Priorities for future public health research in orofacial clefts

Maternal Perspectives: Qualitative Responses about Perceived Barriers to Care among Children with Orofacial Clefts in North Carolina

Objective

To examine maternal perceptions of barriers to care of children with orofacial clefts (OFC) in a population-based survey that solicited open-ended qualitative responses.

Design and Setting

In 2006, a combination mail/phone survey was sent to all mothers of children with OFC. The questionnaire included 76 items. A final open-ended question was included for additional information about cleft-related care. The analysis included responses to the open-ended question and sociodemographic characteristics of the respondents. Qualitative responses were transcribed and entered into a qualitative software package for analysis, and common themes were elucidated.

Participants/Patients

The North Carolina Birth Defects Monitoring Program was used to identify all resident infants born with OFC from 2001 to 2004. Of 478 eligible mothers, 52.9% (n = 248) responded to the survey, and 39.5% (n = 98) responded to the final open-ended question.

Main Outcome Measures

Percentage reporting problems accessing care, frequency of positive and negative comments, and indicators of financial, personal, and structural barriers to care.

Results

Of the 98 respondents, the majority (n = 95, 96.99%) were the biological mother. Almost 40% of mothers indicated that accessing primary craniofacial care was a problem. Of those citing perceived barriers to care, the major issues cited were financial, structural, and personal barriers.

Conclusions

Collaborative efforts between craniofacial centers and teams, health care systems, and birth defects registries are warranted to reduce perceived barriers to care among families of children with OFC. Further exploration of the themes and factors associated with barriers to care and services is needed.

Neuropsychological, behavioral, and academic sequelae of cleft: early developmental, school age, and adolescent/young adult outcomes

This article reviews behavioral, neuropsychological, and academic outcomes of individuals with cleft across three age levels: (1) infancy/early development, (2) school age, and (3) adolescence/young adulthood. The review points out that attachment, neurocognitive functioning, academic performance/learning, and adjustment outcomes are the result of a complex interaction between biological and environmental factors and vary with developmental level, sex, and craniofacial anomaly diagnosis. The degree to which associated genetic or neurodevelopmental conditions may explain inconsistent findings is unknown and suggests the need for caution in generalizing from group data on cleft.

Demographics of orofacial clefts in Canada from 2002 to 2008

Objective : Orofacial clefts such as cleft lip, cleft palate, and cleft lip and palate are the most frequent congenital anomalies of the head and neck. The purpose of this study was to determine the current demographics for orofacial clefts in Canada. Methods : A request for data from all Canadian provinces (excluding Quebec due to incompatibilities with provincial coding systems) for the fiscal years 2002-2003 to 2007-2008 was submitted to the Canadian Institute for Health Information. Variables evaluated included gender, cleft type, gestational age, birth weight, income quintile, and institution health region. Results : Over the period studied, the prevalence of orofacial clefts ranged from 11.0 to 15.3 per 10,000 live births (1 in 654 to 1 in 909 live births). The distribution of cleft types for live births with orofacial clefts was 17% for cleft lip, 41% for cleft palate, and 42% for cleft lip and palate, of which cleft lip and cleft lip and palate were male dominant (62% and 66% male, respectively) and cleft palate was female dominant (56% female). Saskatchewan and Manitoba had significantly higher cleft birthrates (P < .05) compared with the other provinces. Birth weight and gestational age (but not income quintile) were significantly (P < .0001) lower for newborns with orofacial clefting compared with those with no cleft. Conclusions : Canada has one of the highest orofacial cleft birthrates in the world (prevalence of 12.7 per 10,000 live births, approximately 1 in 790 live births). This study presents an updated demographic of orofacial clefts in Canadian newborns and may be useful in predicting the burden of anticipated health care.

Timeliness of surgical care in children with special health care needs: delayed palate repair for publicly insured and minority children with cleft palate

BACKGROUND/PURPOSE

Disparities in access to health care are known to exist for the most vulnerable pediatric population, children with special health care needs. Timely access to surgical care in this population is critical, yet poorly studied.

METHODS

A national database of pediatric hospitals in the United States was searched for nonsyndromic, healthy patients younger than 24 months who underwent cleft palate repair from 2003 to 2008. A multivariate, linear regression model was constructed to determine the relationship of public payer status and race with age at palatal repair.

RESULTS

Age at palate repair was significantly delayed for patients who were publicly insured (1.2 weeks, P = .01), were of nonwhite race/ethnicity (1.5-3.5 weeks, P = .009), and had a diagnosis of cleft lip in addition to cleft palate (3.4 weeks, P = .006) compared to their counterparts in a sample of 2995 patients with cleft palate.

CONCLUSION

There is a small but significant delay in age at repair for patients who are publicly insured or of nonwhite race/ethnicity. These results may herald broader access disparities that could adversely affect clinical outcomes and should be investigated further.

Genetics of nonsyndromic orofacial clefts

With an average worldwide prevalence of approximately 1.2/1000 live births, orofacial clefts are the most common craniofacial birth defects in humans. Like other complex disorders, these birth defects are thought to result from the complex interplay of multiple genes and environmental factors. Significant progress in the identification of underlying genes and pathways has benefited from large populations available for study, increased international collaboration, rapid advances in genotyping technology, and major improvements in analytic approaches. Here we review recent advances in genetic epidemiological approaches to complex traits and their applications to studies of nonsyndromic orofacial clefts. Our main aim is to bring together a discussion of new and previously identified candidate genes to create a more cohesive picture of interacting pathways that shape the human craniofacial region. In future directions, we highlight the need to search for copy number variants that affect gene dosage and rare variants that are possibly associated with a higher disease penetrance. In addition, sequencing of protein-coding regions in candidate genes and screening for genetic variation in noncoding regulatory elements will help advance this important area of research.

Oral health-related quality of life in Dutch children with cleft lip and/or palate

OBJECTIVE

To investigate the oral health-related quality of life (OH-RQoL) of Dutch cleft lip and palate patients. It was hypothesized that (1) there is no difference between cleft patients' and their parents' reports of patients' OH-RQoL; (2) there are no gender differences; (3) there are no differences in OH-RQoL between cleft patients with regard to their symptoms; and (4) there is no difference between patients above and below 12 years of age.

MATERIALS AND METHODS

The sample consisted of 122 patients with clefts (age range, 8-15 years) and their parents. Respondents were recruited from the cleft palate team of Amsterdam. They completed the Child Oral Health-Related Quality of Life questionnaire (COHIP). Items were divided into five different subscales, and scores on all subscales were compared between and within groups.

RESULTS

Patients' and parents' perceptions differed significantly on three of the five subscales. Girls and boys did not differ significantly with regard to their perception of reported OH-RQoL. The cleft lip and cleft lip and alveolus [CL(A)] subgroup scored significantly higher on the functional well-being subscale. The cleft patients aged 12 years and older scored significantly lower on the emotional well-being and oral symptoms subscales when compared with their younger peers.

CONCLUSIONS

Only the second hypothesis was not rejected in this study. This means that parents are not interchangeable with regard to reporting on their children's perceptions related to OH-RQoL, that OH-RQoL changes with age, and that it is important that subgroups are respected when investigating OH-RQoL in cleft patients.

Urban-rural residence and the occurrence of cleft lip and cleft palate in Texas, 1999-2003

PURPOSE

The etiology of orofacial clefts is complex and relatively unknown. Variation in cleft lip with or without palate (CLP) and cleft palate alone (CP) was examined in Texas across urban-rural residence (1999 to 2003).

METHODS

Cases came from the Texas Birth Defects Registry (1,949 CLP and 1,054 CP) and denominator data came from vital records (254 counties; 1,827,317 live births). Variation in maternal residence was measured using four classification schemes: Rural Urban Continuum Codes, Urban Influence Codes, percentage of county in cropland, and Rural Urban Commuting Areas. Poisson regression was used to calculate rate ratios, adjusted for infant sex, plurality, gestational age, maternal parity, age, race/ethnicity, and education.

RESULTS

Compared to the most urban referent category, living in more rural areas was associated with an increased adjusted risk of CLP. For example, the Rural-Urban Continuum Codes demonstrated elevated risks for CLP in "thinly populated areas" compared to "metropolitan-urban areas" (adjusted prevalence ratio = 1.9; 95% confidence intervals (CI) 1.2-2.8); CP was not similarly associated. Percentage of county cropland was not consistently associated with any outcome.

CONCLUSION

The association patterns between non-urban residence and risk of CLP, except for percentage of cropland, suggests a constellation of exposures that may differ across urban-rural residence.

Interdisciplinary craniofacial teams compared with individual providers: is orofacial cleft care more comprehensive and do parents perceive better outcomes?

OBJECTIVE

The primary objective was to examine whether children with orofacial clefts received more comprehensive care and whether their parents perceived better outcomes if the care was delivered by interdisciplinary teams compared with individual providers.

DESIGN

Data about services received and outcomes were collected from mothers of children with orofacial clefts.

PARTICIPANTS

Mothers of children born between 1998 and 2003 with orofacial clefts from Arkansas, Iowa, and New York who participated in the National Birth Defects Prevention Study were eligible.

MAIN OUTCOME MEASURE(S)

Services and treatments received and maternal perception of cleft care, health status, aesthetics, and speech were evaluated by team care status.

RESULTS

Of 253 children, 24% were not receiving team care. Of those with cleft lip and palate, 86% were enrolled in team care. Compared with children with team care, those without had fewer surgeries and were less likely to have seen a dentist, received a hearing test, or had a genetic consultation. Mothers of children lacking team care were twice as likely to give lower ratings for overall cleft care; maternal perceptions of global health, facial appearance, and speech did not differ by team care status.

CONCLUSIONS

Recommended care tended to be received more often among those with team care. A larger, longitudinal study might answer questions about whether team care provides the best care and the role that type and severity of the condition and racial/ethnic differences play in the services received and outcomes experienced.

Critical issues in craniofacial care: quality of life, costs of care, and implications of prenatal diagnosis

Since the 2000 Surgeon General's Report on Oral Health (SGROH), substantial areas of inquiry relative to individuals, especially children and youth, with orofacial clefts and other craniofacial conditions have emerged. These areas include access to and cost of care, stigmatization and quality of life, and social and ethical issues around prenatal diagnosis. This update on the 2000 SGROH examines what we have learned about the cost and ability to access cleft and craniofacial care, prenatal diagnosis, and how quality of life is impacted by these conditions and the burden of care. The development of new research tools to assess quality of life since 2000 will permit further study of the impact of oral and craniofacial conditions on children and families and the effect of treatment on quality of life. Despite a better understanding of the higher use of services and increased costs of care for families of children with craniofacial conditions, major gaps in research must be addressed to assist with program planning and policy development for these groups of children and their families. Further work is also needed to assess the cost-effectiveness of craniofacial team care and to better understand family experience with accessing needed care. Finally, prenatal detection and diagnosis of clefts and craniofacial conditions have advanced dramatically, and the roles of craniofacial professionals and teams have been affected. New understandings of prenatal diagnosis and genomic sciences are redefining genetic counseling, therapy, and future preventive initiatives.

Timeliness of Primary Cleft Lip/Palate Surgery

Objective:

To examine the timeliness of primary cleft surgery, mean age at which surgery occurred, and factors associated with timely cleft surgery among children with orofacial clefts (OFCs).

Design:

Retrospective study of children with OFC using North Carolina vital statistics, birth defects registry, and Medicaid files.

Participants/Patients:

Medicaid-enrolled North Carolina resident children with OFC born from 1995 to 2002.

Main Outcome Measures:

Proportion of children who underwent primary cleft surgery within 18 months of life, mean age when surgery occurred, and factors associated with timely surgery.

Results:

406 children with OFC were continuously enrolled in Medicaid during the first 2 years of life. Overall, 78.1% of children had surgery within 18 months. About 90% of children with cleft lip (CL), 58.0% of children with cleft palate (CP), and 89.6% of children with cleft lip and palate (CLP) received timely cleft surgery; the mean age at which surgery occurred was 5 months. Children whose mothers received maternity care coordination, received prenatal care at a local health department, or lived in the southeastern or northeastern region of the state were more likely to receive timely cleft surgery.

Conclusion:

Most children with OFC in North Carolina born during this time period received primary cleft surgery within 18 months of life, but this varied by maternal demographics and other factors.

The impact of orofacial clefts on quality of life and healthcare use and costs

Orofacial clefts are common birth defects that may impose a large burden on the health, quality of life, and socioeconomic well-being of affected individuals and families. They also result in significant healthcare use and costs. Understanding the impact of orofacial clefts on these outcomes is important for identifying unmet needs and developing public policies to reduce the burden of orofacial clefts at the individual, family and societal levels. This paper reviews and summarizes the main findings of recent studies that have evaluated the impact of orofacial clefts on these outcomes, with a focus on quality of life, socioeconomic outcomes, long-term health, and healthcare use and costs. Several studies identify an increased burden of orofacial clefts on these outcomes, but some of the findings are inconsistent. A summary of the primary limitations of the studies in this area is presented, along with recommendations and directions for future research.

Children with orofacial clefts: health-care use and costs among a privately insured population

OBJECTIVES

Orofacial clefts are common birth defects that often require multiple surgeries and medical treatments during childhood. We used healthcare insurance claims data to estimate health-care expenditures for infants and children < or = 10 years of age with an orofacial cleft.

METHODS

The data were derived from the 2000-2004 MarketScan Commercial Claims and Encounters databases, which include person-specific information on health-care use, expenditures, and enrollment for approximately 50 large employers, health plans, and government and public organizations. Health insurance claims data from 821,619 children < or = 10 years of age enrolled in employer-sponsored plans during 2004 were analyzed. Expenditures for inpatient admissions, outpatient services, and prescription drug claims were calculated for children with and those without an orofacial cleft.

RESULTS

The difference in annual mean costs (i.e., incremental costs) between children aged 0 through 10 years with an orofacial cleft and those without an orofacial cleft was $13,405. The mean and median costs for children < or = 10 years of age with an orofacial cleft were eight times higher than for children of the same age without an orofacial cleft. Mean costs for infants with a cleft and another major, unrelated defect were 25 times higher than those for an infant without a cleft, and five times higher than for infants with an isolated cleft.

CONCLUSION

These findings document substantially elevated medical care costs for privately insured children with an orofacial cleft. Additional study of the economic burden associated with this condition should include a broader range of economic costs.

Review on genetic variants and maternal smoking in the etiology of oral clefts and other birth defects

A spectrum of adverse pregnancy outcomes, including preterm birth, low birth weight, and birth defects has been linked with maternal smoking during pregnancy. This article includes a review of studies investigating interactions between genetic variants and maternal smoking in contributing to birth defects using oral clefting as a model birth defect. The primary gene-smoking studies for other major birth defects are also summarized. Gene-environment interaction studies for birth defects are still at an early stage with several mixed results, but evolving research findings have begun to document clinically and developmentally important interactions. As samples and data become increasingly available, more effort is needed in designing innovative analytical methods to study gene-environment interactions.