The scope of this page is cleft lip and palate in children from birth through school age (to 21 years). Some content is also relevant to individuals with velopharyngeal inadequacy, secondary to various other etiologies.
See the Cleft Lip and Palate Evidence Map for summaries of the available research on this topic.
Craniofacial conditions, including cleft lip and palate, are congenital structural anomalies caused by atypical embryological development.
Speech, language, and hearing deficits are related to the presentation of the cleft. 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). They can be complete (extending through and beyond the lip and/or palate) or incomplete (partially extending through the lip and/or palate). A cleft can occur in isolation or in association with other congenital malformations. Please see ASHA’s resource on Common Types of Palatal Clefts.
Cleft lip and palate may result in a number of deficits that require audiology and/or speech-language pathology treatment, including
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 a disorder or condition in a given time period.
Epidemiological estimates of orofacial clefts vary due to a variety of factors, including the sample population, the surveillance methodology, and the clinical classification (International Perinatal Database of Typical Oral Clefts Working Group, 2011). Worldwide, oral clefts in any form (i.e., cleft palate, cleft lip, or cleft lip with cleft palate) are found in approximately one in every 1,000–1,500 live births overall (Salari et al., 2021; World Health Organization [WHO], 2022). Global prevalence rates vary, with cleft palate occurring in approximately one in 1,500–3,000 births; cleft lip, in approximately one in 3,000–3,300 births; and cleft palate with cleft lip, in approximately one in 1,500–2,200 births (Salari et al., 2021; WHO, 2020). Unilateral cleft lip is more common than bilateral cleft lip. Left-sided cleft lip is more common than right-sided cleft lip (WHO, 2020).
Orofacial clefts are one of the most common congenital disorders in the United States, affecting one in every 1,000 births (Mai et al., 2019) and resulting in 3,937 cases every year (Mai et al., 2019; National Institutes of Health, 2022). Cleft palate and cleft lip with cleft palate occur in one in every 1,700 and 1,600 births, respectively. Isolated cleft lip is less common, presenting in one in every 2,800 U.S. births (Centers for Disease Control and Prevention, 2020; Mai et al., 2019).
The occurrence rate of orofacial clefts varies by population. In the United States, surveillance program data from the U.S. Department of Defense Birth and Infant Health Research Program found higher rates in American Indian or Alaskan Native, White, and Asian or Pacific Islander populations and lower rates in Hispanic and Black, non-Hispanic populations (National Birth Defects Prevention Network, 2022). Isolated cleft palate is more frequently found in biological females than in biological males. In contrast, there is a greater male-to-female ratio for cleft lip and for cleft lip with cleft palate (Mossey et al., 2009; Yow et al., 2021).
The signs and symptoms associated with clefting depend on a variety of factors, including type (i.e., cleft lip, cleft palate, or both) and severity of the cleft and whether the cleft is associated with a craniofacial syndrome. 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). During the production of nasal consonants /m/, /n/, and /ŋ/, the VP valve is open, resulting in acoustic oral–nasal coupling.
The language that an individual speaks may impact the clinician’s ability to successfully assess and treat resonance. Also, an individual’s language may impact the functional severity of the disorder. For example, if a language requires more resonance (e.g., a tonal language), the impact of a cleft may be more severe. Speech-language pathologists (SLPs) should consider linguistic variations, including the presence of lexical tones (in tonal languages) when addressing resonance as some may affect judgments, such as “creaky” or “glottalized” tones. Please see the Linguistic Considerations section in ASHA’s Practice Portal page on Resonance Disorders for further information.
Velopharyngeal dysfunction (VPD) is a general term that does not indicate causality. Velopharyngeal insufficiency (VPI) is due to a structural abnormality (cleft palate, post adenoidectomy). Velopharyngeal incompetence is due to a neurogenic cause (head trauma, stroke, cerebral palsy, neurologic disease). Finally, velopharyngeal mislearning is due to faulty articulation (see Kummer, 2011b, 2020a; Peterson-Falzone et al., 2016; Trost-Cardamone, 1989).
There are a number of causes of VPD, the most common of which is cleft palate or submucous cleft palate. Other common causes include a short palate, deep pharynx, and weak or uncoordinated palatal muscle function caused by neurological disorders. Less common causes of VPD are enlarged tonsils, an irregular adenoid pad, and adenoidectomy (see Possible Causes of Hypernasality and/or Nasal Emission; Peterson-Falzone et al., 2016; Trost-Cardamone, 1989; Vallino et al., 2018).
During speech production, VPD can cause hypernasality, nasal air emission, or both. Hypernasality and nasal air emission that result from an anatomical or a physiological inability to close the VP port are considered obligatory (see the Obligatory Errors subsection under the Articulation section).
(See, e.g., Kummer, 2011a, 2020a; Trost-Cardamone, 2013; Zajac & Vallino, 2017b.)
Structural anomalies within the oral cavity or pharynx (i.e., VPI, fistula, dental anomalies, or malocclusion) can cause obligatory errors and/or compensatory errors. It is important to recognize these distortions and productions to ensure appropriate management.
Obligatory errors exist due to structural abnormalities that result in VPI and oral structural deviations (e.g., oronasal fistulas, dental deviations, or malocclusions).
Obligatory errors occur when articulation placement is normal, but there is a distortion of certain speech sounds due to a structural abnormality (e.g., VPI, oronasal fistula, dental anomaly, or malocclusion). Because the cause is a structural abnormality, these distortions require physical management (e.g., orthodontics, surgery, or prosthetic intervention). Physical correction of the structure may eliminate the distortion, without the need for speech therapy.
Examples of obligatory articulation errors associated with dental and occlusal anomalies (see section on dental and occlusal anomalies) as well as oral fistula include, but are not limited to,
Compensatory errors are actively learned maladaptive articulations that develop in response to abnormal structures found in VPD. These errors develop as a maladaptive way to increase intelligibility or decrease difficulty. They are thought to develop for a number of reasons, including the inability to generate adequate intraoral air pressure for consonant production, the presence of palatal structural anomalies (e.g., fistulas), and abnormal auditory–perceptual learning. Compensatory errors typically involve a change in placement, but the manner of production is maintained. Compensatory errors can persist even after successful physical management of the VPD.
Other maladaptive errors
Learned nasal emission (nasal fricatives) is a maladaptive articulation error that is produced through the nose and used to replace oral fricatives. It is heard as phoneme-specific nasal emission (PSNE) or pharyngeal specific hypernasality and may be associated with nasal turbulence or snorting. Because the cause is faulty articulation, appropriate treatment involves speech therapy.
The following three patterns may be seen:
(See, e.g., Golding-Kushner, 2001, 2015; Golding-Kushner & Shprintzen, 2011; Kummer, 2011a, 2020a; Morgan & O’Gara, 2014; Peterson-Falzone et al., 2016; Trost-Cardamone, 2013; Zajac & Vallino, 2017e.)
Children may also present with articulation and/or phonological errors that are unrelated to cleft palate. See ASHA’s Practice Portal page on 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 et al., 2001; Eshghi et al., 2019, 2022; Estrem & Broen, 1989; Hardin-Jones & Chapman, 2014; O’Gara & Logemann, 1988; O’Gara et al., 1994; Olson, 1965; Peterson-Falzone et al., 2010; Scherer et al., 2008; Shprintzen, 2000; Trost-Cardamone, 2013; Zajac et al., 2021.)
Individuals with cleft palate and VPD may exhibit perceptual voice disorders (D’Antonio et al., 1988; McWilliams et al., 1969). Voice disorders include the following:
Various craniofacial conditions can 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 deficits 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, 2020; Shprintzen & Bardach, 1995). Preterm infants may have feeding and swallowing deficits. Preterm infants with cleft lip and palate are therefore at an even higher risk for aspiration and poor nutritional intake.
Babies with cleft lip only typically have little feeding difficulty. Once the nipple is positioned in the baby’s mouth, they 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 deficits 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 (undersized lower jaw) and glossoptosis (displacement of the tongue), which position the tongue toward or even against the posterior pharyngeal wall (Monasterio et al., 2004; Nassar et al., 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).
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 on Pediatric Feeding and Swallowing.
Dental anomalies often occur in children with a history of cleft of the primary palate. They usually occur in the line of the cleft, which is between the lateral incisor and canine tooth. Dental anomalies can be corrected with orthodontia. Examples include the following:
Malocclusion occurs when the jaws (maxilla and mandible) are not aligned properly. Treatment involves orthodontia and then orthognathic surgery after facial growth has been completed. Examples include the following:
Dental anomalies can interfere with tongue tip movement. Occlusal anomalies can affect the tongue tip to alveolar ridge relationship and bilabial competence (Kummer, 2020c). Both can cause obligatory distortions and/or compensatory productions.
Children with cleft palate with or without cleft lip are at risk for middle ear effusion (MEE) caused by Eustachian tube dysfunction. MEE is typically fluctuating in nature, and when present, MEE can result in conductive hearing loss that can range in severity. MEE can occur in isolated cleft lip, although the prevalence is lower than in children with cleft palate (Deelder et al., 2011; Ruegg et al., 2015; Vallino et al., 2008).
Fluctuating and long-standing conductive hearing loss is a primary concern for individuals with cleft palate. Sensorineural and mixed hearing loss can and does occur but to a lesser extent. Hearing loss can also be associated with craniofacial syndromes such as Stickler syndrome, 22q11.2 deletion syndrome, Apert syndrome, and Treacher Collins syndrome (Nowak, 1998; Zajac & Vallino, 2017c). In some cases, anomalies of the outer and/or middle ear may contribute to conductive or mixed hearing loss. Age of surgical cleft repair and frequency of ventilation tube insertion are significant factors that influence hearing outcomes in children with cleft lip and palate (Skuladottir et al., 2015; Yang et al., 2019).
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:
A cleft is the result of failure or interruption in growth or fusion of the normal craniofacial process (Leslie & Marazita, 2013). Clefts originate between the 4th and 10th week of embryologic development (Peterson-Falzone et al., 2010). There is no one cause of cleft lip and palate. 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). Syndromic cleft refers to a cleft that co-occurs with a syndrome or a disorder as a result of a genetic or chromosomal difference.
Risk factors that increase the likelihood of cleft lip and palate include
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:
For more information on rare diseases, please visit rarediseases.org.
Cultural beliefs may impact individuals’ determination of the cause of craniofacial differences (Loh & Ascoli, 2011; Mednick et al., 2013; Turlapati et al., 2021). This may influence a family’s decisions about seeking treatment (Loh & Ascoli, 2011; Louw et al., 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).
SLPs practice cultural sensitivity when providing education about the causes of cleft lip and palate to individuals and their caregivers. Please see the Counseling and Education Regarding Cleft Lip and Palate section as well as ASHA’s Practice Portal page on Cultural Responsiveness.
See the Cleft Lip and Palate Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Speech screening for the child with a cleft lip and/or palate or suspected velopharyngeal dysfunction (VPD) may be completed by an SLP in a variety of settings, including cleft palate–craniofacial team visits, school, and early intervention.
The SLP attends to signs of
The screening protocol includes a hearing screening and screening of expressive and receptive language skills. Screening may result in recommendations for additional assessments by the team, such as a comprehensive, audiologic, more in-depth speech and language assessment or instrumental assessment.
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. 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.
Infants and toddlers: Some infants and toddlers with clefts may be evaluated by an SLP in an early intervention program to identify language delays, articulatory errors, and voice and swallowing disorders 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 Practice Portal page as well as ASHA’s Practice Portal pages on Late Language Emergence and Early Intervention.
School-age children: Assessment may be conducted by the school SLP, the medical team SLP, or 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 (American Cleft Palate Craniofacial Association, 2022).
Adolescents: Assessment may be conducted by the school SLP and team SLP. Assessments should include perceptual measures of speech, self-reports about speech, and of the impact of speech on activities and participation (e.g., being understood by others, presenting in the classroom, engaging in clubs and sports).
Adults: Using the International Classification of Functioning, Disability and Health (ICF; World Health Organization [WHO], 2001) as a framework, SLPs conduct perceptual speech assessments and seek information about the person’s perception of speech and the impact of speech on quality of life. The SLP can be helpful in connecting adults with appropriate service providers.
Due to the likelihood of transient or permanent hearing loss in this population, the comprehensive assessment typically includes an audiologic assessment by an audiologist and otologic examination by an otolaryngologist. The audiologist monitors middle ear function and hearing sensitivity, and the otolaryngologist assesses and manages otologic concerns. Based on the findings, recommendations to enhance hearing are made, which may include listening devices and/or medical/surgical intervention.
The assessment is conducted in the language(s) used by the child and their family, with the use of interpretation services as necessary (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators). Assessment considers speech and language characteristics unique to the linguistic background of the individual and the cultural variables that affect communication (see ASHA’s Practice Portal page on Bilingual Service Delivery).
Consistent with the WHO’s ICF framework (WHO, 2001), comprehensive assessment is conducted to identify and describe
See ASHA’s Person-Centered Focus on Function: Cleft Lip and Cleft Palate [PDF] for an example of assessment data consistent with the ICF framework. Also see Neumann and Romonath (2012) for a discussion of the application of the ICF framework to cleft lip and palate.
Assessment may result in
Spiritual, religious, and cultural beliefs may influence individuals’ perception of the cause of cleft lip and/or palate. For instance, some individuals may believe that cleft lip and/or palate occur because of evil spirits or as a punishment for a past sin. It is the clinician’s responsibility to exercise cultural sensitivity, which helps develop trust. Professionals need to be aware of beliefs—including differences in cultural reactions to the birth of a child with clefting—and communicate respectfully when providing care (Black et al., 2009; Strauss, 1997). Using ethnographic interviewing techniques can be an effective strategy for gathering information about cultural beliefs and concerns.
See the Cleft Lip and Palate Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Treatment for children with clefts, other craniofacial conditions, and even noncleft velopharyngeal insufficiency (VPI) is best done through a cleft palate–craniofacial team. The team typically includes a patient care coordinator, nurse, or social worker who facilitates team function and efficiency, assists families, and coordinates care for individuals and families. Based on standards developed by the American Cleft Palate Craniofacial Association (ACPA, 2022), a cleft palate team must have, as a minimum, a surgeon, an orthodontist, and an SLP.
Comprehensive teams may also include or have access to professionals in other fields, such as audiology, otolaryngology, ophthalmology, dentistry, genetics, nursing, psychology, and social work. Others may include oral maxillofacial surgeons, developmental pediatricians, geneticists, and plastic and craniofacial surgeons. Additional members vary depending on the individual’s developmental, medical, and psychological needs. See Standards for Approval of Cleft Palate and Craniofacial Teams [PDF] (ACPA, 2022) for essential characteristics of quality for team composition and functioning.
See also the American Speech-Language-Hearing Association’s (ASHA’s) web page, Interprofessional Education/Interprofessional Practice (IPE/IPP).
Treatment of children affected by clefts or other craniofacial conditions involves normalizing structure through physical management (surgical or orthodontic) and normalizing function through 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 Differences (ACPA, 2018).
In addition to speech therapy for compensatory productions secondary to cleft lip/palate, treatment may also be needed for unrelated articulation/phonology disorders and language disorders, if present. See ASHA’s Practice Portal pages on Speech Sound Disorders – Articulation and Phonology, Late Language Emergence, Spoken Language Disorders, and Written Language Disorders.
Feeding disorders 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 the infant and their 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 et al., 2014). Please see ASHA’s Practice Portal page on Pediatric Feeding and Swallowing for further information.
A number of strategies and techniques can be used to facilitate feeding success prior to surgery, including
Some cleft palate centers offer nasoalveolar molding (NAM) for infants with cleft lip and palate before surgery. NAM is a presurgical appliance that is used prior to surgery to align maxillary segments; however, a secondary benefit is that the appliance can function as a dental plate. Some parents report improved feeding with a NAM appliance (Zajac & Vallino, 2017b).
A feeding obturator is a prosthetic appliance that can be used in the first few months of life to assist the infant with cleft palate in feeding. Some craniofacial centers use feeding obturators routinely, believing that the appliance improves the ability of the infant to compress the nipple. Most craniofacial centers do not routinely use these appliances because they feel that with modifications of the nipple or bottle, correct positioning, and appropriate feeding techniques, the obturator simply is not necessary (Miller & Kummer, 2020).
Most babies who have cleft palate with or without cleft lip require a modified bottle to feed successfully. Nipples can vary in shape, size, and pliability to accommodate each baby’s unique needs.
Other frequently used modifications include the following:
See the ACPA’s Feeding Your Baby for demonstrations of feeding using various bottle and nipple types.
Families 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, families 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 affects the degree of success with breastfeeding. Babies with an isolated cleft lip, small soft palate clefts, or submucous clefts may have less difficulty than babies with larger clefts of the lip. Babies with cleft palate are usually unable to achieve adequate nutrition through breastfeeding alone. Expressing milk and using a bottle for delivery is usually needed (see, e.g., Arvedson & Brodsky, 2001; Clarren et al., 1987; Garcez & Giugliani, 2005; Grady, 1977; Mei et al., 2009; Miller, 2011).
As with bottle-feeding, making modifications to the 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 several factors, including
Some babies are able to feed from bottle or breast immediately after surgery, whereas others will use alternate methods (e.g., syringe or spoon-feeding) for the first month or so following surgery (see, e.g., Cohen et al., 1992; Darzi et al., 1996; Peterson-Falzone et al., 2016).
Cleft palate only (without cleft lip) is often associated with a craniofacial syndrome. Many syndromes include features that place the child at risk for airway compromise during feeding, such as structural anomalies (e.g., anatomically smaller airway, glossoptosis) or neurological deficits (e.g., weakened muscles due to hypotonia).
Assessment for potential airway compromise during feeding should be done for these at-risk infants. The infant’s nutritional needs might necessitate alternate feeding methods (e.g., tube feeding).
See ASHA’s Practice Portal page on Pediatric Feeding and Swallowing for assessment and treatment considerations.
Approaches to treatment for articulation disorders associated with cleft palate or velopharyngeal dysfunction (VPD) will depend on whether speech deviations are obligatory (i.e., related to atypical anatomy and/or structural defects) or learned.
Surgical intervention or other physical management is needed to manage speech disorders resulting from
Presurgical orthopedics during infancy 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 (2017d). See also Parameters for Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Differences (ACPA, 2018).
Other physical management approaches may include the following:
Direct speech therapy is appropriate for treatable articulation disorders, including compensatory misarticulations and phoneme-specific nasal air emission due to a pharyngeal placement on sibilants.
The 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 Treatment Decision Tree for Managing Speech Problems Associated With Cleft Palate and VPD [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 the following:
(Golding-Kushner, 2001; Kummer, 2020b; Peterson-Falzone et al., 2016; Trost-Cardamone, 2013.)
Nonspeech oral motor therapy involves the use of oral motor training prior to teaching sound or as a supplement to speech sound instruction. Such approaches are controversial in the treatment of cleft lip and palate (Kummer, 2020b; Ruscello & Vallino, 2020). Consult systematic reviews of this treatment to help guide clinical decision making (see, e.g., Lee & Gibbon, 2015; McCauley et al., 2009). See also the Treatment section of the Speech Sound Disorders Evidence Map filtered for Oral Motor Exercises as well as ASHA’s Practice Portal page on Speech Sound Disorders – Articulation and Phonology.
Performance feedback is integral to speech improvement and helps improve outcomes. This feedback can be provided in several forms and may include instrumentation. A number of technologies can be used in speech therapy to provide feedback. With the exception of the low-tech/no-tech tools listed below, some instrumentation for feedback may not be available to SLPs in early intervention, early childhood, school-based, or hospital-based programs.
Technologies for real-time feedback include the following:
See Kummer (2020b) for a description of some of the 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).
Early intervention for babies and toddlers with clefts involves helping them to develop the use of oral speech sounds after palate repair by increasing consonant inventory, increasing expressive vocabulary, and teaching oral airflow for early emerging fricatives (e.g., /h/; Hardin-Jones et al., 2006; Trost-Cardamone, 2013).
Parent education and training are essential in early intervention. SLPs counsel parents about the expected impact of clefts on speech and encourage parents to foster 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 et al., 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.)
Given the potential impact of hearing loss on speech and language development (Holm & Kunze, 1969; Yoshinaga-Itano et al., 2000), early assessment and ongoing monitoring of ear and hearing status by an audiologist are essential for individuals with cleft lip and palate, especially because of the potential impact of hearing loss on speech and language development (Holm & Kunze, 1969; Yoshinaga-Itano et al., 2000).
Audiologic assessment and management depend on the type and degree of hearing loss and include the following:
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, 2018).
See ASHA’s Practice Portal pages on Hearing Loss in Adults, Hearing Loss in Children, and Language and Communication of Deaf and Hard of Hearing Children for information related to audiologic management.
Successful speech therapy involves a partnership between the community-based SLP (e.g., school, private clinic), 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 develop a treatment program and ongoing monitoring to ensure optimal speech outcomes (Bedwinek, 2010; 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 et al., 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.
Speech difficulties associated with cleft lip and palate can persist into adolescence and adulthood and can impact self-esteem, quality of life, 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 anomalies, malocclusion, or untreated VPI. Malocclusion is corrected through maxillary advancement (orthognathic) surgery, but this cannot be done until facial growth has been completed in adolescence. Therefore, treatment of related obligatory distortions or compensatory productions is deferred until the structure is surgically corrected. Speech is reevaluated after maxillary advancement to determine if speech therapy is indicated for the remaining compensatory productions or to rule out VPI that can develop as a result of surgery.
Although cleft lip and palate is present from birth, many adults deal with the implications of these conditions. Treatment may be complete by adulthood for some adults, but for others, dental, appearance, and speech problems may persist and can impact their quality of life. SLPs may be key in assessment, treatment, and provision of appropriate referrals for adults who have these concerns. This role involves going beyond articulation testing to include self-reports about speech and assessment of the social impact of the cleft. The International Classification of Functioning, Disability and Health (World Health Organization, 2001) can serve as a guide for these questions.
For the person with cleft lip and palate, adulthood marks the transition from child-centered team care to adult-centered care. For many, team care for adults after age 21 years may not be accessible, and care is undertaken by community-based providers who may have limited knowledge about or experience with cleft lip/palate. 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, 2017a).
SLPs advocate for adults with cleft lip and palate, particularly by providing education on the rights of these individuals. It is important to provide education and resources to help raise individuals’ awareness of their rights within the Americans with Disabilities Act.
Counseling and education are important in treating cleft lip and palate, particularly because of beliefs, perceptions, and views on society’s acceptance of individuals with cleft lip and palate.
Cultural sensitivity is essential when providing counseling and education and when designing treatment goals. The clinician must consider the individual’s linguistic environment to ensure that goals meet the linguistic demands of daily life for the individual and their family. For additional information, see ASHA’s Practice Portal page on Cultural Responsiveness.
Researchers have theorized that craniofacial conditions may negatively impact mother–infant interaction and attachment (Clifford, 1969; Endriga et al., 1992; Field & Vega-Lahr, 1984; Waechter, 1977); however, there is currently mixed information on the extent and/or presence of such an impact (Maris et al., 2000). Regardless, SLPs should be aware of the potential impact of facial differences on parents’ and caregivers’ perceptions of individuals’ abilities and capacities when providing counseling and education. 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 belief. Clinicians provide counseling related to psychosocial impact when it is within the SLP scope of practice and refer to additional services (e.g., psychotherapy) when appropriate.
Considerations for counseling include the following:
See Hunt et al. (2005) and Peterson-Falzone et al. (2010) for more detailed discussions of the psychosocial impact of cleft lip and palate. Please also see ASHA’s Practice Portal page on Counseling for Professional Service Delivery.
See the Cleft Lip and Palate Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective 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. (2018). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial differences.
American Cleft Palate Craniofacial Association. (2022). Standards for cleft palate and craniofacial teams.
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://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., de Vigan, C., Lancaster, P. A. L., Merlob, P., Sumiyoshi, Y., Zampino, G., Renzi, C., Rosano, A., & Mastroiacovo, P. (2000). Teratogenic effects of antiepileptic drugs: Use of an international database on malformations and drug exposure (MADRE). Epilepsia, 41(11), 1436–1443. https://doi.org/10.1111/j.1528-1157.2000.tb00119.x
Arvedson, J. C., & Brodsky, L. (2001). Pediatric swallowing and feeding: Assessment and management. Singular.
Beaty, T. H., Ruczinski, I., Murray, J. C., Marazita, M. L., Munger, R. G., Hetmanski, J. B., Murray, T., Redett, R. J., Fallin, M. D., Liang, K. Y., Wu, T., Patel, P. J., Jin, S.-C., Zhang, T. X., Schwender, H., Wu-Chou, Y. H., Chen, P. K., Chong, S. S., Cheah, F.,. . . Scott, A. F. (2011). Evidence for gene–environment interaction in a genome-wide study of nonsyndromic cleft palate. Genetic Epidemiology, 35(6), 469–478. https://doi.org/10.1002/gepi.20595
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(4), 405–415. https://doi.org/10.1044/0161-1461(2009/09-0021)
Broder, H., & Strauss, R. P. (1989). Self-concept of early primary school age children with visible or invisible defects. The Cleft Palate Journal, 26(2), 114–117.
Brunner, M., Stellzig-Eisenhauer, A., Pröschel, U., Verres, R., & Komposch, G. (2005). The effect of nasopharyngoscopic biofeedback in patients with cleft palate and velopharyngeal dysfunction. The Cleft Palate–Craniofacial Journal, 42(6), 649–657. https://doi.org/10.1597/03-044.1
Cavalli, L. (2011). Voice assessment and intervention. In S. Howard & A. Lohmander (Eds.), Cleft palate speech: Assessment and intervention (pp. 181–198). Wiley.
Centers for Disease Control and Prevention. (2020, December 28). Facts about cleft lip & cleft palate. National Center on Birth Defects and Developmental Disabilities. Retrieved September 20, 2022, from https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html
Chapman, K. L. (1991). Vocalization of toddlers with cleft lip and palate. The Cleft Palate–Craniofacial Journal, 28(2), 172–178. https://doi.org/10.1597/1545-1569_1991_028_0172_votwcl_2.3.co_2
Chapman, K. L., & Hardin, M. A. (1992). Phonetic and phonologic skills of two-year-olds with cleft palate. The Cleft Palate–Craniofacial Journal, 29(5), 435–443. https://doi.org/10.1597/1545-1569_1992_029_0435_papsot_2.3.co_2
Chapman, K. L., Hardin-Jones, M. A., Schulte, J., & Halter, K. A. (2001). Vocal development of 9-month-old babies with cleft palate. Journal of Speech, Language, and Hearing Research, 44(6), 1268–1283. https://doi.org/10.1044/1092-4388(2001/099)
Clarren, S. K., Anderson, B., & Wolf, L. S. (1987). Feeding infants with cleft lip, cleft palate, or cleft lip and palate. The Cleft Palate Journal, 24(3), 244–249.
Clifford, E. (1969). Parental ratings of cleft palate infants. The Cleft Palate Journal, 6(3), 235–244.
Cohen, M., Marschall, M. A., & Schafer, M. E. (1992). Immediate unrestricted feeding of infants following cleft lip and palate repair. The Journal of Craniofacial Surgery, 3(1), 30–32.
Cooper‐Brown, L., Copeland, S., Dailey, S., Downey, D., Petersen, M. C., Stimson, C., & Van Dyke, D. C. (2008). Feeding and swallowing dysfunction in genetic syndromes. Developmental Disabilities Research Reviews, 14(2), 147–157. https://doi.org/10.1002/ddrr.19
Cuneo, B. F. (2001). 22q11.2 deletion syndrome: DiGeorge, velocardiofacial, and conotruncal anomaly face syndromes. Current Opinion in Pediatrics, 13(5), 465–472.
Dailey, S. (2013). Feeding and swallowing management in infants with cleft and craniofacial anomalies. Perspectives on Speech Science and Orofacial Disorders, 23(2), 62–72. https://doi.org/10.1044/ssod23.2.62
Dailey, S., & Wilson, K. (2015). Communicating with a cleft palate team: Improving coordination of care across treatment settings. Perspectives on Speech Science and Orofacial Disorders, 25(1), 35–38. https://doi.org/10.1044/ssod25.1.35
D'Antonio, L. L., Muntz, H. R., Province, M. A., & Marsh, J. L. (1988). Laryngeal/voice findings in patients with velopharyngeal dysfunction. The Laryngoscope, 98(4), 432-438.
Darzi, M. A., Chowdri, N. A., & Bhat, A. N. (1996). Breast feeding or spoon feeding after cleft lip repair: A prospective, randomised study. British Journal of Plastic Surgery, 49(1), 24–26. https://doi.org/10.1016/S0007-1226(96)90182-4
Deelder, J. D., Breugem, C. C., de Vries, I. A. C., de Bruin, M., Mink van der Molen, A. B., & van der Horst, C. M. A. M. (2011). Is an isolated cleft lip an isolated anomaly? Journal of Plastic, Reconstructive & Aesthetic Surgery, 64(6), 754–758. https://doi.org/10.1016/j.bjps.2010.10.018
DeRoo, L. A., Wilcox, A. J., Drevon, C. A., & Lie, R. T. (2008). First-trimester maternal alcohol consumption and the risk of infant oral clefts in Norway: A population-based case-control study. American Journal of Epidemiology, 168(6), 638–646. https://doi.org/10.1093/aje/kwn186
Dochy, F., Vanheule, E., De Leenheer, E., & Van Hoecke, H. (2019). Middle ear problems in children with cleft palate: A cross-sectional study. Archives of Otolaryngology and Rhinology, 5(3), 078–082. http://doi.org/10.17352/2455-1759.000203
Endriga, M., Speltz, M. L., & Wilson, K. (1992, May). Mothers and their cleft lip and/or palate infants: Face-to-face interaction prior to first surgery [Poster presentation]. Biennial International Conference on Infant Studies, Miami Beach, FL, United States.
Eshghi, M., Adatorwovor, R., Preisser, J. S., Crais, E. R., & Zajac, D. J. (2019). Vocabulary growth from 18 to 24 months of age in children with and without repaired cleft palate. Journal of Speech, Language, and Hearing Research, 62(9), 3413–3430. https://doi.org/10.1044/2019_JSLHR-L-18-0207
Eshghi, M., Adatorwovor, R., Preisser, J. S., Crais, E. R., & Zajac, D. J. (2022). Lexicogrammatical skills in 2-year-old children with and without repaired cleft palate. Clinical Linguistics & Phonetics, 36(6), 528–546. https://doi.org/10.1080/02699206.2021.1941263
Estrem, T., & Broen, P. A. (1989). Early speech production of children with cleft palate. Journal of Speech and Hearing Research, 32(1), 12–23. https://doi.org/10.1044/jshr.3201.12
Field, T. M., & Vega-Lahr, N. (1984). Early interactions between infants with cranio-facial anomalies and their mothers. Infant Behavior & Development, 7(4), 527–530. https://doi.org/10.1016/S0163-6383(84)80012-0
Garcez, L. W., & Giugliani, E. R. J. (2005). Population-based study on the practice of breastfeeding in children born with cleft lip and palate. The Cleft Palate–Craniofacial Journal, 42(6), 687–692. https://doi.org/10.1597/04-108r1.1
Golding-Kushner, K. J. (2001). Therapy techniques for cleft palate speech and related disorders. Delmar Learning.
Golding-Kushner, K. J. (2015). Issues in speech development and management of children with craniofacial disorders, cleft palate and velopharyngeal dysfunction. In C. Bowen (Ed.), Children’s speech sound disorders (pp. 137–142). Wiley-Blackwell.
Golding-Kushner, K. J., & Shprintzen, R. J. (2011). Velo-cardio-facial syndrome: Volume II, Treatment of communication disorders. Plural.
Goyal, M., Chopra, R., Bansal, K., & Marwaha, M. (2014). Role of obturators and other feeding interventions in patients with cleft lip and palate: A review. European Archives of Paediatric Dentistry, 15, 1–9. https://doi.org/10.1007/s40368-013-0101-0
Grady, E. (1977). Breastfeeding the baby with a cleft of the soft palate: Success and its benefits. Clinical Pediatrics, 16(11), 978–981. https://doi.org/10.1177/000992287701601102
Grames, L. M. (2004). Implementing treatment recommendations: Role of the craniofacial team speech-language pathologist in working with the client’s speech-language pathologist. Perspectives on Speech Science and Orofacial Disorders, 14(2), 6–9. https://doi.org/10.1044/ssod14.2.6
Grames, L. M. (2008, May). Advancing into the 21st century: Care for individuals with cleft palate or craniofacial differences. The ASHA Leader, 13(6), 10–13. https://doi.org/10.1044/leader.FTR1.13062008.10
Grosen, D., Chevrier, C., Skytthe, A., Bille, C., Mølsted, K., Sivertsen, Å., Murray, J. C., & Christensen, K. (2010). A cohort study of recurrence patterns among more than 54,000 relatives of oral cleft cases in Denmark: Support for the multifactorial threshold model of inheritance. Journal of Medical Genetics, 47(3), 162–168.
Hardin-Jones, M. A., & Chapman, K. L. (2014). Early lexical characteristics of toddlers with cleft palate. The Cleft Palate–Craniofacial Journal, 51(6), 622–631. https://doi.org/10.1597/13-076
Hardin-Jones, M. A., Chapman, K. L., & Scherer, N. J. (2006, June). Early intervention in children with cleft palate. The ASHA Leader, 11(8), 8–9. https://doi.org/10.1044/leader.FTR3.11082006.8
Hardin-Jones, M. A., Chapman, K. L., & Scherer, N. J. (2015). Children with cleft lip and palate: A parent’s guide to early speech-language development and treatment. Woodbine House.
Holm, V. A., & Kunze, L. H. (1969). Effect of chronic otitis media on language and speech development. Pediatrics, 43(5), 833–839. https://doi.org/10.1542/peds.43.5.833
Hunt, O., Burden, D., Hepper, P., & Johnston, C. (2005). The psychosocial effects of cleft lip and palate: A systematic review. European Journal of Orthodontics, 27(3), 274–285. https://doi.org/10.1093/ejo/cji004
International Perinatal Database of Typical Oral Clefts Working Group. (2011). Prevalence at birth of cleft lip with or without cleft palate: Data from the International Perinatal Database of Typical Oral Clefts (IPDTOC). The Cleft Palate–Craniofacial Journal, 48(1), 66–81. https://doi.org/10.1597/09-217
Jhingree, S., Xie, Y., Bocklage, C., Giduz, N., Moss, K., Zajac, D., & Jacox, L. A. (2022). Validating spectral moment analysis as a quantitative measure of speech distortions in speakers with Class III malocclusions. Perspectives of the ASHA Special Interest Groups, 7(3), 728–740. https://doi.org/10.1044/2022_PERSP-21-00315
Källén, B. (2003). Maternal drug use and infant cleft lip/palate with special reference to corticoids. The Cleft Palate–Craniofacial Journal, 40(6), 624–628. https://doi.org/10.1597/02-077
Kummer, A. W. (2011a). Disorders of resonance and airflow secondary to cleft palate and/or velopharyngeal dysfunction. Seminars in Speech and Language, 32(2), 141–149. https://doi.org/10.1055/s-0031-1277716
Kummer, A. W. (2011b). Types and causes of velopharyngeal dysfunction. Seminars in Speech and Language, 32(2), 150–158. https://doi.org/10.1055/s-0031-1277717
Kummer, A. W. (2020a). Speech/resonance disorders and velopharyngeal dysfunction (VPD). In A. W. Kummer (Ed.), Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (4th ed., pp. 259–294). Jones & Bartlett Learning.
Kummer, A. W. (2020b). Speech therapy. In A. W. Kummer (Ed.), Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (4th ed., pp. 515–548). Jones & Bartlett Learning.
Kummer, A. W. (2020c). Dental anomalies. In A. W. Kummer (Ed.), Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (4th ed., pp. 149-189). Jones & Bartlett Learning.
Lee, A. S.-Y., & Gibbon, F. E. (2015). Non-speech oral motor treatment for children with developmental speech sound disorders. Cochrane Database of Systematic Reviews, 2015(3), 1–42. https://doi.org/10.1002/14651858.CD009383.pub2
Lee, A. S.-Y., Law, J., & Gibbon, F. E. (2009). Electropalatography for articulation disorders associated with cleft palate. Cochrane Database of Systematic Reviews, 2009(8), 1–22. https://doi.org/10.1002/14651858.CD006854.pub2
Leslie, E. J., & Marazita, M. L. (2013, November). Genetics of cleft lip and cleft palate. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 163(4), 246–258. https://doi.org/10.1002/ajmg.c.31381
Li, Z., Liu, J., Ye, R., Zhang, L., Zheng, X., & Ren, A. (2010). Maternal passive smoking and risk of cleft lip with or without cleft palate. Epidemiology, 21(2), 240–242. https://doi.org/10.1097/EDE.0b013e3181c9f941
Little, J., Cardy, A., & Munger, R. G. (2004). Tobacco smoking and oral clefts: A meta-analysis. Bulletin of the World Health Organization, 82(3), 213–218.
Loh, J., & Ascoli, M. (2011). Cross-cultural attitudes and perceptions towards cleft lip and palate deformities. World Cultural Psychiatry Research Review, 6(2), 127–134.
Lorenz, A. D., Mauksch, L. B., & Gawinski, B. A. (1999). Models of collaboration. Primary Care: Clinics in Office Practice, 26(2), 401–410. https://doi.org/10.1016/S0095-4543(08)70013-7
Lorot-Marchand, A., Guerreschi, P., Pellerin, P., Martinot, V., Gbaguidi, C. C., Neiva, C., Devauchelle, B., Frochisse, C., Poli-Merol, M. L., & Francois-Fiquet, C. (2015). Frequency and socio-psychological impact of taunting in school-age patients with cleft lip–palate surgical repair. International Journal of Pediatric Otorhinolaryngology, 79(7), 1041–1048. https://doi.org/10.1016/j.ijporl.2015.04.024
Louw, B., Shibambu, M., & Roemer, K. (2006). Facilitating cleft palate team participation of culturally diverse families in South Africa. The Cleft Palate–Craniofacial Journal, 43(1), 47–54. https://doi.org/10.1597/04-023.1
Mai, C. T., Isenburg, J. L., Canfield, M. A., Meyer, R. E., Correa, A., Alverson, C. J., Lupo, P. J., Riehle‐Colarusso, T., Cho, S. J., Aggarwal, D., & Kirby, R. S. (2019). National population‐based estimates for major birth defects, 2010–2014. Birth Defects Research, 111(18), 1420–1435. https://doi.org/10.1002/bdr2.1589
Maris, C. L., Endriga, M., Speltz, M. L., Jones, K., & DeKlyen, M. K. (2000). Are infants with orofacial clefts at risk for insecure mother–child attachments? The Cleft Palate–Craniofacial Journal, 37(3), 257–265. https://doi.org/10.1597/1545-1569_2000_037_0257_aiwoca_2.3.co_2
McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology, 18(4), 343–360. https://doi.org/10.1044/1058-0360(2009/09-0006)
McWilliams, B. J., Bluestone, C. D., & Musgrave, R. H. (1969). Diagnostic implications of vocal cord nodules in children with cleft palate. The Laryngoscope, 79(12), 2072-2080.
Mednick, L., Snyder, J., Schook, C., Blood, E. A., Brown, S. E., & Weatherley-White, R. C. A. (2013). Causal attributions of cleft lip and palate across cultures. The Cleft Palate–Craniofacial Journal, 50(6), 655–661. https://doi.org/10.1597/11-300R1
Mei, C., Morgan, A. T., & Reilly, S. (2009). Benchmarking clinical practice against best evidence: An example from breastfeeding infants with cleft lip and/or palate. Evidence-Based Communication Assessment and Intervention, 3(1), 48–66. https://doi.org/10.1080/17489530902978691
Miller, C. K. (2011). Feeding issues and interventions in infants and children with clefts and craniofacial syndromes. Seminars in Speech and Language, 32(2), 115–126. https://doi.org/10.1055/s-0031-1277714
Miller, C. K., & Kummer, A. W. (2020). Feeding problems of infants with clefts or craniofacial anomalies. In A. W. Kummer (Ed.), Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (4th ed., pp. 193–223). Jones & Bartlett Learning.
Monasterio, F. O., Molina, F., Berlanga, F., Lopez, M. E., Ahumada, H., Takenaga, R. H., & Yunza, A. (2004). Swallowing disorders in Pierre Robin sequence: Its correction by distraction. The Journal of Craniofacial Surgery, 15(6), 934–941.
Morgan, A., & O’Gara, M. (2014, November). Therapy principles for children with cleft palate [Paper presentation]. Annual Convention of the American Speech-Language-Hearing Association, Orlando, FL, United States.
Mossey, P. A., Little, J., Munger, R. G., Dixon, M. J., & Shaw, W. C. (2009). Cleft lip and palate. The Lancet, 374(9703), 1773–1785. https://doi.org/10.1016/S0140-6736(09)60695-4
Nassar, E., Marques, I. L., Trindale, A. S., & Bettiol, H. (2006). Feeding-facilitating techniques for the nursing infant with Robin sequence. The Cleft Palate–Craniofacial Journal, 43(1), 55–60. https://doi.org/10.1597/04-018.1
National Birth Defects Prevention Network. (2022). Major birth defects data from population-based birth defects surveillance programs in the United States, 2014–2018 [Data set]. Retrieved September 20, 2022, from https://www.nbdpn.org/birth_defects_data_tables_and.php
National Institutes of Health. (2022). Prevalence of cleft lip & cleft palate. National Institute of Dental and Craniofacial Research. Retrieved September 20, 2022, from https://www.nidcr.nih.gov/research/data-statistics/craniofacial-birth-defects/prevalence#:~:text=The%20annual%20prevalence%20of%20infants,with%20or%20without%20cleft%20palate
Natsume, N., Kawai, T., Ogi, N., & Yoshida, W. (2000). Maternal risk factors in cleft lip and palate: Case control study. British Journal of Oral and Maxillofacial Surgery, 38(1), 23–25. https://doi.org/10.1054/bjom.1999.0133
Neumann, S., & Romonath, R. (2012). Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to cleft lip and palate. The Cleft Palate–Craniofacial Journal, 49(3), 325–346. https://doi.org/10.1597/10-145
Noar, J. H. (1991). Questionnaire survey of attitudes and concerns of patients with cleft lip and palate and their parents. The Cleft Palate–Craniofacial Journal, 28(3), 68–75. https://doi.org/10.1597/1545-1569_1991_028_0279_qsoaac_2.3.co_2
Nowak, C. B. (1998). Genetics and hearing loss: A review of Stickler syndrome. Journal of Communication Disorders, 31(5), 437–454. https://doi.org/10.1016/S0021-9924(98)00015-X
O’Gara, M. M., & Logemann, J. A. (1988). Phonetic analyses of the speech development of babies with cleft palate. The Cleft Palate Journal, 25(2), 122–134.
O’Gara, M. M., Logemann, J. A., & Rademaker, A. W. (1994). Phonetic features by babies with unilateral cleft lip and palate. The Cleft Palate–Craniofacial Journal, 31(6), 446–451. https://doi.org/10.1597/1545-1569_1994_031_0446_pfbbwu_2.3.co_2
Olson, D. A. (1965). A descriptive study of the speech development of a group of infants with unoperated cleft palates [Unpublished doctoral dissertation]. Northwestern University.
Pearson, G. D., & Kirschner, R. E. (2011). Surgery for cleft palate and velopharyngeal dysfunction. Seminars in Speech and Language, 32(2), 179–190. https://doi.org/10.1055/s-0031-1277720
Peterson-Falzone, S. J., Hardin-Jones, M. A., & Karnell, M. P. (2010). Cleft palate speech. Mosby.
Peterson-Falzone, S. J., Trost-Cardamone, J. E., Karnell, M. P., & Hardin-Jones, M. A. (2016). The clinician’s guide to treating cleft palate speech. Mosby.
Ramstad, T., Otten, E., & Shaw, W. C. (1995). Psychosocial adjustment in Norwegian adults who had undergone standardised treatment of complete cleft lip and palate II. Self-reported problems and concerns with appearance. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 29(4), 329–336. https://doi.org/10.3109/02844319509008968
Reid, J. (2004). A review of feeding interventions for infants with cleft palate. The Cleft Palate–Craniofacial Journal, 41(3), 268–278. https://doi.org/10.1597/02-148.1
Richman, L. C. (1978a). The effects of facial disfigurement on teachers’ perceptions of ability in cleft palate children. The Cleft Palate Journal, 15(2), 155–160.
Richman, L. C. (1978b). Parents and teachers: Differing views of behavior of cleft palate children. The Cleft Palate Journal, 15(4), 360–364.
Ruegg, T. A., Cooper, M. E., Leslie, E. J., Ford, M. D., Wehby, G. L., Deleyiannis, F. W. B., Czeizel, A. E., Hecht, J. T., Marazita, M. L., & Weinberg, S. M. (2017). Ear infection in isolated cleft lip: Etiological implications. The Cleft Palate–Craniofacial Journal, 54(2), 189–192. https://doi.org/10.1597/15-010
Ruscello, D. M. (2017). School-based intervention. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 281–318). Plural.
Ruscello, D. M., & Vallino, L. D. (2020). The use of nonspeech oral motor exercises in the treatment of children with cleft palate: A re-examination of available evidence. American Journal of Speech-Language Pathology, 29(4), 1811–1820. https://doi.org/10.1044/2020_AJSLP-20-00087
Salari, N., Darvishi, N., Heydari, M., Bokaee, S., Darvishi, F., & Mohammadi, M. (2021). Global prevalence of cleft palate, cleft lip and cleft palate and lip: A comprehensive systematic review and meta-analysis. Journal of Stomatology, Oral and Maxillofacial Surgery, 123(2), 110–120. https://doi.org/10.1016/j.jormas.2021.05.008
Scherer, N. J. (1999). The speech and language status of toddlers with cleft lip and/or palate following early vocabulary intervention. American Journal of Speech-Language Pathology, 8(1), 81–93. https://doi.org/10.1044/1058-0360.0801.81
Scherer, N. J. (2003, November). Parent-implemented speech and language treatment for young children with clefts [Poster presentation]. Annual Convention of the American Speech-Language-Hearing Association, Chicago, IL, United States.
Scherer, N. J. (2017). Early linguistic development and intervention. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 177–190). Plural.
Scherer, N. J., D’Antonio, L. L., & McGahey, H. (2008). Early intervention for speech impairment in children with cleft palate. The Cleft Palate–Craniofacial Journal, 45(1), 18–31. https://doi.org/10.1597/06-085.1
Scherer, N. J., & Kaiser, A. P. (2007). Early intervention for children with cleft palate. Infants & Young Children, 20(4), 355–366. https://doi.org/10.1097/01.IYC.0000290358.62664.8f
Scherer, N. J., Williams, A. L., & Proctor-Williams, K. (2008). Early and later vocalization skills in children with and without cleft palate. International Journal of Pediatric Otorhinolaryngology, 72(6), 827–840. https://doi.org/10.1016/j.ijporl.2008.02.010
Shprintzen, R. J. (2000). Syndrome identification for speech-language pathologists: An illustrated pocket guide. Singular.
Shprintzen, R. J., & Bardach, J. (1995). Cleft palate speech management: A multidisciplinary approach. Mosby.
Shprintzen, R. J., & Golding-Kushner, K. J. (2008). Velo-cardio-facial syndrome: Volume I, Diagnosis and evaluation. Plural.
Shprintzen, R. J., & Singer, L. (1992). Upper airway obstruction and the Robin sequence. International Anesthesiology Clinics, 30(4), 109–114.
Sivertsen, Å., Wilcox, A. J., Skjærven, R., Vindenes, H. A., Åbyholm, F., Harville, E., & Lie, R. T. (2008). Familial risk of oral clefts by morphological type and severity: Population-based cohort study of first degree relatives. British Medical Journal, 336, 432–434. https://doi.org/10.1136/bmj.39458.563611.AE
Skuladottir, H., Sivertsen, A., Assmus, J., Remme, A. R., Dahlen, M., & Vindenes, H. (2015). Hearing outcomes in patients with cleft lip/palate. The Cleft Palate Craniofacial Journal, 52(2), e23-31.
Stock, N. M., Ridley, M., & Guest, E. (2019). Teachers’ perspectives on the impact of cleft lip and/or palate during the school years. The Cleft Palate–Craniofacial Journal, 56(2), 204–209. https://doi.org/10.1177/1055665618770191
Stoel-Gammon, C. (1994). Measuring phonology in babble and speech. Clinics in Communication Disorders, 4(1), 1–11.
Strauss, R. P. (1997). Social and psychological perspectives on cleft lip and palate. In K. R. Bzoch (Ed.), Communicative disorders related to cleft lip and palate (4th ed., pp. 95–113). Pro-Ed.
Trost-Cardamone, J. E. (1989). Coming to terms with VPI: A response to Loney and Bloem. Cleft Palate Journal, 26(1), 68–70.
Trost-Cardamone, J. (2013). Cleft palate speech: A comprehensive 2-part set. American Speech-Language-Hearing Association.
Turlapati, S., Krishna, S., Deepak, K. U., Kanagaraja, B., Gayathri, K. A., & Jahagirdar, D. (2021). A cross-sectional study: Are myths on cleft lip and palate still prevalent? Cureus, 13(11), e19579. https://doi.org/10.7759/cureus.19579
Turner, S. R., Thomas, P. W. N., Dowell, T., Rumsey, N., & Sandy, J. R. (1997). Psychological outcomes amongst cleft patients and their families. British Journal of Plastic Surgery, 50(1), 1–9. https://doi.org/10.1016/S0007-1226(97)91275-3
Vallino, L. D., Ruscello, D. M., & Zajac, D. J. (2018). Cleft palate speech and resonance: An audio and video resource. Plural.
Vallino, L. D., Zuker, R., & Napoli, J. A. (2008). A study of speech, language, hearing, and dentition in children with cleft lip only. The Cleft Palate–Craniofacial Journal, 45(5), 485–493. https://doi.org/10.1597/06-207.1
van Gelder, M. M. H. J., Reefhuis, J., Caton, A. R., Werler, M. M., Druschel, C. M., Roeleveld, N., & National Birth Defects Prevention Study. (2009). Maternal periconceptional illicit drug use and the risk of congenital malformations. Epidemiology, 20(1), 60–66.
Waechter, E. H. (1977). Bonding problems of infants with congenital anomalies. Nursing Forum, 16(3–4), 298–318. https://doi.org/10.1111/j.1744-6198.1977.tb00641.x
Witzel, M. A., Tobe, J., & Salyer, K. (1988). The use of nasopharyngoscopy biofeedback therapy in the correction of inconsistent velopharyngeal closure. International Journal of Pediatric Otorhinolaryngology, 15(2), 137–142. https://doi.org/10.1016/0165-5876(88)90064-X
World Health Organization. (2001, December). Global registry and database on craniofacial anomalies: Report of a WHO registry meeting on craniofacial anomalies.
World Health Organization. (2020). Birth defects surveillance: A manual for programme managers (2nd ed.). https://www.who.int/publications/i/item/9789240015395
World Health Organization. (2022, March 15). Oral health. Retrieved September 20, 2022, from https://www.who.int/news-room/fact-sheets/detail/oral-health
Yang, C., Lai, J., Lee, A., Cheng, L., & Hwang, C. (2019). Prognostic factors for hearing outcomes in children with cleft lip and palate. Plastic and Reconstructive Surgery, 143(2), 368e-374e.
Yoshinaga-Itano, C., Coulter, B. A., & Thomson, M. A. (2000). The Colorado Newborn Hearing Screening Project: Effects on speech and language development for children with hearing loss. Journal of Perinatology, 20, S132–S137. https://doi.org/10.1038/sj.jp.7200438
Yow, M., Jin, A., & Yeo, G. S. H. (2021). Epidemiologic trends of infants with orofacial clefts in a multiethnic country: A retrospective population-based study. Scientific Reports, 11, Article 7556. https://doi.org/10.1038/s41598-021-87229-4
Zajac, D. J., & Vallino, L. D. (2016). Evaluation and management of cleft lip and palate: A developmental perspective. Plural Publishing.
Zajac, D. J., & Vallino, L. D. (2017a). The adult with cleft lip and palate. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 379–390). Plural.
Zajac, D. J., & Vallino, L. D. (2017b). Feeding the newborn. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 113–127). Plural.
Zajac, D. J., & Vallino, L. D. (2017c). Hearing and otologic management. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 151–175). Plural.
Zajac, D. J., & Vallino, L. D. (2017d). Presurgical and surgical management. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 129–226). Plural.
Zajac, D. J., & Vallino, L. D. (2017e). Speech and resonance characteristics. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 193–226). Plural.
Zajac, D. J., Vallino, L. D., Baylis, A. L., Adatorwovor, R., Preisser, J. S., & Vivaldi, D. (2021). Emergence of prevocalic stop consonants in children with repaired cleft palate. Journal of Speech, Language, and Hearing Research, 64(1), 30–39. https://doi.org/10.1044/2020_JSLHR-20-00282
Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Cleft Lip and Palate page.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Cleft lip and palate [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Cleft-Lip-and-Palate/