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[WORK IN PROGRESS] Newborn palate examination and detection of cleft palate AFS v.2

By Anthony · 9 April 2024

Learning objectives

1) To understand the prevalence, improve early detection of cleft palate, its impact on patients and family. 2) To incorporate the best practice recommendations into personal practice when examining the newborn

Prevalence

  • In the UK cleft lip and palate occurs in 1 in 650 births. Half have a cleft palate only (CPO), without cleft lip.
HOT TIP: Half of Cleft Palate Only have an additional abnormality, a signal to look carefully for others.

  • And vice versa, always check the palate when an abnormality is present.
Delayed detection is a problem

When the Best Practice Guidelines for Newborn Palate Examination were introduced in 2014, rates of delayed detection had not changed for 10 years.

2014: 25% were not detected within 72 hrs, the age limit for completion of the UK Newborn Infant Physical Examination (NIPE) guideline.

2019: Within 5 years the rate had fallen to 13%

2020-2022: During COVID the improvement was not maintained.

*CRANE Annual Report 2022
HOT TIP: Delayed detection is significant, leading to:

  • Poor nutrition and growth,
  • Impaired hearing and speech development.
  • Failed access to timely medical and surgical management.
  • Parents commonly become angry and disappointed with their doctors and nurses.
  • NHS makes financial payouts for delayed detection
HOT TIP: Red Flag symptoms

  • Breathing difficulties (think Robin sequence: small lower jaw, tongue liable to obstruct airway through a wide cleft palate)
  • Feeding difficulties. Weak suck and ‘latching on’ to the breast, with noisy wet clicking sounds while feeding
  • Milk comes out of one or both nostrils during a feed, not related to ‘winding’
HOT TIP: Visualisation is the gold standard method of examination: A normal palate is completely intact and a single uvula hangs down in the midline

It is important to familiarise yourself with what a normal palate looks like and what a cleft palate looks like.
Normal palate
HOT TIP: The optimal examination technique is using a tongue depressor and flash light. The uvula is clearly seen at the tip of the wooden spatula

Clefts of the palate extend forward in the midline from the back of the palate where the muscles of the soft palate have failed to join. This shows a cleft of the soft palate extending into the hard palate.
Cleft palate occurs in different sizes and widths. Small clefts are the most difficult to see. This is why it is important to see the whole of the uvula which hangs down at the back of the throat
(A) Cleft of the soft palate (B) Wide cleft of the hard palate, the bony plates of the nasal septum are visible (C) Narrow cleft of the hard palate (D) Wide cleft of the hard palate

Looking at and handling models of normal and cleft palates helps understanding:

Life size silicone models of the palate (A) Four normal (B) Three sizes of cleft

 

Photos courtesy of Marrbel Cleft Palate Diagnostic Models (mar-bel etc)
Photos courtesy of Marrbel Cleft Palate Diagnostic Models (mar-bel etc)

In the UK cleft lip and palate occurs in 1 in 650 births. Half have a cleft palate only (CPO), without cleft lip.

HOT TIP:

Half of Cleft Palate Only have an additional abnormality, a signal to look carefully for others.

And vice versa, always check the palate when an abnormality is present.

When the Best Practice Guidelines for Newborn Palate Examination were introduced in 2014, rates of delayed detection had not changed for 10 years.

  • 2014: 25% were not detected within 72 hrs, the age limit for completion of the UK Newborn Infant Physical Examination (NIPE) guideline.
  • 2019: Within 5 years the rate had fallen to 13%
  • 2020-22: During COVID the improvement was not maintained.

Hotspot test
This is a palate

Prevalence

  • In the UK cleft lip and palate occurs in 1 in 650 births. Half have a cleft palate only (CPO), without cleft lip.

HOT TIP: Half of Cleft Palate Only have an additional abnormality, a signal to look carefully for others.

  • And vice versa, always check the palate when an abnormality is present.

Delayed detection is a problem

When the Best Practice Guidelines for Newborn Palate Examination were introduced in 2014, rates of delayed detection had not changed for 10 years.

  • 2014: 25% were not detected within 72 hrs, the age limit for completion of the UK Newborn Infant Physical Examination (NIPE) guideline.
  • 2019: Within 5 years the rate had fallen to 13%
  • 2020-22: During COVID the improvement was not maintained.

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Email us at rcpchlearning@rcpch.ac.uk