The Role of the Clinical Nurse Specialist From the Perspective of Parents of Children Born With Cleft Lip and/or Palate in the United Kingdom: A Qualitative Study

Early Follow-up of Parents by a Specialized Cleft Nurse After the Birth of an Infant with Cleft lip and/or Palate

OBJECTIVE

To document the impact of early follow-up by specialized cleft nurses (SCNs) to families of infants with cleft lip and/or cleft palate (CL/P).

DESIGN

Prospective inclusion of a control group, which received standard care alone, followed by an intervention group, which in addition received early SCN follow-up.

SETTING

The cleft lip and palate team at a University hospital.

PARTICIPANTS

70 families (69 mothers and 57 fathers); control group (n = 38); intervention group (n = 32).

INTERVENTION

SCNs offered a consultation at the maternity ward and follow-ups by phone or face-to-face at one, three, eight weeks and six months after birth.

OUTCOME MEASURES

Use of Internet-Questionnaire, Quality of discharge teaching scale (QDTS), Post discharge coping difficulty scale (PDCDS), Response on follow-up by health professionals.

RESULTS

Infants in the intervention group were admitted less frequently to a Neonatal Intensive Care unit (NICU); 21.9% vs 51.4%, P = .012. Parents in the intervention group used internet for cleft-related reasons less frequently (74.6% vs 85.9%), P = .112 and the mothers benefitted less from cleft-related activity on the internet (P = .013). The intervention group reported higher mean score for satisfaction with total cleft care (P = .001). There were no significant group differences regarding mean total score for discharge teaching (P = .315) and coping difficulties (P = .919).

CONCLUSION

Early follow-up by a SCN with expertise in cleft care is highly valued by parents. Closer cooperation between the cleft team and health professionals at birth hospitals and Child health centers is necessary for optimal follow-up.

The effect of position on feeding performance in infants with cleft lip and palate: Quasiexperimental study

PURPOSE

This single-group, quasiexperimental study was conducted to determine the effect of feeding position on the physiological parameters and feeding performance of term-born infants with cleft lip and palate (CLP) in the preoperative period.

METHODS

The study sample consisted of 45 infants aged 0-6 months with CLP followed up preoperatively in our outpatient clinic between January 2021 and 2022. Infants who were being fed with a specialty bottle for babies with CLP and whose families consented to participate in the study were included. After 2 h of fasting, the infants were fed in the elevated supine (ESU) position for the first meal, then in the elevated side-lying (ESL) position for the second meal after another 2 h of fasting. The infants' heart rate and oxygen saturation values before, during, and after each feed and indicators of feeding performance were compared between the positions.

RESULTS

There was no significant difference between the positions in terms of heart rate and oxygen saturation before, during, or after feeding (p > .05). There was no statistically significant difference in measures of feeding performance according to the infants' feeding position (p > .05).

CONCLUSION

According to the findings obtained in this study, infants with CLP showed no statistically significant differences in heart rate, oxygen saturation, or feeding performance when fed in the ESL and ESU positions.

PRACTICE IMPLICATIONS

However, despite the lack of statistical significance, both physiological values and feeding performance tended to be better when the infants were fed in the ESL position, nurses can practice ESL position according to the infant's opposite direction of the side of the cleft lip or palate.

Care of an infant born with a cleft palate: a case study

Orofacial clefts are the most common facial congenital abnormalities in humans. Their management is complex due to a range of immediate and ongoing challenges. These include breathing, feeding, speech, hearing and dental issues. This article uses a case study approach to outline these challenges for a patient who was born with a cleft palate. The case is followed by a discussion of contemporary evidence-based care. The article focuses on family-centred care and multidisciplinary teamwork, and the author also details the central role of the children's nurse.

Parental Stress, Infant Feeding and Well-being in Families Affected by Cleft Lip and/or Cleft Palate: The Impact of Early Follow-up

OBJECTIVE

To document the impact of early follow-up by specialized cleft nurses (SCNs) provided to families affected by cleft lip and/or palate (CL/P) and the status of parental stress, infant feeding and well-being.

DESIGN

Prospective inclusion of a control group, which only received standard care, followed by an intervention group that also received early SCN follow-up.

SETTING

The cleft lip and palate team at Oslo University Hospital, Norway.

PARTICIPANTS

Seventy families (69 mothers and 57 fathers) distributed into an intervention group (n = 32) and a control group (n = 38).

INTERVENTION

SCNs provided a consultation at the maternity ward and a follow-up conversation by phone or face-to-face at scheduled times for six months.

OUTCOME MEASURES

Parental Stress Index (PSI), Perceived Stress Scale (PSS-14), feeding questionnaire, survey of infant diets, weight percentiles.

RESULTS

The mothers reported higher stress scores than the fathers, but in the control group only in the PSI parent domain at T2 and T3 (P = .007, P = .018). Infants in the intervention group used pacifiers less frequently than in the control group (55.2% vs. 81.1%, P = .023). Otherwise, no significant differences were found between the groups. Overall, the infants received less breast milk than norms.

CONCLUSION

Contextual strategies for early follow-up of families affected by clefts need to be developed, with an emphasis on involving fathers and those parents reporting elevated stress and/or feeding difficulties. There is a need for diagnosis-specific guidelines about the use of pacifiers as well as collaboration between the health professionals involved to increase breastmilk feeding.

Transitioning from child to adult cleft lip and palate services in the United Kingdom: Are the NICE Guidelines reflected in young adults' experiences?

Cleft lip and/or palate (CL/P) is one of the most common congenital conditions worldwide. Individuals born with CL/P will embark on a long-term treatment pathway throughout childhood and often into adulthood. As they grow older, young people become more involved in medical decisions. The National Institute for Clinical Excellence (NICE) has published guidance for health professionals on how transitions of responsibility should be managed in health services. The aim of the current study was to examine the extent to which the NICE recommendations are currently being implemented in UK CL/P services according to young adults' first-hand accounts. Semi-structured interviews were carried out with 15 young adults with CL/P aged 16-25 years. Interview questions were designed to map onto the NICE guidance. Data were analysed to assess whether each guideline was met, partially met, or not met for each individual participant. Overall, findings suggest that further consideration is needed as to how best to implement the recommendations effectively. The introduction of assigned transition workers in CL/P services to co-ordinate transition to adult care offers one possible solution. Focusing on the provision of holistic, patient-centred care, this aspect of the CL/P service could include giving patients access to medical history documentation, liaison with key health professionals including GPs and dental practitioners, and the development of age-appropriate resources to facilitate the transition process.

Isolation, Uncertainty and Treatment Delays: Parents' Experiences of Having a Baby with Cleft Lip/Palate During the Covid-19 Pandemic

OBJECTIVES

Previous literature finds that having a child with a cleft lip and/or palate (CL/P) may pose social and emotional challenges for parents. For parents of children born during the Covid-19 pandemic, such challenges may be heightened. Further, novel demands brought about by the pandemic could have caused additional hardships. The aim of this study was to describe the impact of the pandemic on new parents through qualitative exploration of their experiences.

DESIGN

Semi-structured interviews were conducted with 14 parents of children born in the United Kingdom with CL/P between January and June 2020, around the start of the pandemic. Data were analysed using inductive thematic analysis.

RESULTS

Three themes, with sub-themes, were identified. The first theme, "Changes to Healthcare: The Impact of Restrictions and Reduced Contact", discussed the impact of the pandemic on perinatal care, the care received from the specialist CL/P teams, and parents' experiences of virtual consultations. The second theme, "Family Functioning During the Pandemic", covered parental anxiety, fathers' experiences, and social support. The third theme, "Surgical Prioritisation: Delays and Uncertainty", addressed changes to surgical protocols, coping with uncertainty, complications associated with delayed surgery, and how parents created positive meaning from this period.

CONCLUSIONS

A range of increased and additional psychosocial impacts for parents were identified, along with several coping strategies, utilization of social support, and the positive aspects of their experiences. As the pandemic continues, close monitoring of families affected by CL/P remains imperative, particularly for those at risk of emotional distress.

Differences in specific concerns perceived by parents of children with cleft lip and/or palate based on the types of cleft

BACKGROUND

Parents of children with cleft lip and/or palate (CL/P) have concerns including guilt and worry. Differences in concerns by cleft type is, however, under-researched.

AIM

To compare differences in perceived concerns among parents of children with CL/P by cleft type, adjusting for children's gender and age.

DESIGN

Cross-sectional study conducted in an outpatient centre, assessing psychological status of 171 parents of children aged <12 with CL/P using 12 items.

RESULTS

Across cleft types, 'I am worried about whether the child's teeth will be straight' was the most strongly perceived concern (70.8%). After adjusting for gender and age, logistic regression showed significant differences in type of CL/P for (eg) 'I am worried that the child's appearance will not be beautiful', associated with CL over CP (OR = 0.07, 95% CI: 0.02-0.26) and CLP over CP (8.52, 3.23-22.50);' 'I am concerned about my child being able to speak well', associated with CP (3.12, 1.07-9.11) and CLP (5.69, 2.43-13.33) over CL, and 'I am worried that the child could suffer due to his/her appearance', associated with CL over CP (0.08, 0.02-0.29) and CLP over CP (10.07, 13.78-27.36).

CONCLUSIONS

Parents' concerns were influenced by cleft type.

The Impact of the Covid-19 Pandemic on Cleft Lip and Palate Service Delivery for New Families in the United Kingdom: Medical and Community Service Provider Perspectives

OBJECTIVES

Professionals in the United Kingdom providing care to new families affected by cleft lip and/or palate (CL/P) had to adapt to ensure families' needs were met during a time of uncertainty due to Covid-19. The aims of this study were to explore the impacts of the pandemic on CL/P care provision for new families from the perspectives of professionals working in medical and community settings along with any personal impact on professionals and their reflections on the future of CL/P care.

DESIGN

Semistructured interviews (n  =  27) were completed about experiences from March 2020 to October 2020 with consultant cleft surgeons (n  =  15), lead clinical nurse specialists (n  =  8), and staff working at the Cleft Lip and Palate Association (n  =  4). Transcripts were analyzed using inductive thematic analysis.

RESULTS

Three themes were identified: (1) the impact of Covid-19 on the provision of cleft care in the United Kingdom, including working conditions, delays to treatment, and Covid-19 policies; (2) the impact of the pandemic on professionals' mental health, including personal distress and concerns about Covid-19 exposure; and (3) reflections on the future of CL/P care, whereby professionals expressed both hope and concern about the Covid-19 recovery effort.

CONCLUSIONS

The ongoing Covid-19 pandemic has impacted CL/P service delivery for new families significantly, warranting recommendations for cohesive psychological support for families in addition to a safe and resourced recovery effort. Support for professionals is also suggested, following existing evidence-based models for providers' needs that address the difficulties of working throughout challenging times.

Incidence of fistula after primary cleft palate repair: a 25-year assessment of one surgeon’s experience

Background

Cleft lip and cleft palate are the most frequent congenital craniofacial deformities, with an incidence of approximately 1 per 700 people. Postoperative palatal fistula is one of the most significant long-term complications. This study investigated the incidence of postoperative palatal fistula and its predictive factors based on 25 years of experience at our hospital.

Methods

We retrospectively reviewed 636 consecutive palatal repairs performed between January 1996 and October 2020 by a single surgeon. Data from patients’ medical records regarding cleft palate repair were analyzed. The preoperative extent of the cleft was evaluated using the Veau classification system, and the cleft palate repair technique was chosen according to the extent of the cleft. SPSS version 25.0 was used for all statistical analyses, and exploratory univariate associations were investigated using the t-test.

Results

Fistulas occurred in 20 of the 636 patients; thus, the incidence of palatal fistula was 3.1%. The most common fistula location was the hard palate (9/20, 45%), followed by the junction of the hard and soft palate (6/20, 30%) and the soft palate (5/20, 25%). The cleft palate repair technique significantly predicted the incidence of palatal fistula following cleft palate repair (P=0.042). Fistula incidence was significantly higher in patients who underwent surgery using the Furlow double-opposing Z-plasty technique (12.1%) than in cases where the Busan modification (3.0%) or two-flap technique (2.0%) was used.

Conclusions

The overall incidence of palatal fistulas was 3.1% in this study. Moreover, the technique of cleft palate repair predicted fistula incidence.

Analysis of Clinical Pathway for Patients With Cleft Lip and Palate

AIM

To evaluate the implementation of a clinical pathway (CP) and identify clinical factors affecting the CP for cleft lip and palate (CLP) patients.

METHODS

A specific CP for CLP patients was developed at CLP Medical Center of Stomatological Hospital affiliated to Nanjing Medical University in 2008. The authors reviewed the collected data of 1810 consecutive patients using the CP for repairing cleft lip, cleft palatal, and alveolar cleft. The patients were treated between January 2008 and December 2019. The rate of completion and risk factors affecting dropout from the CP were analyzed.

RESULTS

The completion rates of the CP in cleft lip, cleft palate and alveolar cleft patients were 68.3% (n = 345), 82.4% (n = 785) and 76.1% (n = 268), respectively. The overall completion rate was 77.2% (n = 1398). The main reasons for dropping out were pre-operation events (n = 212, 11.7%) and post-operation events (n = 188, 10.4%). Among the factors of dropout of CP, laboratory test abnormalities accounted for the majority of pre- and post-operation events (n = 179, 9.9%). In statistical analysis, the combined abnormities and events associated with operations were significant risk factors affecting the dropout rate from CP.

CONCLUSION

The use of CP for CLP patients was reliable but the completion rate was relatively low because of perioperative events. These results provided some evidence of risk factors which should be considered when modifying the protocol of CP for CLP patients in order to achieve higher completion rate.

"Unexpected event": Having an infants with cleft lip and/or palate

This study aimed to determine the difficulties that the mothers of infants with a cleft lip and/or palate (CL/P) go through, the problems they encounter in this process, and how they perceive the support of healthcare professionals, families, and friends. The study used a phenomenological approach from qualitative research methods. The study sample included 18 mothers of 0 to 3-month-old infants with CL/P. The data were collected using socio-demographic information form and semi-structured interview form. The data obtained from the interviews were evaluated using content and thematic analysis approaches. On the basis of the interviews conducted with mothers of infants with CL/P, the following themes emerged: (a) "unexpected event: having an infant with CL/P," (b) "using social media," (c) "stigma," and (d) "uncertainty of long-term treatment." In this study, it was determined that mothers experienced shock, confusion, sadness, and disappointment in this process; therefore, they used social media to seek support from the families as well as conducted research on the disease that involved a lot of uncertainty due to long-term treatments. The present study can help healthcare professionals, who play a role in the care and treatment of infants with CL/P, to understand and know what mothers need in the preoperative period.

Experiences of Canadian Parents of Young Children With Cleft Lip and/or Palate

PURPOSE

Prior literature has described the perspectives of parents of young children with clip lip and/or palate; however, few studies have described parents' experiences within a Canadian health care system. This study aims to better understand the experiences of parents of young children with cleft lip and/or palate seen at a Canadian tertiary care center and identify their care needs.

DESIGN

In-depth semistructured interviews.

SETTING

Pediatric tertiary care center.

PARTICIPANTS

Parents of children younger than 7 years of age with cleft lip and/or palate.

RESULTS

From 14 interviews, 4 themes were identified. The diagnosis theme was associated with reactions, timing, and search for information. Key concerns within the theme of physiology and function were around feeding and speech. The health care experience theme included burden of care, peripheral hospitals and services, the cleft lip and palate clinic, and clinicians. The psychosocial theme included parents' reactions to their child's pain, coping strategies, family interactions, and school/day care experiences. Parents felt care could be improved by having: access to good information and community speech therapists, shorter appointment wait times, a peer support network, and increased cleft knowledge within their child's school and peer groups.

CONCLUSIONS

The experience of parents of children with cleft lip and/or palate is complex but can be organized into 4 themes. Clinics may consider suggestions offered by parents to improve care. Future work should address parents' needs and aim to create a parent-reported quality-of-life measure specific to parents of young children with cleft lip and/or palate.

The Cleft Nurse Specialist: A Key Building Block in the Cleft Multidisciplinary Team

INTRODUCTION

The cleft nurse specialist (CNS) plays a key role in counselling and supporting parents from the diagnosis onward. The CNS started in 2012 and we aimed to perform a qualitative study to determine the benefits this brought to the cleft community from the parents' perspective.

METHODS

The cleft database was used to locate babies born in 2010/2011 and 2013/2014. Parents were contacted by phone by 2 authors and completed a questionnaire on the care and support they received following the diagnosis, in the early days and around the time of surgery.

RESULTS

Parents of 38 babies completed the survey. In 2010/2011, only 21% had an antenatal diagnosis compared to 47% in 2013/2014.2011/2012: 3 unilateral cleft lip and palate (UCLP), 3 bilateral cleft lip and palate (BCLP), 4 CLO, 9 cleft palate only (CPO).2013/2014: 5 UCLP, 7 BCLP, 7 CPO.2011/2012: 68% were counselled by a surgeon, 42% were seen >1 week after birth, with some over a month.2013/2014: 84% were counselled by the CNS, 53% were seen within 48 hours, and 100% within 7 days.Parents in 2013/2014 felt more supported by the cleft team throughout pregnancy and the early days, with home visits being particularly advantageous.

CONCLUSION

The introduction of the CNS to the cleft multidisciplinary team has significantly improved the pathway for parents and is a key link with the wider cleft team. With the improvement in antenatal diagnosis, counselling occurs at an earlier stage and prepares parents for the difficulties commonly experienced in the early days. Key themes included; home visits and direct contact with the CNS.

Provision of Care for Families Affected by Craniofacial Conditions: The Views of Nonspecialist Health Professionals

OBJECTIVE

A diagnosis of a congenital craniofacial condition can have a significant impact on the psychological well-being of the affected family. As the first health professionals likely to come into contact with families, nonspecialists, such as diagnostic sonographers, midwives, and health visitors play a crucial role in facilitating familial adjustment. Yet, previous research has demonstrated parental dissatisfaction with the care delivered by nonspecialists. The aim of this study was to investigate the provision of care for families affected by craniofacial conditions from the perspective of nonspecialist health professionals, with a view to informing the development of educational materials.

DESIGN

Individual semistructured telephone interviews (n = 14) were conducted with 3 diagnostic sonographers, 2 fetal medicine consultants, 3 midwives, 4 health visitors, and 2 children's nurses.

RESULTS

Participants identified a range of barriers to the delivery of optimal care, including dealing with parental reactions, time pressure, hospital protocols and resources, a lack of contact with specialist craniofacial teams, and the emotional impact of delivering a diagnosis. Most participants had received no prior training in the area of congenital craniofacial conditions, while those who had felt current training materials were insufficient. All participants expressed a desire for further training and provided guidance regarding preferred content and format.

CONCLUSIONS

This study provides insight into the challenges faced by nonspecialists, as well as a range of information and training needs that could improve their knowledge and confidence. Suggestions for the development of educational materials for nonspecialist health professionals are made.

Promoting Psychosocial Adjustment in Individuals Born With Cleft Lip and/or Palate and Their Families: Current Clinical Practice in the United Kingdom

Objectives:

The importance of psychosocial aspects of care has received growing recognition in recent years. However, the evidence base for psychosocial intervention remains limited. Specialist clinicians working in cleft lip and/or palate (CL/P) services hold a wealth of knowledge and experience yet to be elicited. The aims of this study were to identify common psychosocial challenges and potential risk and/or protective factors for psychosocial distress from the perspective of specialist clinicians and to establish the types of interventions currently being delivered in practice.

Design:

Individual interviews with 17 clinical nurse specialists and 19 specialist clinical psychologists, representing all 16 UK CL/P surgical sites. Data were analyzed using inductive content analysis.

Results:

Numerous psychosocial challenges affecting individuals with CL/P and their families were identified across the life span. Risk factors were predominantly contextual in nature, while protective factors appeared amenable to intervention. Participants drew upon a range of therapeutic models and approaches to guide formulation and intervention, while acknowledging the lack of evidence to support these approaches in CL/P populations specifically.

Conclusions:

Findings have important implications for the way in which psychosocial support for CL/P and related conditions is delivered and evaluated. A framework for the standardized assessment of holistic individual and familial well-being is proposed. Suggestions for increasing the evidence base for specific psychosocial interventions are made, including enhanced family functioning; social, emotional, and appearance concerns; treatment decision-making; and screening for psychosocial and developmental issues.