Associated Problems in Persons with Cleft Lip and Palate: The problems associated with Cleft Lip and Palate depend on 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:

• Feeding Problems
• Speech Sound Development
• Language and Cognition Development
• Speech/Resonance Disorder and Velopharyngeal Dysfunction
• Psychological/Psychosocial Aspects
• Hearing Impairment
• Dental and Occlusion

Feeding Problems

The feeding problems of infants who have a cleft depend on the type of cleft (lip or palate) and the severity of the cleft (unilateral or bilateral; incomplete or complete).

Problems with Cleft Lip and Alveolus only

• Usually do not have significant problems with feeding, especially if the cleft is unilateral.
• They may have initial problems in achieving an adequate lip seal on the nipple to generate effective negative pressure for sucking.
• Infants with cleft lip and alveolus may also have initial difficulty in latching on to the nipple.
• However, once the nipple is placed intraorally, the infant’s tongue and jaw movements are usually sufficient to produce compression of the nipple against the intact part of the alveolus and palate for effective sucking.

Problems with Cleft Palate only

• Infants with a small cleft of the velum only are often able to feed without special modifications.
• In some cases, the infant is able to occlude the cleft with the back of the tongue during part of the sucking movement so that negative pressure can be obtained (Glass & Wolf, 1999).
• Infants with a complete cleft of the soft and hard palate are usually not able to breastfeed because of the fact that they will simply be unable to create negative pressure for suction.
• The open palate often results in nasal regurgitation, which is the reflux of fluid into the nasopharyngeal and nasal cavities. This can cause discomfort and disorganization with breathing during feeding.
• The open cleft allows air to continue to flow in through the nose and then the mouth during feeding. This can result in an excessive intake of air and may cause the infant to become bloated or have episodes of frequent spitting up.
• The difficulty with oral feeding can cause excessive expenditure of energy, and thus calories, during feeding.
• Weight gain and adequate nutrition during the early months of infancy are primary concerns for infants with cleft palate (Glass & Wolf, 1999; Jones, 1988; Kaye et al., 2017; Redford-Badwal, Mabry, & Frassinelli, 2003). A full-term newborn infant generally needs 2 to 3 ounces of breast milk or formula per pound of body weight per day to gain weight appropriately (Butte, 2005; The Cleft Palate Foundation, 1998).
• The infant with a cleft palate usually takes much longer to feed (within 20 to 30 minutes). The lengthy feeding times caused by the feeding difficulty can be very stressful for both the infant and caretaker, thus affecting the normally pleasurable bonding experience (Carlisle, 1998; Zeytinoğlu, Davey, Crerand, Fisher, & Akyil, 2017).

Problems with Cleft Lip and Palate

• Difficulty with all aspects of feeding because of the inability to achieve an anterior seal with the lips, inability to compress the nipple because of the open palate, and failure to generate negative pressure suction (Masarei et al., 2007).
• Significant nasopharyngeal reflux of liquid secondary to the open nasopharynx is also present.
• Breast feeding is usually not possible in this group of infants.
• As with infants with cleft palate only, the use of assisted feeding techniques is usually necessary for successful feeding.

Problems after the Cleft Lip and Palate Repair

• Immediate unrestricted feeding is allowed by some groups, whereas others recommend a restricted approach to facilitate good healing.
• Other centers may recommend supplemental tube feeding for a period of 7–10 days.
• Some centers have implemented immediate, unrestricted feeding after the cleft repair without
  problems.

Speech Sound Development

• Infants with cleft palate, however, have an inadequate sound production mechanism and also frequently have hearing deficits (Jones, Chapman, & Hardin-Jones, 2003; O’Gara & Logemann, 1988).
• They are not able to impound oral airflow for plosives. Therefore, their babbling sounds are restricted to nasal phonemes (/m/, /n/) only, at least until the palate has been repaired.
• Infants with an open cleft palate may even vocalize less than their unaffected peers (Harding & Grunwell, 1996; Kummer, 2011; Long & Dalston, 1982b; O’Gara & Logemann, 1988).
• They may also begin to use glottal stops for plosives rather than developing the typical babbling pattern (Chapman, 1991; Smith & Kuehn, 2007).
• If the palate is repaired by 9–10 months, the child will have missed the developmental stage where plosives are usually produced and practiced through normal babbling.
• The critical period for brain development for speech sound production (Dowling, 2004), it makes sense that the longer the palate remains unrepaired, the harder it is to correct the child’s speech.
• Another factor is regular otologic care, which can prevent hearing loss and help mitigate the risk for delayed speech development.
• Children with craniofacial syndromes often have symptoms of childhood apraxia of speech (CAS). For example, children with VCFS/22q deletion syndrome can have mild to severe apraxia, in addition to obligatory and compensatory productions from velopharyngeal insufficiency (Kummer, Lee, Stutz, Maroney, & Brandt, 2007).

Language and Cognition Development

• Children with a syndrome may experience more severe language disorders than children without a syndrome due to developmental delays associated with the syndrome.
• Children with nonsyndromic clefts may be at risk for early delays in both language and cognitive development, these delays seem to disappear with time (Broen et al., 1998; Collett, Leroux, & Speltz, 2010; Jocelyn et al., 1996; Neiman & Savage, 1997; Richman & Nopoulos, 2009; Shames & Rubin, 1979).
• This may be because of the cleft palate repair, the resolution of middle ear disease that can cause fluctuant hearing loss, and/or the correction of velopharyngeal insufficiency that can affect expressive language development.
• Children with clefts have immature syntactic development, short utterance length, and overall delays in expressive language compared with their unaffected peers (Whitcomb, Ochsner, & Wayte, 1976).
• Children with nonsyndromic clefts show some early deficits in prelinguistic skills during the first 3 years of life (Fox, Lynch, & Brookshire, 1978; Hentges  et al., 2011; Kapp-Simon & Krueckeberg, 2000; Neiman & Savage, 1997; Scherer, Williams, & Proctor-Williams, 2008; Snyder & Scherer, 2004; Speltz et al., 2000).
• Children with clefts have lower scores in verbal performance than nonverbal performance on standardized tests (Broen et al., 1998; Lamb et al., 1973).
• One study showed no differences in comprehension (Receptive language) compared to unaffected peers (Long & Dalston, 1983).
• Children with clefts are at risk for minor delays in cognitive development when compared to their unaffected peers, particularly in the early years (Hardin-Jones & Chapman, 2011; Kapp-Simon & Krueckeberg, 2000; Neiman & Savage, 1997; Snyder & Scherer, 2004; Speltz et al., 2000).

Speech/Resonance Disorder and Velopharyngeal Dysfunction

Resonance and Airflow

• During speech production, VPD can cause hypernasality (a resonance disorder), nasal air emission, or both.
• Hypernasality may increase in connected speech due to increased demands on the VP mechanism.
• Nasal air emission is an aerodynamic phenomenon resulting in audible or inaudible release of air from the nasal cavity during production of oral pressure consonants (i.e., the stops, fricatives, and affricates).
• Nasal air emission can also be caused by airflow through a palatal fistula into the nasal cavities.

Articulation

• 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

Obligatory errors exist due to structural abnormalities that result in velopharyngeal insufficiency and oral structural deviations (e.g., oronasal fistulas, dental deviations, or malocclusions). Obligatory errors include the following:

• Hypernasality on vowels, liquids, and glides (in severe cases, voiced oral consonants may also be nasalized).
• Articulation errors related to dental status or malocclusion (e.g., sibilant distortion with Class III dental malocclusion).
• Obligatory nasal air emission due to VPD or fistula, that is consistent across the oral pressure consonants (stops, fricatives, and affricates). This pattern of airflow into the nasal cavity can persist postoperatively, despite adequate VP closure.

Compensatory Errors

• Compensatory errors are learned articulation errors. They are, for the most part, errors in place of articulation or direction of airflow.
• Compensatory errors that developed due to anatomical inability to close the VP port can persist even after successful physical management of the VP mechanism.
• Compensatory productions for VPI include both plosives and fricatives. Affricates are typically substituted by pharyngeal fricatives, however, because they are too difficult to produce in the pharynx.

Voice

Voice problems in children with cleft palate may include the following:

• Laryngeal hyperfunction from attempting to compensate for loss of pressure at the VP valve may result in muscle tension dysphonia with or without changes to the vocal folds (e.g., vocal nodules; inflammation and edema).
• Soft voice syndrome due to loss of pressure through the VP port or when the child reduces vocal intensity as a compensatory strategy to minimize or disguise hypernasality, nasal emission, or hoarseness (see, e.g., Peterson-Falzone et al., 2010).

Psychological/Psychosocial Aspects

Family Issues

• Initial Shock and Adjustment: The birth of a child with a cleft is a stressful event in their lives. Parents often experience both shock and sadness and describe the experience as traumatic (Habersaat Peter, & Borghini, 2009).
• Cleft Palate as a Chronic Medical Condition: Parents of a child with a cleft or craniofacial condition spend a lot of time taking their child to medical appointments. This can pose practical challenges, including difficulty with transportation, time away from work (which can threaten their employment), time away from their other children, a strain on their financial resources and visits can be stressful.

School Issues

• Knowledge and Expectation of Teachers: Teachers have reported that they do not know much about CLP (like most of the population) and what they think they know may be incorrect (Finnegan, 1982).
• Learning Ability and School Performance: children with CLP, which is often associated with various craniofacial syndromes, tend to score lower on intelligence tests than unaffected peers (Persson et al., 2008). They also score lower in academic achievement than norms or matched controls (Bell et al., 2016; Wehby et al., 2015).
• Social Interaction: By school age, a significant number of children with a cleft or craniofacial condition do not have as many friendships as other children their age (Tobiasen & Speltz, 1996). This appears to be
  a result of several factors. First, affected children, especially girls, seem to be more socially inhibited than their peers.
• Teasing: Children with clefts are probably teased more often than their unaffected peers (Broder, Smith,
  & Strauss, 2001). Teasing seems to be influenced by the child’s physical appearance and speech differences because children tend to report less teasing after surgeries that address those problems.
• Self-Perception: Children with CLP see themselves as less acceptable to their peers, less socially competent, less satisfied with their facial appearance, and more often sad or angry than their peers. Children can develop a negative concept of self-worth over time.

Societal Issues

• Physical Attractiveness: One of the forces at work for a child with a cleft is society’s response to facial difference. Physical attractiveness, especially facial beauty, is an area that has been well researched, with findings that are among the most reliable and robust in the psychological literature.
• Speech Quality: Poor speech, especially hypernasality, appears to be associated with the assumption that the speaker has negative social characteristics (Havstam, Laakso, Lohmander, & Ringsberg, 2011; Lee, Gibbon, & Spivey, 2017; Watterson, Mancini, Brancamp, & Lewis, 2013).

Behavior and Psychiatric Issues

• Behavioral Issues Related to Medical Care: Medical procedures is generally stressful and often difficult for family members and patients. Psychological interventions can help children with clefts with their concerns related to their treatment.
• Quality of Life:  It is important that professionals working with individuals with clefts and other craniofacial conditions be aware of the possible negative effect of these conditions on QOL.
• Hearing Impairment: Many children with clefts have some degree of hearing impairment, which may vary with the frequency of recurrent ear infections.

Hearing Impairment

• 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).
• Fluctuating and long-standing conductive hearing loss is the primary concern for children with cleft palate.
• 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).

Dental and Occlusion

Dental deviations and malocclusion can affect articulatory placement.

Dental deviations include the following:

• Congenitally missing teeth
• Malrotated teeth
• Ectopic teeth (abnormally located)
• Supernumary or duplicated teeth

Malocclusions include the following:

• Overjet/overbite, often associated with Class II malocclusion (upper teeth protrude beyond lower teeth)
• Underjet/underbite, often associated with anterior crossbite or Class III malocclusion (lower teeth protrude beyond upper teeth)
• Open bite (teeth do not fully occlude)
• Lateral (buccal) crossbite (lower teeth buccal to upper teeth)

References:

⇒ Cleft Palate and Craniofacial Conditions A Comprehensive Guide to Clinical Management –  Ann W. Kummer, PhD, CCC-SLP, FASHA (Book)
⇒ Cleft Lip and Palate – ASHA

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Associated Problems in Persons with Cleft Lip and Palate