Question 1 out of 209A nurse is caring for a toddler who is postoperative following a cleft palate repair.Which of the following actions should the nurse take?Show Explanation65% of exam takers got this question correct.Correct Answer:A.Restrain the toddler's arms at the elbowsWhen caring for a toddler who is postoperative following a cleft palate repair, thenurse should apply elbow restraints [unless prescribed otherwise] to prevent thetoddler from rubbing or disrupting the sutured area.Incorrect Answers:B.When caring for a toddler who is postoperative following a cleft palaterepair, the nurse should avoid the use of hard utensils due to the risk of injury to therepair.
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Cleft Lip or Palate Interventions
Cleft-cracked Plate
Cleft Lip or Palate may occur separately or together and are due to a failure of fusion of tissues during fetal development. It is the most common facial abnormality in children. Difficulties arise with these children with feeding as they are usually unable to form an adequate seal around a nipple or breast. This inadequate seal may cause aspiration or ingestion of excessive amounts of air as well as inadequate caloric consumption. Management following surgical repair includes safety measures to prevent trauma to the healing suture line for both cleft lip and palate.
8 KEY FACTS
Mothers may be initially shocked at the appearance of their newborn. Newborns may have other anomalies, such as heart defects, skeletal malformations and urinary or genital malformations. It is important to encourage continuous mother-baby bonding by holding the infant immediately after birth if possible and reinforce that corrective surgeries are available with excellent success rates.
A prosthodontic or orthodontic device may be used and functions as a prosthetic palate in patients with a cleft palate.
Newborns with this condition are either unable to form an adequate seal around the nipple or breast, unable to create adequate suction, or both. Modified nipples allow for a larger portion of the nipple to reside inside the mouth allowing a seal to form further inside the mouth. Mothers who breastfeed can pump and use the modified nipple to give their newborn breast milk.
A poor seal around the nipple or breast creates excessive air ingestion during feeding. Adequate burping is important to expel the additional air.
Repair is performed once an infant weighs approximately 10 pounds and usually at an age of 2-3 months for cleft lip and 6-9 months for cleft palate. Early surgical repair is important to promote normally appearing facial features later in life. Care of the surgical site is important to promote adequate healing.
Post feeding rinsing of the suture line with normal saline decreases the risk of infection. An antibiotic ointment or petroleum jelly may also be applied as directed.
Restraints of the arms/elbow after surgical repair prevents the child from physically touching and causing trauma to the suture sites.
It is important to avoid hard or rigid utensils such as straws, hard sippy cups, or spoons, especially after cleft palate repair. This is indicated to reduce physical trauma to the suture lines.
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Parents generally request the specific “care path” for their child so that expectations for cleft lip and cleft palate repair plastic surgery can be defined. These treatment protocols vary between centers and among surgeons; there is no absolute right or wrong. Nevertheless, we believe that any protocol should deliver a clear vision of care from infancy to adulthood.
For information specific to your child, request a consultation online or call us at [469] 375-3838.
Our usual sequence of care is as follows:
| Age | Treatment |
| Birth to 3 mos | presurgical orthodontics |
| 3 mos | cleft lip and soft palate repair |
| 18 mos | hard palate repair [columella lengthening] |
| 4 yrs | pharyngeal flap [if needed] |
| 7-8 yrs | alveolar bone graft/orthodontics |
| 14-16 yrs | orthodontics/orthognathics/rhinoplasty |
Many parents are very concerned about the presence of scars. Unfortunately, all cleft lip repairs leave visible scars. Every effort is made to keep scars to a minimum and to place scars so that they are easily concealed.
Secondary [or “redo”] surgeries at any stage may be necessary. Our occurrence of secondary surgery is less than 5%.
After Surgery Care
The goal after surgery is to protect the new repair and stitches. For this reason there will be some changes in the child’s feeding, positioning, and activity for a short time. Remember, these are only temporary!
Infants will not be able to suck on a nipple/bottle or pacifier for 10 days after surgery. A syringe with a short piece of soft rubber tubing will be used for feeding. Older children may drink from a cup. It is helpful if the child has practiced drinking from the syringe before surgery. As soon as the infant awakes from anesthesia and acts hungry they may be offered a feeding of clear liquid [Pedialyte, sugar water, apple juice]. When this is tolerated, they may resume their regular formula. Infants who have already begun cereal or baby foods may be offered diluted feedings with the syringe. Older children will be on a blenderized diet that pours easily from a cup.
There may be some discomfort as the child swallows so they may not drink much the first evening. This is why IV fluids are continued until their drinking improves. Pain medicine will also be given to relieve distress.
A child who has had a cleft lip repair should be positioned on their side or back to keep them from rubbing their face in the bed. A child with only a cleft palate repair may sleep on their stomach.
It is important to keep the stitches clean and without crusting. Parents are shown how to clean the suture line and apply ointment while in the hospital. This will continue until the stitches are removed about a week later.
It is important to keep the child from hurting the incision or putting hands or toys in their mouth. For this reason they will wear arm restraints [NoNo’s] which keep them from bending their elbows. These are also used for 10 days after surgery.
Children usually spend one night in the hospital and are discharged when they begin to drink an adequate amount of fluids. Parents are encouraged to stay with their child and participate in their care. Chair beds are available in the rooms for overnight sleeping.