment (Clifford, 1969; Endriga, Speltz, & Wilson, 1992; Field & Vega-Lahr, 1984; Waechter, 1977). However, recent research indicates that the mother–infant relationship does not appear to be affected by facial differences associated with clefting (Maris, Endriga, Speltz, Jones, & DeKlyen, 2000). By 2 years of age, most infants with cleft lip and palate demonstrate secure maternal attachments (Maris et al., 2000).
There is no one cause of cleft lip and palate. However, most cases are thought to result from multifactorial inheritance—an interaction between the person's genes (genetic predisposition) and specific environmental factors (see, e.g., Beaty et al., 2011). Clefting can also be caused by chromosomal differences in individuals born with genetic syndromes.
Risk factors that increase the likelihood of cleft lip and palate include the following:
Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of speech and language problems, as well as feeding and swallowing problems, associated with cleft lip and palate. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
A team approach to service delivery is essential throughout the individual's care, and SLPs typically provide services as part of, or in collaboration with, a team. See Standards for Cleft Palate and Craniofacial Teams from the American Cleft Palate-Craniofacial Association (ACPA, 2016) for essential characteristics of quality for team composition and functioning. See also ASHA's web page, Interprofessional Education/Interprofessional Practice (IPE/IPP).
Appropriate roles for SLPs include, but are not limited to,
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so. This is of paramount importance for those serving on a cleft palate-craniofacial team, where decisions regarding surgical intervention require significant SLP input.
Speech screening for the child with clefting or suspected VP dysfunction may be completed by an SLP in a variety of settings, including a cleft palate-craniofacial team visit.
The SLP attends to signs of
The screening protocol may also include a hearing screening and screening of expressive and receptive language skills. Screening may result in recommendations for additional assessments/examinations by the team and/or a comprehensive speech and language assessment.
Assessment and treatment of clefts may require use of appropriate personal protective equipment.
An SLP conducts a comprehensive speech and language assessment using both standardized and nonstandardized measures. (See ASHA's resource on assessment tools, techniques and data sources).
Some infants and toddlers with clefts may be evaluated by an SLP in early intervention to identify language delays, even before they are seen by a team. An understanding of the speech and language characteristics of these children is essential for accurate assessment. For children who are not yet talking, the assessment includes measures of vocalization diversity and complexity, vocalization rate, and use of communicative gestures (Scherer, 2017). (For more information, see the Early Speech and Language Characteristics section of this Portal page, ASHA's Practice Portal pages Late Language Emergence and Early Intervention.)
For school-age children, the assessment may be conducted by the school SLP, who provides services to the child within the context of an educational setting. The assessment may also be conducted by the team SLP or by an SLP in another outpatient or private clinic. Collaboration between the team SLP and other SLPs involved in service delivery for a child with a history of cleft lip and palate is encouraged (ACPA, 2016).
Due to the likelihood of transient or permanent hearing loss in this population, the comprehensive assessment typically includes an audiologic assessment by an audiologist.
See Comprehensive Assessment for Cleft Lip and Palate: Typical Components. Specific components of an assessment will depend on the individual's age and stage of development.
The assessment is conducted in the language(s) used by the child and his or her family, with the use of interpretation services as necessary (see ASHA's Portal Page, Collaborating With Interpreters). Assessment takes into account speech and language characteristics unique to the linguistic background of the individual and the cultural variables that affect communication.
Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe
See ASHA's Person-Centered Focus on Function: Cleft Lip and Palate [PDF] for an example of assessment data consistent with ICF. See also Neumann and Romonath (2012) for a discussion of the application of ICF to cleft lip and palate.
Assessment may result in
Studies of populations in Cambodia, China, Egypt, India, Kenya, Nigeria, Peru, Russia, and South Africa, have found that causal explanations of cleft lip and palate sometimes reflect religious beliefs (e.g., evil spirits or punishment for a past sin). Other causal explanations include a poor diet or starvation during pregnancy, viewing a solar eclipse during pregnancy, or having lived near a nuclear plant during pregnancy (Loh & Ascoli, 2011; Mednick et al., 2013).
Cultural beliefs about the cause of cleft lip and palate may influence a family's decisions about seeking treatment (Loh & Ascoli, 2011; Louw, Shibambu, & Roemer, 2006; Mednick et al., 2013). For example, individuals who believe that clefting is "fate" or "God's will" may not seek treatment, so as not to interfere with the spiritual world (Loh & Ascoli, 2011).
Cultural differences might also affect the interaction between the clinician and family, and cultural sensitivity on the part of the clinician is essential for developing trust. Professionals need to understand cultural differences—including differences in maternal reactions to the birth of a child with clefting—and learn to communicate across cultural lines when providing care (Black, Girotto, Chapman, & Oppenheimer, 2004; Strauss, 1997). Using ethnographic interviewing techniques can be an effective strategy for gathering information about cultural beliefs and concerns.
For more information, see ASHA's Practice Portal page, Cultural Competence.
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).
The primary components of treatment are surgical repair and behavioral intervention (i.e., speech therapy).
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 treatment for articulation disorders associated with cleft palate or VPD will depend on whether or not speech deviations are obligatory (i.e., related to atypical anatomy and/or structural defects) or learned.
Surgical intervention or other physical management is needed for speech deviations resulting from
Presurgical orthopedics may be used to move cleft segments closer together and into better alignment prior to surgical repair. These include
Surgeries can include one or more of the following:
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:
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
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]).
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 for children with compensatory misarticulations may include
Strategies and techniques used in therapy include
(Golding-Kushner, 2001; Peterson-Falzone et al., 2016; Trost-Cardamone, 2013)
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:
See Kummer (2014b) for a description of various technologies used in speech therapy for cleft-type speech errors.
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
Prior to palatal repair, goals include the following:
After palatal repair, goals include the following:
(Hardin-Jones et al., 2006, 2015; Peterson-Falzone et al., 2016; Scherer, 2017)
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).
A number of strategies and techniques can be used to facilitate feeding success prior to surgery, including
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).
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:
See the Cleft Palate Foundation video, "Feeding Your Baby," for demonstrations of feeding using various bottle and nipple types.
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.
Decisions about the timing and methods of feeding after surgical cleft repair vary and depend on a number of factors, including
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).
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.
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
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.
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.
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 VPD (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 VPD, treatment of resonance disorders, and language problems of children with cleft lip and palate (Bedwinek et al., 2010).
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
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).
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 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.
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.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American Cleft Palate-Craniofacial Association. (2009). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Chapel Hill, NC: Author.
American Cleft Palate-Craniofacial Association. (2016). Standards for cleft palate and craniofacial teams. Chapel Hill, NC: Author.
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.
Anderson, K. L., & Matkin, N. D. (1991, Winter). Relationship of degree of long-term hearing loss to psychosocial impact and educational needs. Educational Audiology Association Newsletter, 8, 17–18.
Arpino, C., Brescianini, S., Robert, E., Castilla, E. E., Cocchi, G., Cornel, M. C., . . . Zampino, G. (2000). Teratogenic effects of antiepileptic drugs: Use of an international database on malformations and drug exposure (MADRE). Epilepsia, 41, 1436–1443.
Arvedson, J. C., & Brodsky, L. (2001). Pediatric swallowing and feeding: Assessment and management. Albany, NY: Singular.
Beaty, T. H., Ruczinski, I., Murray, J. C., Marazita, M. L., Munger, R. G., Hetmanski, J. B., . . . Wu, T. (2011). Evidence for gene-environment interaction in a genome-wide study of nonsyndromic cleft palate. Genetic Epidemiology, 35, 469–478.
Bedwinek, A. P., Kummer, A. W., Rice, G. B., & Grames, L. M. (2010). Current training and continuing education needs of preschool and school-based speech-language pathologists regarding children with cleft lip/palate. Language, Speech, and Hearing Services in Schools, 41, 405–415.
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The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Cleft Lip and Palate (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Cleft-Lip-and-Palate/.