A 6-week-old baby is referred for poor feeding. On examination, you notice a cleft palate that has been previously undetected at the earlier baby checks. What is the best way to examine newborns to detect all cleft palates?
The RCPCH and NICE have released a joint consensus guideline (October 2014) on best practices for detecting cleft palate in neonates for any health professionals conducting newborn checks. This was done using systematic literature reviews and a Delphi consensus panel. Here are the key points.
Palate examination: identification of cleft palate in the newborn. October 2014. RCPCH and NICE.
What is a cleft palate?
A cleft palate is a birth condition caused by the roof of the mouth not joining up during early fetal development. The two halves of the palate don’t fuse properly, leaving an open space or ‘cleft’. This causes problems with feeding.
A delay in diagnosis can impact growth and development and will delay surgical intervention.
What prompted this guideline?
Delayed detection of cleft palate is a real concern, with delays impacting families and their relationship with healthcare providers. It has also cost the NHS in the UK a significant amount of money over the last ten years in legal claims due to delayed diagnosis.
The evidence suggests that delayed diagnosis is an international problem and is due to inadequate examination. Therefore, the working group was formed to determine best practices for examination.
In the UK, the rates of delayed detection (i.e. after the initial newborn check) are 13%.
The guidance recommends using the following strategies to perform cleft palate inspection as part of the routine newborn check.
1. Visual inspection. There was no consensus on using palpation as a diagnostic aid, mainly due to concerns about technique. Overall, visual inspection is the best way to detect cleft palate and can be used alone.
2. Torch and tongue depression. The panel recommends using a tongue depressor and a torch to ensure an optimal view of the palate (hard at the front and soft at the back of the mouth).
3. Missing some of the palate. If you can’t see the whole palate during the examination, the parents should be informed of this. This examination should then be reattempted 24 hours later. There was no consensus about what would happen after that – it wasn’t felt that discharge from the hospital should be delayed, but the baby should have a further review.
Hi Nathalie, my approach to this is to consider that bifid uvula is very much on the embryological spectrum of cleft palate but they may well be asymptomatic. I don’t routinely do anything about the finding other than including it in the overall assessment of the patient. If there is any suggestion of a symptomatic effect (feeding problems, ear problems, difficulty with language particularly phonation) I would tend to refer to ENT/speech therapy/cleft palate service early for further investigation. I think its also reasonable to tell the parents that you have found this and though it may not be immediately relevant they can then be aware of the potential warning signs of a problematic submucosal cleft palate. I would be interested to hear others approach to this.
Good little article. I have just spent 10 weeks checking babies every day by palpating alone. I think that I will pass this on the our department.
Thanks Brendon.
What is the consensus on finding a neonate with a bifed uvula but the palate feels/looks intact? Thanks