Outcomes of Cleft Palatal Repair for Internationally Adopted Children:

Predictors of Adverse Outcomes Following Cleft Palate Repair: An Analysis of Over 2500 Patients Using International Smile Train Data

OBJECTIVE

The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes.

DESIGN

Multi-institution, retrospective review of Smile Train Express database.

SETTING

1110 Smile Train partner hospitals.

PATIENTS/PARTICIPANTS

2560 patients.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery.

RESULTS

The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair.

CONCLUSIONS

Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

Persisting speech difficulties at 7-8 years of age - a longitudinal study of speech production in internationally adopted children with cleft lip and palate

AIM

To longitudinally investigate speech production (consonant proficiency, consonant errors and perceived velopharyngeal competence) in 17 internationally adopted (IA) children with unilateral cleft lip and palate (UCLP) at three time points.

METHOD

Consonant proficiency (percent consonants correct, consonant inventory) and number and type of consonant errors were calculated based on blind phonetic transcriptions of words from the Swedish Test of Articulation and Nasality (SVANTE). Velopharyngeal competence was perceptually rated by three blinded experienced speech-language pathologists at the ages of 3, 5 and 7-8 years.

RESULTS

A significant positive development of speech production was found, although most children still scored very low for consonant proficiency at the age of 7-8 compared with normative values: the median for percent consonants correct was 79.7 and many children still had persisting cleft-related and developmental consonant errors. At the age of 7-8, almost half of the children were rated as having a competent velopharyngeal function and only three as having an incompetent velopharyngeal function.

CONCLUSION

Persisting speech difficulties at school age in IA children with UCLP were found in the present study, which is one of the very few longitudinal studies. Our results highlight the need for detailed follow-up of speech production in clinical settings. Speech disorders may have a severe impact on a child's intelligibility and participation with peers, and there is a need for more studies investigating the actual everyday effect of the difficulties found.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Longitudinal data on speech outcomes in internationally adopted children compared with non-adopted children with cleft lip and palate

BACKGROUND

At the beginning of the 21st century, international adoptions of children with cleft lip and/or palate increased dramatically in Sweden. Many children arrived partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. To date, the speech development of internationally adopted (IA) children has been described up to age 7-8 years, but later development remains unstudied.

AIMS

To investigate speech development between ages 5 and 10 years in children born with cleft lip and palate (CLP) adopted from China and to compare them with non-adopted (NA) children with CLP. A secondary aim was to compare the frequencies of secondary palatal surgery and number of visits to a speech and language pathologist (SLP) between the groups.

METHODS & PROCEDURES

In a longitudinal study, 23 IA children from China were included and matched with 23 NA children born in Sweden. Experienced SLPs blindly reassessed audio recordings from routine follow-ups at ages 5 and 10 years. Velopharyngeal function (VPF) was assessed with the composite score for velopharyngeal competence (VPC-Sum) for single words and rated on a three-point scale (VPC-Rate) in sentence repetition. Target sounds in words and sentences were phonetically transcribed. Per cent correct consonants (PCC) were calculated at word and sentence levels. For in-depth analyses, articulation errors were divided into cleft speech characteristics (CSCs), developmental speech characteristics (DSCs) and s-errors. Information on secondary palatal surgery and number of visits to an SLP was collected.

OUTCOMES & RESULTS

VPF differed significantly between the groups at both ages when assessed with VPC-Sum, but not with VPC-Rate. Regardless of the method for assessing VPF, a similar proportion in both groups had incompetent VPF but fewer IA than NA children had competent VPF at both ages. IA children had lower PCC at both ages at both word and sentence levels. More IA children had CSCs, DSCs and s-errors at age 5 years, and CSCs and s-errors at age 10. The development of PCC was significant in both groups between ages 5 and 10 years. The proportion of children receiving secondary palatal surgery did not differ significantly between the groups, nor did number of SLP visits.

CONCLUSIONS & IMPLICATIONS

CSCs were more persistent in IA children than in NA children at age 10 years. Interventions should target both cleft and DSCs, be comprehensive and continue past the pre-school years.

WHAT THIS PAPER ADDS

What is already known on this subject At the beginning of the 21st century, IA children with cleft lip and/or palate arrived in Sweden partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. Studies up to age 7-8 years show that adopted children, compared with NA peers, have poorer articulation skills, demonstrate both cleft-related and developmental articulation errors, and are more likely to have velopharyngeal incompetence. Several studies also report that adopted children more often require secondary palatal surgery due to fistulas, dehiscence or velopharyngeal incompetence compared with NA peers. What this paper adds to existing knowledge This longitudinal study provides additional knowledge based on longer follow-ups than previous studies. It shows that the proportion of children assessed to have incompetent VPF was similar among IA and NA children. It was no significant difference between the groups regarding the proportion that received secondary palatal surgery. However, fewer IA children were assessed to have a competent VPF. Developmental articulation errors have ceased in most IA and all NA children at age 10 years, but significantly more adopted children than NA children still have cleft-related articulation errors. What are the potential or actual clinical implications of this work? Speech and language therapy should target both cleft-related and developmental articulation errors. When needed, treatment must be initiated early, comprehensive, and continued past the pre-school years, not least for adopted children.

Racial and Ethnic Disparities in Primary Cleft Lip and Cleft Palate Repair

OBJECTIVE

To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair.

DESIGN

Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018.

PATIENTS AND MAIN OUTCOME MEASURES

Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity.

RESULTS

In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively).

CONCLUSIONS

This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.

A national registry-based study of surgery and demography comparing internationally adopted and children born in Sweden with cleft lip and/or palate

This national registry-based study compares surgical procedures, demography, and concurrent medical conditions, in internationally adopted and Swedish-born children with cleft lip and/or palate until the age of five years. Data on the cleft type and gender for 331 internationally adopted children and 2064 Swedish-born children born from 2007 to 2018, were extracted from the registry and analyzed. Data on surgical procedures performed in Sweden and concurrent medical conditions and were collected for internationally adopted children and Swedish-born children with unilateral or bilateral cleft, born 2007-2013. A higher prevalence of unilateral and bilateral clefts (p < 0.0001), as well as a predominance of male patients with unilateral clefts (p = 0.0025), were identified among the internationally adopted children compared with children born in Sweden. Differences in the concurrence of other medical conditions in internationally adopted children versus Swedish-born infants were non-significant. Primary palatal surgeries performed in Sweden were significantly delayed for the adopted group. More secondary palatal surgeries such as speech improving surgery and palatal re-repair were needed for internationally adopted children (p < 0.0001) until age five.Conclusions: The Swedish CLP Registry provided national coverage of the CL/P cohort. Internationally adopted children exhibited a predominance of more severe cleft types, a predominance of males, delayed primary palatal surgery and increased need for secondary surgeries before age five.

Quality of Life of Adopted Chinese Versus Nonadopted Dutch Children with Cleft Lip and/or Palate: A Propensity Score Matched Analysis

Objective

To examine quality of life in internationally adopted children with cleft lip and/or palate (CL/P) versus non-adopted children with CL/P.

Design

Cross sectional study.

Setting

Multidisciplinary cleft team of a secondary and tertiary hospital in the Netherlands.

Methods

Parents of children under the age of 8 treated by the multidisciplinary cleft team of our institutions were asked to fill out a questionnaire containing demographic and clinical data and a validated parent proxy measure of cleft-specific quality of life instrument for children aged 0–8: the CleftChild-8. Adopted children were matched to non-adopted children using propensity score matching based on sex, age, type of cleft, if palatal surgery was completed and the level of education of the parent. CleftChild-8 scores were then compared between the matched samples of adopted and non-adopted children with CL/P.

Main Outcome Measure(s)

Differences in (sub)domain scores of the CleftChild-8.

Results

Most median CleftChild-8 scores of the adopted children (n = 29) were slightly lower compared to the 29 matched non-adopted children. A significant difference was seen for the domain score ‘satisfaction with (operative) treatment’ and 3 of the 13 subdomain scores: ‘post-operative results’, ‘acceptance by siblings’ and ‘acceptance by family/friends’.

Conclusions

By parent report, adopted children with CL/P experienced some areas of lower quality of life when compared to non-adopted children. Members of cleft teams should be aware of the problems associated with adoption and offer additional guidance and counseling to adopted children and their parents.

A Comparison of Outcomes After Palatoplasty in Patients With Non-Syndromic Pierre Robin Sequence Versus Patients With Non-Syndromic Isolated Cleft Palate

The purpose of this retrospective study was to compare outcomes of cleft palate repair in patients with non-syndromic Pierre Robin sequence (NS-PRS) versus those with non-syndromic isolated cleft palate (NS-ICP). Pierre Robin sequence (PRS) was defined as a diagnosis of the triad of microretrognathia, glossoptosis, and cleft palate, and the severity of PRS was assessed based on the presence of respiratory and feeding problems. All patients underwent palatoplasty between January 2000 and December 2011. The authors examined age at palatoplasty, type of cleft palate, fistula rate, velopharyngeal (VP) function, nasal emission, hypernasality, and need for secondary speech surgery, in addition to PRS severity in the NS-PRS patients. A total of 15 NS-PRS patients and 40 NS-ICP patients were reviewed. The incidence of VP dysfunction, nasal emission, hypernasality, and secondary speech surgery was not significantly different between the NS-PRS patients and NS-ICP patients. Age at palatoplasty was significantly different between the 2 groups (P = 0.012) but type of CP was not (P = 1.00). Only 2 NS-PRS patients were classified as category III (severe), and all of the NS-PRS patients who had VP insufficiency were classified as PRS severity category I (not severe). The findings of this study indicate that NS-PRS patients may not have worse outcomes than NS-ICP patients.

Internationally adopted children with and without a cleft lip and palate showed no differences in language ability at school-age

AIM

The aim of this study was to investigate language ability in internationally adopted children aged 7-8 years with and without a unilateral cleft lip and palate.

METHODS

We compared 27 internationally adopted children with a unilateral cleft lip and palate, adopted from China, with a group of 29 children without a cleft lip and palate, adopted from different countries. Participants were recruited from two cleft lip and palate teams in Sweden and through adoption organisations. Assessments were performed using standardised tests of speech and of receptive and expressive language ability. In addition, a parental questionnaire in which speech, language and communication aspects were rated was used.

RESULTS

There were no significant differences in language ability between the groups. The only difference was related to speech ability, where the internationally adopted children with unilateral cleft lip and palate scored significantly lower. However, a high proportion of children in both groups scored low on measures of expressive language compared with test norms.

CONCLUSION

The results suggested that having a cleft lip and palate did not increase the risk of language difficulties. Instead, being internationally adopted may be associated with a risk of delayed language development lasting for several years post-adoption.

Normal Speech Should be the Expected Outcome in the Adopted Cleft Child

Significantly worse speech outcomes and higher complication rates are reported among internationally adopted cleft patients. We evaluated our cohort to provide more accurate counseling to adoptive parents.

METHODS

We reviewed internationally adopted children with unrepaired cleft palate who had 2-flap palatoplasty with radical intravelarveloplasty from 2003 to 2015 in a single-surgeon, consecutive series.

RESULTS

Seventy-two children adopted with unrepaired cleft palate were identified, 2 with syndromic association. The average age at palatoplasty was 28.1 months. Meaningful speech assessment was available in 58 patients. Successful speech was defined by a competent or borderline-competent velopharyngeal mechanism (Pittsburgh Weighted Speech Score <2). Twenty-five patients (43%) had successful speech outcomes. Twenty-nine patients (50%) were recommended secondary operation for nasality. Nonfistula repair secondary operation was performed using the following: fat grafting (9 patients, 43%), intravelarveloplasty (8 patients, 38%), and sphincter pharyngoplasty (4 patients, 19%). The average Pittsburgh Weighted Speech Score improved 5.8 to 1.3 (P = 1.3E-6); 4.8 to 1.0 (P = 0.0009) with fat grafting alone. After all interventions, normal speech was achieved in 43 (74%) of 58 patients. Palatal fistula (9.2% vs 0.9%, P = 0.001) and velopharyngeal insufficiency (50% vs 6.7%, P = 0.0004) rates were both significantly higher in the internationally adopted cohort than our nonadopted population data. The need for secondary surgery was independent of cleft type (P = 0.89), age (P = 0.78), or presence of a "wide" cleft (P = 1).

CONCLUSIONS

Our results demonstrate higher fistula and secondary surgery rates. Successful speech outcomes were achieved in most patients with minimally invasive secondary procedures.

Perioperative care for internationally adopted children: Medical, surgical, and psychosocial considerations for a population of concern

The overall number of international adoptions has dropped in the last 20 years, but a relative increase in the proportion of these children with special and surgical needs has occurred. Cleft lip/palate and anorectal malformations are two common surgical pathologies for internationally adopted children. Internationally adopted children with cleft lip/palate have high rates of speech impairment and frequent need for reoperation, and children with anorectal malformation commonly need multiple reoperations. For both groups, surgery prior to adoption may have actually contributed to morbidity. Both speech impairment and anorectal malformation negatively affect quality of life, independent of adoption. Additionally, internationally adopted children frequently have experienced trauma, single or complex, and institutionalization. Each of these can independently contribute to impaired psychosocial and behavioral development. These children face surgery, sometimes multiple surgeries, while adapting to a new culture, learning a new language, and bonding with a new family. The impact of prior medical experiences without the presence of a caregiver and/or while institutionalized is understudied. The surgical experience and perioperative outcomes within this population warrant research, and clinical coordination between teams may help improve care for this uniquely vulnerable population.

Cleft lip repair: are outcomes between unilateral and bilateral clefts comparable?

This study sought to compare patient demographics, operative course, and peri-operative outcomes between unilateral and bilateral cleft patients. Primary cleft lip repairs were isolated from the National Surgical Quality Improvement Program Pediatric Database (NSQIP-P). Unilateral and bilateral cases of primary cleft lip were identified by ICD codes. Demographics, comorbidities, and post-operative outcomes were compared between cohorts. Patients were propensity matched to control for differences before repeating the analysis. About 4550 cleft lip repairs were evaluated over the 5-year period. Of the cases where the cleft type was identifiable, 75.5% were unilateral clefts and 24.5% were bilateral clefts. The bilateral cleft population had significantly more comorbidities including higher rates of ventilator dependence (1.0% versus 0.4%, p = 0.02), asthma (1.6% versus 0.7%, p = 0.011), tracheostomy (1.6% versus 0.5%, p < 0.001), gastrointestinal disease (16.9% versus 12.7%, p < 0.001), previous cardiac surgery (3.6% versus 2.2%, p = 0.015), developmental delay (9.9% versus 4.6%, p < 0.001), structural central nervous system abnormalities (5.0% versus 2.5%, p < 0.001), and nutritional support (8.0% versus 3.2%, p < 0.001). Following propensity matching, there were no significant differences in complications, readmissions, or reoperations between the cohorts. Patients with bilateral cleft lip have significantly more comorbidities than unilateral cleft lip patients. However, peri-operative outcomes are comparable between the groups.

Surgical outcome of two-flap palatoplasty at King Fahad Medical City: A tertiary care center experience

The purpose of this study was to assess surgical outcomes of two-flap palatoplasty for management of cleft palate.Between January 2009 and January 2017, we recruited 29 nonsyndromic patients who underwent two-flap palatoplasty for cleft palate repair at the oral and maxillofacial department. Their medical records were procured, and surgical outcomes were assessed. Velopharyngeal insufficiency (VPI) was evaluated on the basis of speech assessment by a speech therapist. Speech abnormality (nasality, nasal emission, and articulation error) was assessed by a speech therapist using the GOSS-Pass test. Swallowing and regurgitation were assessed by a swallowing team. Fistula and wound dehiscence were clinically assessed by the primary investigator. Documented data were evaluated using statistical analysis. Among the study patients; 75.8 % had normal speech, 20.7 % developed VPI; 17.3% had hypernasality; 4.3% had hypernasality as well as nasal emission; 4.3% had hypernasality, nasal emission, and articulation errors; and 4.3% had articulation errors. Approximately 20% of the patients had fistulas (83.3% had oronasal fistulas and 16.7% had nasovestibular fistulas). Normal swallowing findings were noted in 93% of the patients. There were statistically significant relationships between age-repair and VPI (r=0.450, t=0.014), age-speech (r=0.525, t=0.003), and age-fistula development (r=0.414, t=0.026). Conversely, there were no significant relationships between age and dehiscence (r=0.127, t=0.512), age and swallowing (r=0.360, t=0.055), and age and regurgitation (r=0.306, t=0.106). Two-flap palatoplasty is a reliable technique with excellent surgical and speech outcomes. Early repair is associated with better speech outcome and less incidence of VPI.

Cleft Palate Repair: Description of an Approach, Its Evolution, and Analysis of Postoperative Fistulas

BACKGROUND

Fistulas following cleft palate repair impair speech, health, and hygiene and occur in up to 35 percent of cases. The authors detail the evolution of a surgical approach to palatoplasty; assess the rates, causes, and predictive factors of fistulas; and examine the temporal association of modifications to fistula rates.

METHODS

Consecutive patients (n = 146) undergoing palatoplasty during the first 6 years of practice were included. The technique of repair was based on cleft type, and a common surgical approach was used for all repairs.

RESULTS

The fistula rate was 2.4 percent (n = 125) after primary repair and 0 percent (n = 21) after secondary repair. All complications occurred in patients with type III or IV clefts. Cleft width and cleft-to-total palatal width ratio were associated with fistulas, whereas syndromes, age, and adoption were not. Most complications could also be attributed to technical factors. During the first 2 years, modifications were made around specific anatomical features, including periarticular bony hillocks, maxillopalatine suture, velopalatine pits, and tensor insertion. The fistula rate declined by one-half in subsequent years.

CONCLUSIONS

The authors describe a surgical approach to cleft palate repair, its evolution, and surgically relevant anatomy. Fistulas were associated with increasing cleft severity but could also be attributed to technical factors. A reduction in frequency and severity of fistulas was consistent with a learning curve and may in part be associated with modifications to the surgical approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Internationally adopted children with cleft lip and/or cleft palate: Middle ear findings and hearing during childhood

OBJECTIVE

Adopted children with cleft lip and/or cleft palate form a diverse group of patients. Due to increased age at palatal repair, adopted children have a higher risk of velopharyngeal insuffiency and poor speech outcome. Delayed palate repair may also lead to longer lasting Eustachian tube dysfunction. Decreased function of the Eustachian tube causes otitis media with effusion and recurrent acute otitis media, which can lead to other middle ear problems and hearing loss.

METHODS

One-hundred-and-thirty-two adopted children treated by the Cleft palate team in Wilhelmina Children's Hospital during January 1994 and December 2014 were included. Retrospectively, middle ear findings, the need for ventilation tube insertion and hearing during childhood were assessed. Findings were compared with 132 locally born children with cleft lip and/or cleft palate.

RESULTS

Adopted children had a mean age of 26.5 months old when they arrived in our country. After the age of two the total number of otitis media with effusion episodes and the need for ventilation tube placement did not significantly differ among adopted and non-adopted children. Adopted children had significantly more tympanic membrane perforations. Hearing threshold levels normalized with increasing age. Although within normal range, adopted children showed significantly higher pure tone averages than locally born children when they were eight to ten years old.

CONCLUSION

In general, adopted patients with cleft lip and/or cleft palate did not have more middle ear problems or ventilation tubes during childhood. However, theyhave more tympanic membrane perforations.

Cleft Care of Internationally Adopted Children From China

Objective:

To quantify a population of international adoptees from China with cleft lip and/or palate to assess presentations and team management practices.

Design:

Single institution retrospective.

Patients:

One hundred one patients with cleft lip and/or palate and history of international adoption from China.

Results:

Forty-nine males and 52 females were adopted from 2001 to 2014. Median age at arrival was 26 months. A total of 88.1% had a combined cleft lip and palate: 59 unilateral, 30 bilateral. Only 4 patients had isolated cleft palate. A total of 85.6% had cleft lip repair before adoption; 41.6% had both cleft lip and palate repairs in China. A total of 14.9% of adoptees had no prior surgery. In China, median age at lip repair was 10 months, and palate repair was 19 months. Once in the United States, lip repair was at 24 months and palate repair at 24 months. Eighty-three revision surgeries were performed. A total of 79.2% of children demonstrated moderate to severe articulation disorders. A total of 36.6% had velopharyngeal insufficiency with hypernasal speech. Forty percent required palatal revision surgery to achieve normal resonance. Fifty seven percent of patients presented with concomitant medical issues but less than 10% with global delays or autism.

Conclusions:

Chinese adoptees have more complex presentations and delayed surgical care compared to their domestic counterparts. Engaging prospective families starting before adoption helps to manage expectations. Long-range planning, timely surgery, aggressive therapy, and close careful follow-up can mitigate some of these differences. Speech and language problems including articulation disorders, expressive delays, and hypernasality are frequent and can persist despite interventions.

Nasal Obstruction in Children With Cleft Lip and Palate: Results of a Cross-Sectional Study Utilizing the NOSE Scale

OBJECTIVE

To characterize the epidemiology and risk factors for nasal obstruction among subjects with cleft lip and/or cleft palate (CL/P) utilizing the well-validated Nasal Obstruction Symptom Evaluation (NOSE) survey.

DESIGN

Retrospective cross-sectional study.

SETTING

Cleft Lip and Palate Program, Children's Hospital of Philadelphia.

PATIENTS, SUBJECTS

One thousand twenty-eight surveys obtained from 456 subjects (mean age: 10.10 (4.48) years) with CL/P evaluated between January 2015 and August 2017 with at least 1 completed NOSE survey.

INTERVENTIONS

Nasal Obstruction Symptom Evaluation surveys completed at each annual visit.

MAIN OUTCOME MEASURES

Composite NOSE and individual symptom scores.

RESULTS

Sixty-seven percent of subjects had nasal obstruction at some point during the study period, with 49% reporting nasal obstruction at latest follow-up. subjects aged 14 years and older reported the most severe symptoms ( P = .002). Subjects with cleft lip and alveolus (CL+A) and unilateral cleft lip and palate (CLP) reported more severe nasal blockage than other phenotypes ( P = .021). subjects with a history of either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP) had significantly higher NOSE scores than subjects with no history of speech surgery ( P = .006). There was no significant difference ( P > .050) in NOSE scores with regard to history of primary tip rhinoplasty, nasal stent use, or nasoalveolar molding.

CONCLUSIONS

There are more severe nasal obstructive symptoms among subjects older than 14 years of age, with CL+A or unilateral CLP, and with a history of PPF or SP. Future studies utilizing the NOSE are needed to evaluate and address this prevalent morbidity in the CLP population.

Speech Production Skills in Children With Cleft Palate Who Were Internationally Adopted

Objective:

The objective of this study was to investigate the impact of international adoption (IA), age at palatoplasty (PR age), and velopharyngeal sufficiency (VPS) on articulation outcomes.

Design:

This was a cross-sectional, prospective, observational study.

Setting:

Outpatient hospital clinic.

Participants:

Fifty-one IA and 65 not-adopted (NA) children between the ages of 3 and 9 with nonsyndromic cleft palate with or without cleft lip.

Main Outcome Measure(s):

The Goldman-Fristoe Test of Articulation—2nd Edition (GFTA-2) standard score and cleft-related articulation errors (CREs).

Results:

Articulation impairment was observed for 40% to 76% of NA children and 71% to 92% IA children, depending on age. PR age mean IA = 2.07 (0.86) years; NA = 1.23 (0.71) years. Children who were IA had poorer performance on the GFTA-2 ( B = −13.82, P = .015). Children who were IA were not significantly more likely to make CRE; rather, age at the time of assessment ( B = −.10, P = .002) and VPS ( B = .24, P = .021) were associated with CRE.

Conclusions:

Children who were IA demonstrated poorer articulation skills. Although primary palatoplasty was accomplished later among children who were IA, age at assessment and VP status (not PR age) were significantly correlated with articulation outcomes. Implications for timing of surgical intervention are discussed.

Longitudinal Comparison of the Speech and Language Performance of United States-Born and Internationally Adopted Toddlers with Cleft Lip and Palate

Objective:

This study compares the early speech and language development of children with cleft palate with or without cleft lip who were adopted internationally with children born in the United States.

Design:

Prospective longitudinal description of early speech and language development between 18 and 36 months of age.

Participants:

This study compares four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were adopted internationally with four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were born in the United States, matched for age, gender, and cleft type across three time points over 10 to 12 months.

Main Outcome Measures:

Children's speech-language skills were analyzed using standardized tests, parent surveys, language samples, and single-word phonological assessments to determine differences between the groups.

Results:

The mean scores for the children in the internationally adopted group were lower than the group born in the United States at all three time points for expressive language and speech sound production measures. Examination of matched pairs demonstrated observable differences for two of the four pairs. No differences were observed in cognitive performance and receptive language measures.

Conclusions:

The results suggest a cumulative effect of later palate repair and/or a variety of health and environmental factors associated with their early circumstances that persist to age 3 years. Early intervention to address the trajectory of speech and language is warranted. Given the findings from this small pilot study, a larger study of the long-term speech and language development of children who are internationally adopted and have cleft palate with or without cleft lip is recommended.

Speech and Surgical Outcomes in Children With Veau Types III and IV Cleft Palate: A Comparison of Internationally Adopted and Nonadopted Children

OBJECTIVE

This study compares speech and surgical outcomes in internationally adopted and nonadopted patients undergoing cleft palate repair, and examines the influence of age at initial palatoplasty.

DESIGN

Retrospective cohort study setting: Tertiary Care Children's Hospital.

PATIENTS

70 international adoptees and 211 nonadoptees with Veau type III and IV clefts (without associated syndrome) repaired at our institution.

OUTCOME MEASURES

Outcomes included VPI, compensatory misarticulations, intelligibility, nasal air emission, oronasal fistula, and secondary speech surgery. Speech evaluations completed near 5 years of age were gathered from a prospectively collected database.

RESULTS

Adoptees underwent palatoplasty 5.2 months after arrival, a mean of 10.4 months later than nonadoptees. Adoptees were significantly more likely to develop moderate/severe VPI and trended toward more frequent need for secondary speech surgery. Oronasal fistula occurred at similar rates. Increased age at initial palatoplasty was a significant predictor of moderate to severe VPI, and need for secondary speech surgery.

CONCLUSIONS

International adoptees undergo palatoplasty 10.4 months later than nonadoptees and are significantly more likely to develop moderate/severe VPI, with a trend toward increased secondary speech surgery. An association between treatment delay and moderate/severe VPI and secondary speech surgery has been demonstrated. While a causal relationship between delayed repair and inferior outcomes in international adoptees has not been proven, this data suggests that surgical intervention upon unrepaired cleft palates soon after adoption may be beneficial. The opportunity for a change in practice exists, as half of the 10.4-month relative delay in palate repair occurs postadoption.

Speech production in 3-year-old internationally adopted children with unilateral cleft lip and palate

BACKGROUND

In the last decade, a large number of children with cleft lip and palate have been adopted to Sweden. A majority of the children were born in China and they usually arrive in Sweden with an unoperated palate. There is currently a lack of knowledge regarding speech and articulation development in this group of children, who also have to deal with a late first language switch.

AIMS

To study consonant proficiency in 3-year-old internationally adopted children with unilateral cleft lip and palate (UCLP) compared with peers with UCLP born in Sweden. Also to study the type and frequency of consonant errors and to perceptually compare velopharyngeal competence between the groups.

METHODS & PROCEDURES

Thirty-two children born between 2006 and 2010 with UCLP participated in the study-14 adopted from China and 18 children born in Sweden. Both groups were treated by the same cleft palate team. Audio recordings at 3 years of age were perceptually analysed by blinded listeners. Consonant proficiency was measured via per cent consonants correct adjusted for age (PCC-A), per cent correct manners (PCM) and per cent correct places (PCP). The prevalence of audible nasal air leakage and velopharyngeal competence were judged and compared between groups. The type and frequencies of consonant errors related to place and manner of articulation were also analysed.

OUTCOMES & RESULTS

The internationally adopted children had significantly fewer correct consonants compared with the Swedish-born children. This was true for PCC-A, PCP and PCM. This group also had significantly higher prevalence of glottal stops/fricatives and deleted target consonants more often. Also the internationally adopted children had a higher prevalence of incompetent velopharyngeal function. The only outcome variable with similar results in the groups was audible nasal air leakage.

CONCLUSIONS & IMPLICATIONS

The present study indicated that there were significant differences regarding consonant proficiency and velopharyngeal competence between internationally adopted children with a UCLP and their Swedish-born peers with UCLP at the age of 3 years. Internationally adopted children with UCLP should be considered an at risk group for a higher prevalence of speech difficulties than non-adoptees. Thus, it is particularly important to follow this group of children over time. Longitudinal studies of speech and language development in internationally adopted children with UCLP are needed.

Language Development in Children With Cleft Palate With or Without Cleft Lip Adopted From Non-English-Speaking Countries

PURPOSE

The purpose of this study was to determine whether language skills differed between children with cleft palate or cleft lip and palate (CP±CL) who were adopted into an English-speaking home from a non-English-speaking country (late English exposure [LE]) and children with CP±CL raised from birth in an English-speaking home (early English exposure [EE]).

METHOD

Children (51 LE, 67 EE), ages 3;0 (years;months) to 9;0, completed the Clinical Evaluation of Language Fundamentals (CELF), Preschool Second Edition or Fourth Edition. Linear regression analysis was used to assess the impact of age of adoption and time in an English-speaking home on language skills, as measured by the CELF-P2 and CELF-4.

RESULTS

Children with CP±CL who were adopted scored less well on all language indices, with mean adjusted differences between LE and EE children ranging from 0.4 to 0.7 SD on the CELF index scales. Only 53% of the EE children and 57% of the LE children obtained scores above 90 on all indices. For LE children, younger age at adoption was associated with better language skills.

CONCLUSION

CP±CL increases risk for language delay, with the highest risk for LE children. LE children with CP±CL should receive language services soon after adoption.

A standardized approach for the assessment and treatment of internationally adopted children with a previously repaired anorectal malformation (ARM)

INTRODUCTION

A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population.

METHODS

The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016.

RESULTS

56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common.

CONCLUSION

The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.

Optimizing Surgical Treatment of Internationally Adopted Children with Cleft Lip and/or Palate: Understanding the Family Experience

Objective

To understand the experience of families with children undergoing cleft surgery following adoption from a country outside the United States. To identify factors, including the timing of surgery, that influence family function throughout the surgical experience.

Design

Semistructured qualitative interviews were conducted with parents of internationally adopted children postrepair of cleft lip and/or cleft palate and coded by a multidisciplinary study team. Mixed methods were used to contextualize themes derived from the parent interviews.

Results

Twenty parent interviews were conducted, and four core themes were identified: (1) parental anxieties prior to surgery, (2) considerations for the timing of surgery, (3) impact of the surgical experience on the child and family, and (4) modifiable sociocontextual factors. Parents considered a strong child bond with at least one parent and the ability of the child to communicate basic needs to be important before undergoing surgery. In retrospect, parents generally felt that the surgical experience did not have a negative impact on their child or their families and that the surgical experience may have even facilitated bonding and attachment with their child. Acceleration of family bonding was expressed more often by parents of children who were adopted at older than 2 years.

Conclusions

In our study, parents reported that cleft surgery soon after international adoption did not appear to impair child bonding or adjustment. Specific family and provider factors that could optimize the experience for families were identified.

Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database

BACKGROUND

Posterior pharyngeal flap (PPF) surgery is effective for treating velopharyngeal insufficiency but has historically been associated with risk of airway compromise. This study aims to identify risk factors for complications from and readmission after PPF using a national database.

METHODS

Patients who underwent PPF surgery were selected from the 2012 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) database. Patient characteristics, comorbidities, and complication/readmission data were analyzed.

RESULTS

Among 225 study patients, 12 (5.3%) suffered perioperative complications. The most common complications were pulmonary in nature (5 patients, 2.2%), including prolonged postoperative mechanical ventilation (3 patients, 1.3%). Underlying asthma (P = .024) or any cardiac risk factor (P = .047) conveyed significant complication risk. Further, severe cardiac risk factors were associated with postoperative bleeding (P = .024). Readmission (4 patients, 1.7%) and reoperation (3 patients, 1.3%) occurred at mean intervals of 9 and 10 days after the original procedure. Seventy-nine patients (35%) were discharged postoperatively on an outpatient basis, and this subgroup included only one patient (1.2%) with a complication (P = .038).

CONCLUSIONS

The overall perioperative complication rate for PPF surgery is low at 5.3%. Patients with underlying cardiac risk factors, severe American Society of Anesthesiologists Physical Status class, and asthma should prompt greater attention given their heightened risk profiles.

Surgical learning curve in performing palatoplasty: A retrospective study in 200 patients

OBJECTIVES

The aim of the study was to assess the influence of the experience of the surgeon on the occurrence of fistulas following palatoplasty.

MATERIALS AND METHODS

A retrospective review was performed of consecutive children treated between 2006 and 2013 for cleft palate by a single surgeon. Cleft palate repair was performed using the von Langenbeck technique, Furlow palatoplasty, buccal flap or Vomer flap. Data was collected for age, sex, date of birth, syndrome, adoption, cleft palate type, type of repair, cleft width, fistula occurrence and location of fistula.

RESULTS

A total of 276 operations were performed in 200 children (Veau I, II, III, IV). Mean age at surgery was 21.9 months (range: 6.2 months to 26 years 8.3 months). Postoperatively, palatal fistulas occurred in eight patients (4.0%), however, the incidence was 3.0% in the non-adoption group and 9.7% in the adoption population. In this study there was no statistically significant evidence of a surgical learning curve, and no significant associations between fistula rate and sex, adoption, syndrome, cleft type, cleft width, or type of repair.

CONCLUSION AND CLINICAL RELEVANCE

This study demonstrates a fistula formation rate of 3.0% for the non-adoption population and 9.7% for the adoption population. There was no statistically significant evidence of a learning curve during the first few years of performing cleft palate repair. No other independent risk factors for postoperative fistula formation were identified; however, the benefit of a vomer flap and subsequent reduction in fistula incidence was demonstrated.