Cleft lip and palate are congenital conditions that occur when the lip or mouth does not form properly during pregnancy. These conditions, occurring either separately or together, are among the most common birth defects globally. The impact of cleft lip and palate extends beyond physical appearance, affecting feeding, speech, hearing, and overall quality of life. Surgical intervention is the cornerstone of treatment, aiming to restore function and improve aesthetics. However, successful surgical outcomes heavily rely on meticulous post-operative nursing care. This article provides an in-depth exploration of nursing diagnoses and post-operative care strategies essential for infants and children following cleft lip and palate repair.
Understanding Cleft Lip and Palate
Cleft lip arises when the tissues of the upper lip fail to join completely before birth. This can range from a minor notch in the lip to a severe separation extending into the nose. Cleft palate, conversely, occurs when the roof of the mouth (palate) does not close fully, leaving an opening between the mouth and nasal cavity. These defects can occur unilaterally (one side), bilaterally (both sides), or in the midline, and may present in varying degrees of severity.
While the exact causes are multifactorial and not fully understood, genetic predisposition and environmental factors are believed to play significant roles. Cleft lip and palate can sometimes occur in conjunction with other congenital anomalies, such as spina bifida, hydrocephalus, and cardiac defects, necessitating a comprehensive assessment and multidisciplinary approach to care.
Surgical repair is typically performed in stages. Cleft lip surgery is often undertaken first, usually between 6 to 10 weeks of age, focusing on lip closure and early facial aesthetics. Cleft palate repair follows later, generally between 12 to 18 months, aiming to close the palatal opening and facilitate normal speech development and feeding. The timing and specific surgical techniques are tailored to each child’s unique condition and the surgeon’s expertise.
Effective management of cleft lip and palate requires a collaborative team of healthcare professionals. This multidisciplinary team typically includes surgeons, pediatricians, nurses, orthodontists, prosthodontists, otolaryngologists (ENT specialists), speech therapists, and social workers. Nurses play a pivotal role in coordinating care, educating families, and providing direct patient care, especially in the post-operative phase.
Nursing Care Priorities Post-Surgery
Post-operative nursing care for cleft lip and palate surgery is critical for ensuring optimal healing, preventing complications, and supporting the infant and family. Nursing priorities in the post-operative period include:
- Maintaining a Patent Airway: Post-operative edema and nasal congestion can compromise the infant’s airway.
- Preventing Aspiration: Infants are at risk of aspiration due to altered oral anatomy and post-surgical swelling.
- Managing Pain: Post-operative pain needs effective management to promote comfort and prevent crying, which can strain surgical sites.
- Ensuring Adequate Nutrition: Feeding methods need to be adapted to protect the surgical site and ensure adequate nutritional intake.
- Preventing Infection: Surgical sites are susceptible to infection, requiring meticulous wound care.
- Promoting Family Coping and Education: Parents need emotional support, education, and practical guidance to care for their infant post-surgery.
Post-Operative Nursing Assessment
A thorough nursing assessment is the foundation of effective post-operative care. Key assessment parameters include:
- Respiratory Status: Assess respiratory rate, depth, effort, breath sounds, and oxygen saturation. Monitor for signs of respiratory distress such as tachypnea, retractions, nasal flaring, and cyanosis.
- Airway Patency: Observe for nasal congestion, secretions, and signs of airway obstruction.
- Surgical Site: Assess the incision site for approximation, redness, swelling, drainage, and signs of infection. Monitor for any bleeding or hematoma formation.
- Pain Level: Evaluate pain using age-appropriate pain assessment tools. Observe for non-verbal pain cues such as facial grimacing, restlessness, and increased heart rate.
- Nutritional Status: Monitor intake and output, daily weight, and hydration status. Assess feeding tolerance and ability to suck and swallow.
- Fluid and Electrolyte Balance: Monitor for signs of dehydration or fluid overload.
- Parental Anxiety and Coping: Assess parents’ emotional state, understanding of post-operative care, and coping mechanisms.
Common Post-Operative Nursing Diagnoses
Based on the assessment findings, common nursing diagnoses for post-operative cleft lip and palate repair include:
- Ineffective Airway Clearance related to post-operative edema, secretions, and altered oral anatomy.
- Risk for Aspiration related to cleft palate repair, altered oral anatomy, and potential feeding difficulties.
- Acute Pain related to surgical incision and tissue manipulation.
- Impaired Tissue Integrity related to surgical incision and suture line.
- Risk for Infection related to surgical incision and invasive procedures.
- Imbalanced Nutrition: Less Than Body Requirements related to feeding difficulties and post-operative restrictions.
- Anxiety (Parental) related to infant’s condition, post-operative care, and potential complications.
- Deficient Knowledge (Parental) related to post-operative care, feeding techniques, and potential complications.
Nursing Interventions and Actions: Post-Operative Care
Nursing interventions are directed towards addressing the identified nursing diagnoses and achieving optimal patient outcomes.
1. Maintaining Airway Clearance and Preventing Aspiration
Nursing Actions:
- Position the infant appropriately: Elevate the head of the crib or infant seat to a 30-45 degree angle to promote drainage and prevent the tongue from obstructing the airway. For feeding, position the infant upright, greater than 60 degrees, and maintain this elevation for at least 30 minutes after feeding to minimize reflux.
- Monitor Respiratory Status Closely: Continuously assess respiratory rate, depth, effort, and oxygen saturation. Report any signs of respiratory distress immediately.
- Suction as Needed: Perform gentle oral and nasal suctioning using a bulb syringe or soft suction catheter to remove secretions. Be extremely careful not to touch the surgical site, especially after cleft lip repair. Position the infant on their side to facilitate drainage of oral secretions.
- Humidified Oxygen: If ordered, administer humidified oxygen to maintain oxygen saturation and ease breathing, especially in the initial post-operative phase.
- Avoid Prone Position Post Lip Repair: Do not place the infant on their abdomen after cleft lip repair as this can put pressure on the suture line. Position the infant on their back or side.
Infant being fed in an upright position after cleft palate surgery
2. Pain Management
Nursing Actions:
- Administer Analgesics as Prescribed: Provide pain medication as ordered, around-the-clock initially, transitioning to PRN as pain subsides. Acetaminophen and ibuprofen are commonly used for mild to moderate pain, while stronger analgesics may be required in the immediate post-operative period.
- Assess Pain Regularly: Use age-appropriate pain scales (e.g., FLACC scale for infants) to assess pain levels and effectiveness of pain management.
- Non-Pharmacological Pain Relief: Employ non-pharmacological comfort measures such as swaddling, rocking, gentle holding, pacifier use (if appropriate and not contraindicated by surgical type), and quiet environment.
- Minimize Crying: Anticipate the infant’s needs to prevent crying, which can increase pain and tension on the surgical site. Ensure timely feeding, diaper changes, and comfort measures.
3. Maintaining Tissue Integrity and Preventing Infection
Nursing Actions:
- Meticulous Suture Line Care: Cleanse the suture line gently after each feeding and as needed with sterile saline or prescribed solution using sterile cotton-tipped applicators. Pat dry carefully. Apply prescribed antibiotic ointment as ordered. Avoid rubbing the suture line; use a gentle rolling motion for cleaning.
- Monitor Surgical Site for Infection: Assess the incision site regularly for redness, swelling, increased warmth, drainage (purulent or increased serous), and odor. Monitor the infant’s temperature for fever. Report any signs of infection promptly to the surgeon.
- Prevent Trauma to Surgical Site: Apply Logan bow or adhesive strips as ordered to protect the cleft lip repair site. Use elbow restraints to prevent the infant from touching or rubbing the surgical site. Ensure restraints are applied correctly and removed periodically for range of motion exercises and parental holding, one arm at a time.
- Avoid Sharp Objects Near Surgical Site: Keep sharp objects and toys away from the infant’s face. Avoid using straws, spoons directly in the mouth (especially after palate repair), or pacifiers if contraindicated by the surgical plan.
- Maintain a Clean Environment: Ensure a clean and safe environment to minimize the risk of infection. Practice meticulous hand hygiene before and after caring for the infant.
4. Ensuring Adequate Nutrition and Safe Feeding
Nursing Actions:
- Initiate Feeding as Prescribed: Follow the surgeon’s orders regarding when to initiate feeding post-operatively. Typically, clear liquids are started first, progressing to formula or breast milk as tolerated.
- Use Appropriate Feeding Techniques and Devices: Employ specialized feeding bottles and nipples designed for infants with cleft lip and palate, such as Pigeon bottles or Haberman feeders. Syringe feeding or spoon-feeding may be necessary, particularly after palate repair. Avoid traditional nipples that require strong sucking.
- Feed in an Upright Position: Maintain an upright position (greater than 60 degrees) during feedings to facilitate swallowing and minimize nasal regurgitation.
- Feed Slowly and in Small Amounts: Offer small, frequent feedings, allowing the infant ample time to swallow and breathe. Pace feedings to prevent fatigue and aspiration.
- Burp Frequently: Burp the infant frequently during and after feedings to reduce air swallowing and prevent abdominal distention, which can compromise respiration and increase reflux.
- Monitor Intake and Output: Accurately record fluid intake and output to ensure adequate hydration and nutrition. Monitor daily weight to assess nutritional status.
- Avoid Milk Curd Buildup: After feeding formula or breast milk, offer a small amount of sterile water to rinse the suture line and prevent milk curd buildup, which can increase infection risk.
- Advance Diet Gradually: As healing progresses and as ordered by the surgeon, gradually advance the diet from liquids to soft foods. Ensure food consistency is appropriate to avoid trauma to the palate repair site.
5. Promoting Parental Coping and Education
Nursing Actions:
- Provide Emotional Support: Acknowledge and address parents’ feelings of shock, guilt, anxiety, and disappointment. Offer a supportive and empathetic environment.
- Educate Parents About Cleft Lip and Palate: Provide clear, concise, and accurate information about cleft lip and palate, the surgical procedures, and post-operative care. Use visual aids and written materials to reinforce teaching.
- Demonstrate and Teach Feeding Techniques: Provide hands-on demonstrations and allow parents to practice feeding techniques under supervision. Ensure parents are comfortable and confident with feeding methods before discharge.
- Teach Suture Line Care: Instruct parents on proper suture line cleaning, antibiotic ointment application, and signs of infection to monitor for at home. Provide written instructions for reference.
- Explain Pain Management: Educate parents about pain medication administration, non-pharmacological comfort measures, and how to assess their infant’s pain.
- Discuss Potential Complications: Inform parents about potential post-operative complications such as infection, bleeding, airway obstruction, feeding difficulties, and ear infections. Provide clear instructions on when to seek medical attention.
- Encourage Parental Involvement in Care: Encourage parents to participate actively in their infant’s care, including feeding, bathing, and comfort measures. This promotes bonding and increases parental confidence.
- Provide Resources and Referrals: Connect parents with support groups, cleft lip and palate associations (e.g., The American Cleft Palate-Craniofacial Association, Cleft Palate Foundation), and genetic counseling services. Provide information about long-term follow-up care, including speech therapy, dental care, and audiology evaluations.
- Address Long-Term Care Needs: Discuss the multidisciplinary approach to cleft lip and palate care and the importance of ongoing follow-up with specialists throughout childhood.
Discharge Planning and Home Care Instructions
Effective discharge planning is essential for a smooth transition home and continued successful recovery. Discharge instructions should include:
- Feeding Guidelines: Detailed instructions on feeding techniques, volumes, frequency, and types of formula or food.
- Medication Administration: Clear directions on pain medication and any antibiotics, including dosage, frequency, and potential side effects.
- Suture Line Care: Step-by-step instructions on suture line cleaning and ointment application.
- Activity Restrictions: Guidance on activity limitations and positioning to protect the surgical site.
- Signs and Symptoms of Complications: Detailed information on signs of infection, bleeding, respiratory distress, feeding problems, and ear infections that require immediate medical attention.
- Follow-Up Appointments: Schedule follow-up appointments with the surgeon and other specialists as needed.
- Emergency Contact Information: Provide contact information for the surgeon’s office and emergency services.
- Community Resources: Reiterate information about support groups and community resources.
Conclusion
Post-operative nursing care is paramount to the successful outcomes of cleft lip and palate repair. By focusing on meticulous assessment, accurate nursing diagnoses, and evidence-based interventions, nurses play a critical role in ensuring airway patency, pain management, infection prevention, adequate nutrition, and family support. A comprehensive and compassionate nursing approach, combined with effective parental education, empowers families to confidently care for their infants at home and navigate the journey of cleft lip and palate treatment, ultimately contributing to improved health outcomes and quality of life for these children.
References
- Burca, N. D. L., Gephart, S. M., Miller, C., & Zukowsky, K. (2016, October). Promoting Breast Milk Nutrition in Infants With Cleft Lip and/or Palate. Advances in Neonatal Care, 16(5), 337-344.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed.). F.A. Davis Company.
- Kenner, C., Altimier, L., & Boykova, M. V. (Eds.). (2019). Comprehensive Neonatal Nursing Care. Springer Publishing Company.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Tolarova, M. M., & Elluru, R. G. (2022, March 10). Pediatric Cleft Lip and Palate Clinical Presentation: Physical Examination. Medscape Reference. Retrieved July 18, 2022.
