Cleft lip (CL) results from failure of the maxillary and medial nasal processes to fuse during about weeks 5–7 of gestation. Cleft palate (CP) results from failure of the palatal shelves to fuse slightly later (about weeks 7–12). They may occur together (cleft lip with or without cleft palate) or as an isolated cleft palate, which has different causes and a stronger link to syndromes.

• Cleft lip may be unilateral or bilateral, incomplete (a notch) or complete (extending into the nostril).
• Cleft palate may involve the soft palate only or both hard and soft palate; a submucous cleft is hidden under intact mucosa and may present later as nasal speech or feeding problems.

Causes and risk factors — most cases are multifactorial (genetic plus environmental):

• Family history of clefting
• Maternal smoking, alcohol use, pregestational diabetes, obesity
• Certain anticonvulsants taken in pregnancy (e.g., phenytoin, valproate, topiramate), isotretinoin
• Low maternal folate intake (periconceptional folic acid may lower risk)
• Syndromes: 22q11.2 deletion syndrome (velocardiofacial syndrome — cleft palate, congenital heart disease, immune and calcium problems), Van der Woude syndrome (lip pits), trisomy 13, and Pierre Robin sequence (small jaw → tongue falls back → U-shaped cleft palate and upper-airway obstruction)

Functional consequences

• Feeding: the infant cannot seal the mouth or create suction, so milk flow is poor and feeds are long and tiring; milk may escape through the nose; air swallowing and aspiration risk increase.
• Ears: the tensor veli palatini muscle does not open the eustachian tube normally → otitis media with effusion → conductive hearing loss.
• Speech: velopharyngeal insufficiency causes hypernasal speech and articulation errors.
• Dental: missing, extra, or malpositioned teeth; maxillary growth problems.
• Psychosocial: parental grief and bonding difficulty; later self-image concerns.

• Visible cleft of the lip at birth; inspect and palpate the palate with a gloved finger (a cleft palate can be missed on inspection alone), and check the uvula (bifid uvula suggests submucous cleft)
• Feeding: weak or ineffective suck, nasal regurgitation, coughing or choking during feeds, prolonged feeds (more than 30 minutes), fatigue, excessive air swallowing
• Weight gain and hydration: daily weight, wet diapers
• Airway: small jaw, snoring, retractions, desaturation (Pierre Robin sequence)
• Associated anomalies: heart murmur, dysmorphic features (screen for syndromes)
• Family: reactions, grief, readiness to learn feeding techniques
• Older infants: recurrent ear infections, hearing, speech development, dental eruption

Care is delivered by an interdisciplinary cleft/craniofacial team: plastic or craniofacial surgeon, otolaryngologist, audiologist, speech-language pathologist, pediatric dentist and orthodontist, pediatrician, geneticist, nurse coordinator, feeding specialist or dietitian, social worker, and psychologist. (Orthopedic surgery is not routinely part of the team.)

Typical treatment timeline (varies by center)

Preoperative requirements: adequate weight gain and nutrition, hemoglobin, and freedom from respiratory infection — an upper respiratory infection increases anesthetic airway complications (laryngospasm, bronchospasm), and elective repair is usually postponed.

Perioperative medications

• Acetaminophen — weight-based dosing; hepatotoxicity with overdose; count all sources.
• Opioids (e.g., morphine) for moderate to severe pain — monitor respiratory rate, sedation, and SpO₂ closely, since airway swelling after palate repair adds to the risk of respiratory depression; keep naloxone available.
• Ibuprofen may be used when the surgeon permits, usually not before 6 months of age (bleeding risk, kidney effects; avoid in dehydration).
• Antibiotics per surgeon; watch for allergy and diarrhea.

Listed in priority order.

1. Airway and aspiration prevention
   • Feed in an upright (semi-sitting) position; have suction available
   • Pierre Robin sequence: side-lying or prone positioning under continuous monitoring while hospitalized, nasopharyngeal airway or other airway support as ordered
   • Postoperatively, airway is the first priority: swelling of the tongue and palate, secretions, and blood can obstruct breathing — monitor respiratory effort, SpO₂, and frequent swallowing (hidden bleeding)
2. Preoperative feeding
   • Use a cleft-specific bottle system (squeezable bottle or a feeder with a one-way valve) that lets the caregiver assist milk flow in rhythm with the infant's sucking; do not simply enlarge a nipple hole, which causes uncontrolled flow and aspiration
   • Direct the nipple toward the side of the mouth or the intact part of the palate; burp frequently (large air intake)
   • Offer small, frequent feeds; pause to let the infant rest and breathe; limit feeds to about 20–30 minutes to avoid exhaustion
   • Breastfeeding is often possible with an isolated cleft lip (breast tissue fills the gap); with a cleft palate, support pumping and feeding expressed breast milk
   • Monitor weight, intake and output
3. Postoperative care — cleft lip
   • Position on the back or side, never prone, to protect the lip suture line
   • Keep hands away from the face with soft elbow immobilizers; remove one at a time, under supervision, on a regular schedule to check skin, circulation, and range of motion
   • Clean the suture line gently as ordered (e.g., saline) after feeds; apply ointment if prescribed
   • Minimize crying (tension on sutures): comfort, pain control, parental presence
4. Postoperative care — cleft palate
   • Side-lying or prone positioning is acceptable to drain secretions
   • Nothing hard in the mouth: no straws, spoons, forks, pacifiers, hard-spouted cups, or tongue depressors; use an open cup or feeding method specified by the surgeon
   • Diet progresses from clear liquids to soft or blended foods; offer water after feeds to rinse the palate
   • Observe for bleeding, foul-smelling nasal drainage or fever (infection), and fistula (fluid coming through the nose)
5. Pain management — use a behavioral scale suited to preverbal children, such as FLACC; self-report faces scales are for older children
6. Family support — encourage holding and bonding; show photographs of successful repairs; teach feeding with return demonstration; connect with a cleft team and parent support groups

• Hold the baby upright to feed, burp often, and allow rest breaks; watch for weight gain and wet diapers
• Clean the mouth and nose after feeds as instructed
• After lip repair: keep the baby off the stomach, keep arm immobilizers on except during supervised breaks, and protect the lip from injury
• After palate repair: nothing hard in the mouth for the period advised by the surgeon (usually several weeks); follow the soft diet
• Report fever, bleeding, breathing difficulty, refusal to drink, or separation of the incision
• Ear infections and hearing loss are common — attend all hearing and ear checks; treat ear infections promptly
• Speech: early and ongoing speech-language evaluation is important; most children develop good speech with repair and therapy, but some need further treatment
• Dental care begins with the first tooth; regular orthodontic follow-up
• Future pregnancies: genetic counseling; stop smoking; take folic acid before conception

• Cleft lip fails to fuse earlier than cleft palate; isolated cleft palate is more often syndromic (22q11.2 deletion)
• Palpate the palate — a cleft palate can be missed on inspection; prenatal ultrasound often misses isolated cleft palate
• Feeding priority: upright position, cleft-specific bottle, frequent burping, rest breaks; breastfeeding possible with cleft lip only
• Lip repair about 3–6 months; palate repair about 9–18 months, before speech develops
• Delay surgery if the infant has an upper respiratory infection
• After lip repair: no prone position, elbow immobilizers, protect suture line
• After palate repair: nothing hard in the mouth (no straws, spoons, pacifiers)
• Airway is the first postoperative priority
• Long-term: otitis media and conductive hearing loss, speech (hypernasality), dental problems
• Pain in infants: FLACC, not a self-report faces scale
• Interdisciplinary team includes speech, audiology, dental/orthodontics, surgery