Internationally Adopted Children With Unilateral Cleft Lip and Palate-Consonant Proficiency and Perceived Velopharyngeal Competence at the Age of 5

Foreign-born 5-year-old children with cleft palate had poorer speech outcomes than their native-born peers

AIM

Speech difficulties are common in children with cleft palate, but research on foreign-born children is limited. This study aimed to compare speech outcomes, surgery and speech intervention in 5-year-old foreign-born and Swedish-born children with cleft palate with or without cleft lip.

METHODS

This retrospective study analysed data from the Swedish cleft lip and palate registry for children born between 2009 and 2016 using Pearson's Chi-squared test and binary logistic regression.

RESULTS

Among 160 foreign-born (106 boys, 54 girls) and 847 Swedish-born (479 boys, 368 girls) 5-year-olds, foreign-born children had significantly lower rates of sufficient velopharyngeal competence (77% vs. 86%), age-appropriate consonant production (28% vs. 60%), and speech without non-oral speech errors (70% vs. 86%). Differences remained after adjustment for cleft type, gender and additional diagnosed conditions. After further adjustments for age at completed primary palatal surgery, differences in age-appropriate consonant production and speech without non-oral speech errors remained significant. Foreign-born children underwent completed primary palatal surgery at older ages and received more secondary palatal surgery and speech intervention than Swedish-born peers.

CONCLUSION

Foreign-born children showed poorer speech outcomes than Swedish-born peers, despite more secondary palatal surgery and speech intervention. Age at completed primary palatal surgery could partly explain these differences.

The impact of surgical technique and cleft width on the rate of secondary surgery and velopharyngeal function in children with UCLP at 5 years of age

Several factors may influence speech outcome and the rate of secondary palatal surgery in patients with cleft palate. The aim of this study was to evaluate different types of intra-velar veloplasty within an otherwise uniform surgical protocol. The impact of cleft width and the surgeon's experience on outcome measurements was examined. This cross-sectional study included 62 individuals with unilateral cleft lip and palate born in 2000-2015. Based on the surgical technique used, they were divided into three groups. The cleft width was measured on dental casts. Blinded speech and language pathologists assessed velopharyngeal function with the composite score for velopharyngeal competence (VPC-Sum) for single words. They rated velopharyngeal function on a three-point scale (VPC-R) in sentences. Target consonants in words were phonetically transcribed. The percentage of correct consonants (PCC) was calculated. Surgical technique was not associated with any outcome. Cleft width was associated with the rate of secondary palatal surgery (OR 1.141, 95% CI 1.021-1.275, p = .020) and velopharyngeal insufficiency when using VPC-R (OR 2.700, 95% CI 1.053-6.919, p = .039) but not when using VPC-Sum (OR 1.985, 95% CI.845-4.662, p = .116). PCC was not associated with cleft width and did not differ between surgical techniques. Radical muscle dissection did not exhibit superiority over intra-velar veloplasty reinforced by the palatopharyngeal muscle. Follow-ups at later ages with larger groups will be necessary to evaluate and compare surgical techniques accurately. Cleft width had a greater impact on the rate of secondary surgery and velopharyngeal function than surgical technique, but neither affected the PCC.

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.

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.

The Impact of Race and Ethnicity on Surgical Risk and Outcomes Following Palatoplasty: An Analysis of the NSQIP Pediatric Database

OBJECTIVE

To determine how race and ethnicity affect palatoplasty 30-day outcomes.

DESIGN

Retrospective review.

PATIENTS/SETTING

The 2012 to 2019 National Surgical Quality Improvement Program (NSQIP) Pediatric database was used to identify patients ≤ 2 years who underwent primary palatoplasty. We compared demographics, comorbidities, and 30-day outcomes among different racial and ethnic groups. Logistic regression was used to determine independent risk factors for adverse events.

MAIN OUTCOME MEASURES

Increased risk for adverse events and postoperative surgical outcomes, including complications, readmission, and prolonged length of stay.

RESULTS

A total of 8537 patients were identified in the database. African-American patients had the highest proportion of premature infants and infants with a BMI < 15% at the time of repair. Asian patients underwent palatoplasty at a later age compared to other races (12.7 months vs 11.7-12.1 months). Postoperatively, the odds of a complication were significantly higher in Asian patients (aOR = 1.73, 95% CI: 1.17-2.57) and other/unknown patients (aOR = 1.40, 95% CI: 1.05-1.86), but not among African American (aOR = 1.02, 95% CI: 0.70-1.47) or Hispanic (aOR = 0.93, 95% CI: 0.69-1.26) patients. Other/unknown patients were more likely to require postoperative ventilation (aOR = 2.34, 95% CI: 1.38-3.95). The odds of readmission were highest in Asian and other/unknown patients. African American, Hispanic, and other/unknown patients were more likely than Caucasian patients to be hospitalized > 2 days postoperatively.

CONCLUSION

This study highlights ethnic differences in presentation and 30-day outcomes following palatoplasty. Further evaluation of disparities in cleft care should be performed to improve healthcare access and surgical outcomes.

English-Only Treatment of Compensatory Speech Errors in a Bilingual Adoptee With Repaired Cleft Palate: A Descriptive Case Study

Purpose The purpose of this clinical focus article is to provide a descriptive case study of a late-adopted, bilingual adolescent with cleft palate speech errors. Specifically, we examined the cross-linguistic generalization of remediated compensatory cleft errors, following treatment in English (second language) only. The overarching goal of this study is to gain insights into the complexity of speech intervention for the adopted population with delayed cleft palate repair. Method A 14-year-old female adopted from China with a repaired unilateral cleft lip and palate and maladaptive articulation errors underwent 55 one-hour sessions of a motor-based, speech therapy approach over a 15-month span, targeting English phonemes only. Pre-, mid-, and posttreatment evaluation included perceptual and instrumental assessment of speech and resonance. Outcome measures at each time point included perceptual speech and resonance ratings, nasometry scores, and percent consonants correct (PCC) in both English and Mandarin. Results PCC in English improved from 60% in single words and 35% in sentences pretreatment to 100% in single words and sentences during posttreatment assessment. Without direct treatment in Mandarin, PCC in Mandarin improved from 56% in single words and 50% in sentences pretreatment to 100% in single words and 99% in sentences during posttreatment assessment. Posttreatment nasometry scores decreased by 20% for the nasal sample and 17% for the oral sample compared to pretreatment. Conclusions This descriptive case study demonstrated successful remediation of cleft palate speech errors, following 15 months of treatment in a late-adopted bilingual adolescent using a motor-based therapy approach. Treatment of errors in English (second language) led to generalization of correct productions in Mandarin (first language). This study presents the potential for bilingual late adoptees to achieve intelligible speech in both languages when motor-based therapy principles are applied to intervention.

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.