The effects of oral clefts on hospital use throughout the lifespan

Publicly funded healthcare costs associated with orofacial clefts for children born in Alberta, Canada between 2002 and 2018

BACKGROUND

Orofacial clefts (OFCs) include cleft palate (CP), cleft lip (CL), and cleft lip with cleft palate (CLP) and require multidisciplinary healthcare services. Alberta, Canada has a publicly funded, universal access healthcare system. This study determined publicly funded healthcare costs for children with an OFC and compared these costs to children without congenital anomalies.

METHODS

This retrospective population-based cohort analysis used the Alberta Congenital Anomalies Surveillance System to identify children born between 2002 and 2018 with an isolated OFC. They were matched 1:1 to a reference cohort based on sex and year of birth. The study population included 1614 children, from birth to 17 years of age linked to administrative databases to estimate annual inpatient and outpatient costs. Average annual all-cause costs were compared using two-sample independent t tests.

RESULTS

The mean total cleft-related costs per patient were highest for children with CLP ($74,138 CAD, standard deviation (SD) $43,447 CAD), followed by CP ($53,062 CAD, SD $74,366 CAD), and CL ($35,288 CAD, SD $49,720 CAD). The mean total all-cause costs per child were statistically significantly higher (p < .001) in children with an OFC ($56,305 CAD, SD $57,744 CAD) compared to children without a congenital anomaly ($18,600 CAD, SD $61,300 CAD).

CONCLUSIONS

Despite public health strategies to mitigate risk factors, the trend for OFCs has remained stable in Alberta, Canada for over 20 years. The costs reported are useful to other jurisdictions for comparison, and to families, healthcare professionals, service planners, and policy makers.

Special Needs Insurance: More Stability for a Growing Family's Budget

OBJECTIVE.—

To propose an insurance product called special needs insurance. The insurance will pay parents a lump sum up to $100,000 if they have a child that is born with or develops a special needs condition such as Down syndrome, cerebral palsy or autism.

BACKGROUND.—

Raising a child is expensive; raising a child with a special need can be hundreds of thousands of dollars more expensive. These additional costs include direct costs that are not covered by health insurance and indirect costs such as the loss of earnings when a working parent must tend to a special needs child.

METHOD.—

We analyze a gamut of birth and early childhood disabilities, both physical and cognitive, from the medico-actuarial perspective. We describe each condition using relevant medical literature and calculate prevalence rates from epidemiological studies (appendix A1-A15). After accounting for multiple births, we develop a final premium.

RESULTS.—

We find that physical impairments are sufficiently well understood to guarantee a fixed payout, whereas cognitive impairments such as autism are less understood, and so for these we propose a cognitive fund that does not guarantee a fixed payout. We find that an average single premium of $4,600 allows the insurer to profitably pay out the proposed benefits.

CONCLUSIONS.—

Raising a special needs child can put a significant strain on the affected family's budget. We propose an insurance product that provides relief through a large lump sum payout. Although no new insurance product can be guaranteed success, our analysis of this product gives an interested insurer reasonable justification to take on this new risk.

EUROlinkCAT protocol for a European population-based data linkage study investigating the survival, morbidity and education of children with congenital anomalies

INTRODUCTION

Congenital anomalies (CAs) are a major cause of infant mortality, childhood morbidity and long-term disability. Over 130 000 children born in Europe every year will have a CA. This paper describes the EUROlinkCAT study, which is investigating the health and educational outcomes of children with CAs for the first 10 years of their lives.

METHODS AND ANALYSIS

EUROCAT is a European network of population-based registries for the epidemiological surveillance of CAs. EUROlinkCAT is using the EUROCAT infrastructure to support 22 EUROCAT registries in 14 countries to link their data on births with CAs to mortality, hospital discharge, prescription and educational databases. Once linked, each registry transforms their case data into a common data model (CDM) format and they are then supplied with common STATA syntax scripts to analyse their data. The resulting aggregate tables and analysis results are submitted to a central results repository (CRR) and meta-analyses are performed to summarise the results across all registries. The CRR currently contains data on 155 594 children with a CA followed up to age 10 from a population of 6 million births from 1995 to 2014.

ETHICS

The CA registries have the required ethics permissions for routine surveillance and transmission of anonymised data to the EUROCAT central database. Each registry is responsible for applying for and obtaining additional ethics and other permissions required for their participation in EUROlinkCAT.

DISSEMINATION

The CDM and associated documentation, including linkage and standardisation procedures, will be available post-EUROlinkCAT thus facilitating future local, national and European-level analyses to improve healthcare. Recommendations to improve the accuracy of routinely collected data will be made.Findings will provide evidence to inform parents, health professionals, public health authorities and national treatment guidelines to optimise diagnosis, prevention and treatment for these children with a view to reducing health inequalities in Europe.

Genetic variants in S-adenosyl-methionine synthesis pathway and nonsyndromic cleft lip with or without cleft palate in Chile

BACKGROUND

The S-adenosyl-methionine (SAM) availability is crucial for DNA methylation, an epigenetic mechanism involved in nonsyndromic cleft lip with or without cleft palate (NSCL/P) expression. The aim of this study was to assess the association between single-nucleotide polymorphisms (SNPs) of genes involved in SAM synthesis and NSCL/P in a Chilean population.

METHODS

In 234 cases and 309 controls, 18 SNPs in AHCY, MTR, MTRR, and MAT2A were genotyped, and the association between them and the phenotype was evaluated based on additive (allele), dominant, recessive and haplotype models, by odds ratio (OR) computing.

RESULTS

Three deep intronic SNPs of MTR showed a protective effect on NSCL/P expression: rs10925239 (OR 0.68; p = 0.0032; q = 0.0192), rs10925254 (OR 0.66; p = 0.0018; q = 0.0162), and rs3768142 (OR 0.66; p = 0.0015; q = 0.0162). Annotations in expression database demonstrate that the protective allele of the three SNPs is associated with a reduction of MTR expression summed to the prediction by bioinformatic tools of its potentiality to modify splicing sites.

CONCLUSIONS

The protective effect against NSCL/P of these intronic MTR SNPs seems to be related to a decrease in MTR enzyme expression, modulating the SAM availability for proper substrate methylation. However, functional analyses are necessary to confirm our findings.

IMPACT

SAM synthesis pathway genetic variants are factors associated to NSCL/P. This article adds new evidence for folate related genes in NSCL/P in Chile. Its impact is to contribute with potential new markers for genetic counseling.

The effects of state facial surgery mandates on timeliness of primary cleft repair surgery in the United States

OBJECTIVE

This study examines the effects of state facial surgery mandates on the timeliness of primary cleft repair surgery for privately insured children with oral clefts in the United States.

MATERIALS AND METHODS

Using IBM Health MarketScan^® Database from 2001 to 2017, we estimate regression models separately for age at cleft lip repair and cleft palate repair by having a mandate while considering child-level factors and other state differences. The sample includes 1,451 children who had primary cleft lip repair by age 12 months, and 1,402 children who had primary cleft palate repair by age 18 months.

RESULTS

A mandate was associated with earlier cleft lip repair by 13 days (95% CI, -21.5 to -4.7 days) when controlling for state differences, regardless if the child had other birth defects. For children needing cleft palate repair, a mandate was associated with earlier surgery by 87 days (95% CI, -136.1 to -38.4 days) only when no other birth defects were present.

CONCLUSIONS

State facial surgery mandates were associated with earlier cleft lip repair for children with or without other birth defects, and earlier cleft palate repair for children without other birth defects (besides oral clefts). Findings suggest benefits to privately insured children with oral clefts from state mandates to cover needed services.

Parent-reported socioemotional and cognitive development in children with a cleft lip and/or palate at 18 months: Findings from a UK birth cohort

BACKGROUND

One of the most common congenital conditions in the world, cleft lip and/or palate (CL/P) has been shown to potentially impact long-term physical and developmental outcomes in affected children. However, little is known about the factors that contribute to such outcomes, and there is a lack of consensus about which screening tools may be most effective. The aims of the current study were (a) to assess parent-reported socioemotional and cognitive development in children born with CL/P at 18 months of age; (b) to identify factors associated with the incidence of developmental concerns; and (c) to assess the utility of the widely recommended Ages and Stages Questionnaires (ASQs) in identifying developmental concerns from an early age in the CL/P population.

METHODS

Parent-reported questionnaire data were extracted from The Cleft Collective Cohort Study for 322 mothers of children with CL/P aged 18 months.

RESULTS

Mean scores across both ASQ measures indicated typical development in the study sample overall. However, 31.1% of children met a referral criterion on at least one domain. Child-related risk factors included problems with physical development and feeding method. Parent-related risk factors included the mother's levels of anxiety and depression and mother's marital status. Additional developmental concerns extracted from mothers' qualitative data included feeding difficulties, speech development, sleep patterns, aggressive behaviours, vision, oral health, hearing, breathing and motor skills.

CONCLUSIONS

The majority of children in this study were developing as expected at 18 months of age. However, parent-reported developmental concerns were identified in a minority of children, suggesting a need to screen for potential risk factors in routine practice. Further, the ASQ appears to offer a viable option in the early identification of developmental concerns in children with CL/P. A combined medical and systemic approach to healthcare is recommended to support the prevention of long-term developmental concerns in the child and poor psychological adjustment in parents.

The Prevalence of Nonsyndromic Oral Clefts in Twins Compared to Singletons: The Association With Birth Weight

PURPOSE

To examine the prevalence of nonsyndromic oral clefts in twins compared to singletons in the United States and to evaluate the association between birth weight and nonsyndromic oral clefts.

DESIGN

A large population-based cross-sectional study was performed using the data from the US National Center for Health Statistics database in 2017.

PARTICIPANTS

Our sample consisted of 128 310 twins and 3 723 273 singletons.

METHODS

The variables collected were sociodemographic variables, environmental predictors, and clinical measures. Descriptive analysis, bivariate, and multivariate logistic regression were performed.

MAIN OUTCOME MEASURE

The main outcome variable in our study is nonsyndromic oral clefts.

RESULTS

The prevalence of nonsyndromic oral clefts was 5.22 per 10 000 in twins and 5.12 per 10 000 in singletons. Results show no significant risk of nonsyndromic oral clefts in twins compared to singletons (P = .92). There was a significant relationship between birth weight and infant diagnosed with nonsyndromic oral clefts (P = .01). Unadjusted odds ratio for birth weight was 2.52 (95% CI: 2.25-2.82). Adjusted odds for potential confounders such as mother's age, race, mother's education, gender of the infant, APGAR 5-minute score, gestational age, prenatal smoking, number of prenatal care visits, and mother's body mass index were resulted in similar but with a slightly lower odds of 2.11 (95% CI: 1.78-2.50).

CONCLUSION

Compared to singletons, twins did not have higher risk of nonsyndromic oral clefts. Infants with low birth weight were more prone to have nonsyndromic oral clefts.

Treatment Experiences in Adults Born With Cleft Lip and/or Palate: A Whole of Life Survey in the United Kingdom

Objectives:

Adults with cleft lip and/or palate (CL/P) may report dissatisfaction with aesthetic and/or functional outcomes and express desire for further treatment. Although medical intervention can improve quality of life, surgical procedures require complex decision-making and can invoke psychological distress. The aim of this study was to gain a better understanding of ongoing treatment-related support needs by examining self-reported treatment experiences of a sample of adults born with CL/P.

Design:

An online, mixed-methods survey was designed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research at the University of the West of England. A total of 207 eligible responses were received. Qualitative data were analyzed using inductive content analysis, while quantitative data were analyzed using descriptive statistics.

Results:

Although participants were satisfied with surgical and dental/orthodontic outcomes overall, many reported ongoing difficulties. Some stated they would seek further treatment while others felt conflicted about risks and benefits. Some had refused treatment, citing treatment fatigue, anxiety, and/or concerns that treatment would be unsuccessful. More than 40% of participants were unaware of their entitlement to cleft-related treatment provided by the National Health Service, and many others had experienced difficulties accessing care.

Conclusions:

Although advances in health care may offer opportunities for adults to improve their quality of life, treatment decisions should be weighed with the support of a clinical psychologist where available. Guidance for young adults considering future treatment is also recommended. Finally, training and resources for local practitioners may improve general awareness of CL/P services and increase access to specialist care for adults with ongoing CL/P-related concerns.

Data Linkage: Cleft Live-Birth Prevalence and Hospitalizations in Western Australia: 1980 to 2016

OBJECTIVE

To provide information on live-birth prevalence and hospitalizations, including anxiety and depression, for cleft lip and/or palate (CL/P) in Western Australia (WA), using live-birth data 1980 to 2015.

DESIGN

Retrospective data linkage.

SETTING

Tertiary hospital.

PATIENTS

Cleft cohort consisted of people live-born with CL/P in WA between 1980 and 2015, and a gender and age-matched control group.

MEASURES

Live-birth prevalence for CL/P by year. Hospital event counts, event ages, and length of stay (LOS) days by 18 diagnosis groups and 4 birth year categories between the cleft cohort and control group, and between cleft types. Count of events per alive persons per calendar year, and relative risk for proportions of persons in the cleft cohort and control group by diagnosis group.

RESULTS

Live-birth prevalence for CL/P was 19.7 per 10 000 (1 in 522). The cleft cohort had significantly higher event counts, lower event ages, and higher LOS days than the control group. Cleft lip and palate had significantly higher event counts, lower event ages, and higher LOS days than cleft lip or cleft palate only. There were 2 significant differences for anxiety or depression between the cleft cohort and control group, lower event ages, and higher LOS days in 1990s birth year category.

CONCLUSIONS

This study provides a cleft data reference for WA. Live-birth prevalence for all clefts and by cleft type offers an appropriate method for estimating service utilization and provision. Patients with cleft accessed hospital services more frequently, at an earlier age, with higher LOS days than the control group.

State-Mandated Coverage of Cleft Lip and Cleft Palate Treatment

OBJECTIVE

We conducted a comprehensive review of state laws and regulations that require private health insurance plans to cover the services needed by children born with cleft lip and/or cleft palate (CL/P). The goal is to better understand how states are reducing the barriers children with CL/P face when seeking recommended health care services.

DESIGN

We identified all state laws and regulations mandating insurance coverage of services for children with CL/P by private insurance carriers from 1999 through 2017 using Westlaw legal database. We categorized laws and regulations into ten services: facial surgery (facial, corrective, reconstructive), oral surgery, orthodontics, dental care, habilitation/rehabilitation/speech therapy, prosthetic treatment, audiology, nutrition counseling, genetic testing, and psychological counseling. We also captured broad mandates indicating coverage for all necessary treatments.

RESULTS

There was a trend toward increased coverage of services for CL/P over time. In 1999, 27 states and Washington, DC did not have relevant laws or regulations. By 2017, there were 19 states without laws or regulations mandating services. The most common mandated service was facial surgery followed by habilitation/rehabilitation/speech therapy, orthodontics, dental care, and oral surgery. Nutrition, audiology, genetic testing and psychological counseling were rarely included in mandated services.

CONCLUSIONS

States vary widely in their requirements for coverage of services needed by children with CL/P in private health insurance plans. There has been an increase in mandates over the past two decades to cover services, although significant variation continues to exist across states.

Development of a valid and reliable instrument for the assessment of quality of life in parents of children with clefts

PURPOSE

Orofacial clefts are the most common congenital malformations that affect craniofacial structures. Studies show that they have a major influence on psychological development of the patient, and on their families. A review of the literature showed a lack of specific questionnaires for children and their parents. This study investigated the impact of orofacial clefts in children on the quality of life of their parents. In addition, the results of the treatment and the quality of work of the health team members involved in this process were evaluated.

MATERIALS AND METHODS

For the purpose of this study, an original questionnaire was made to analyse the effect of orofacial clefts in children who had undergone surgery on the quality of life of 73 of their parents. The questionnaire consisted of 28 simple statements, which were evaluated with a 5-degree Likert scale (from 1-fully disagree to 5-fully agree), did not require any specific additional clarification, and were easy to complete.

RESULTS

Analysis of areas of the questionnaire that applied to the parents, resulted in two subscales, parental social health and child social health, which had satisfactory Cronbach's coefficients (0.907 and 0.897, respectively). However, some issues had a relatively poor coefficient of internal consistency, which justified their expulsion from the final model of the parent questionnaire.

CONCLUSION

The questionnaire developed for this study comprised two subscales concerned with the social health of parents/respondents and the social health of adolescents, as perceived by the parents. It was a valid and reliable instrument, and it showed satisfactory quality of life for parents of adolescents with clefts.

High-Resolution Epigenomic Atlas of Human Embryonic Craniofacial Development

Defects in patterning during human embryonic development frequently result in craniofacial abnormalities. The gene regulatory programs that build the craniofacial complex are likely controlled by information located between genes and within intronic sequences. However, systematic identification of regulatory sequences important for forming the human face has not been performed. Here, we describe comprehensive epigenomic annotations from human embryonic craniofacial tissues and systematic comparisons with multiple tissues and cell types. We identified thousands of tissue-specific craniofacial regulatory sequences and likely causal regions for rare craniofacial abnormalities. We demonstrate significant enrichment of common variants associated with orofacial clefting in enhancers active early in embryonic development, while those associated with normal facial variation are enriched near the end of the embryonic period. These data are provided in easily accessible formats for both craniofacial researchers and clinicians to aid future experimental design and interpretation of noncoding variation in those affected by craniofacial abnormalities.

Maternal underweight and obesity and risk of orofacial clefts in a large international consortium of population-based studies

Background

Evidence on association of maternal pre-pregnancy weight with risk of orofacial clefts is inconsistent.

Methods

Six large case-control studies of orofacial clefts from Northern Europe and the USA were included in analyses pooling individual-level data. Cases included 4943 mothers of children with orofacial clefts (cleft lip only: 1135, cleft palate with cleft lip: 2081, cleft palate only: 1727) and controls included 10 592 mothers of unaffected children. Association of orofacial cleft risk with pre-pregnancy maternal weight classified by level of body mass index (BMI, kg/m 2 ) was evaluated using logistic regression adjusting for multiple covariates.

Results

Cleft palate, both alone and with cleft lip (CP+/-CL), was associated with maternal class II+ pre-pregnancy obesity (≥ 35)compared with normal weight [adjusted odds ratio (aOR) = 1.36; 95% confidence interval (CI) = 1.16, 1.58]. CP+/-CL was marginally associated with maternal underweight (aOR = 1.16; 95% CI = 0.98, 1.36). Cleft lip alone was not associated with BMI.

Conclusions

In this largest population-based study to date, we found an increased risk of cleft palate, with or without cleft lip, in class II+ obese mothers compared with normal-weight mothers; underweight mothers may also have an increased risk, but this requires further study. These results also suggest that extremes of weight may have a specific effect on palatal development.

Prevalence of Cleft Lip/Palate in the Fangshan District of Beijing, 2006-2012

OBJECTIVE

To estimate the cleft lip with or without cleft palate (CL/P) prevalence among births between 2006 and 2012 in Fangshan district of Beijing, China.

DESIGN

Surveillance data analysis.

SETTING

All hospitals that provide obstetric services in the district.

PATIENTS

The CL/P cases presented for this report were from 13 weeks' gestation to 7 days postpartum.

MAIN OUTCOME MEASURES

The CL/P prevalence was defined as the number of cases per 10 000 births, including live births and stillbirths at 28 weeks' gestation or beyond.

RESULTS

The overall CL/P prevalence was 18.9 (95% confidence interval [CI]: 15.1-22.7) per 10 000 births. From 2006 to 2012, the CL/P prevalence was 19.3, 20.2, 10.9, 16.1, 17.5, 25.4, and 22.3 per 10 000 births; annually, no significant change was noted ( P_{for trend} = .311). The prevalence of cleft palate, cleft lip, and cleft lip and palate were 3.4 (95% CI: 2.0-5.4), 6.2 (95% CI: 4.2-8.8), and 9.4 (95% CI: 6.9-12.4) per 10 000 births, respectively. The CL/P prevalence among the nonpermanent residents (31.4 per 10 000 births) was 2.31 times that of permanent residents (13.6 per 10 000 births). Among nonpermanent residents, the CL/P prevalence showed an upward trend over the study period ( P_{for trend} = .036), that increased from 38.8 (95% CI: 16.5-76.6) per 10 000 births in 2006 to 54.6 (95% CI: 25.7-100.4) per 10 000 births in 2012.

CONCLUSIONS

The overall CL/P prevalence was stable in the Fangshan district. However, the CL/P prevalence of the nonpermanent residents increased significantly.

Psychiatric Diagnoses in Individuals with Non-Syndromic Oral Clefts: A Danish Population-Based Cohort Study

Background

The aim of this study was to investigate the risk of psychiatric diagnoses in individuals with non-syndromic oral clefts (OC) compared with individuals without OC, including ages from 1 to 76 years.

Methods

Linking four Danish nationwide registers, we investigated the risk of psychiatric diagnoses at Danish psychiatric hospitals during the period 1969–2012 for individuals born with non-syndromic OC in Denmark 1936–2009 compared with a cohort of 10 individuals without OC per individual with OC, matched by sex and birth year. The sample included 8,568 individuals with OC, observed for 247,821 person-years, and 85,653 individuals without OC followed for 2,501,129 person-years.

Results

A total of 953 (11.1%) of the individuals with OC (9.6% for cleft lip (CL), 10.8% for cleft lip and palate (CLP) and 13.1% for cleft palate (CP)) and 8,117 (9.5%) in the comparison group had at least one psychiatric diagnosis. Cox proportional hazard regression model revealed that individuals with OC had significantly higher risk of a psychiatric diagnosis (hazard ratio (HR) = 1.19, 95% CI: 1.12–1.28). When examining cleft type, no difference was found for CL (HR = 1.03, 95% CI: 0.90–1.17), but CLP was associated with a small increased risk (HR = 1.13, 95% CI: 1.01–1.26), whereas individuals with CP had the largest increased risk (HR = 1.45, 95% CI: 1.30–1.62). The largest differences were found in schizophrenia-like disorders, mental retardation and pervasive developmental disorders, but we found no increased risk of mood disorders and anxiety-related disorders.

Conclusion

Individuals with non-syndromic OC had significantly higher risk of psychiatric diagnoses compared with individuals without OC. However, the elevated risk was observed for individuals with CLP and CP but not for individuals with CL and the absolute risk increase was modest.

Passive Smoke Exposure as a Risk Factor for Oral Clefts-A Large International Population-Based Study

Maternal cigarette smoking is a well-established risk factor for oral clefts. Evidence is less clear for passive (secondhand) smoke exposure. We combined individual-level data from 4 population-based studies (the Norway Facial Clefts Study, 1996-2001; the Utah Child and Family Health Study, 1995-2004; the Norwegian Mother and Child Cohort Study, 1999-2009; and the National Birth Defects Prevention Study (United States), 1999-2007) to obtain 4,508 cleft cases and 9,626 controls. We categorized first-trimester passive and active smoke exposure. Multivariable logistic models adjusted for possible confounders (maternal alcohol consumption, use of folic acid supplements, age, body size, education, and employment, plus study fixed effects). Children whose mothers actively smoked had an increased risk of oral clefts (odds ratio (OR) = 1.27, 95% confidence interval (CI): 1.11, 1.46). Children of passively exposed nonsmoking mothers also had an increased risk (OR = 1.14, 95% CI: 1.02, 1.27). Cleft risk was further elevated among babies of smoking mothers who were exposed to passive smoke (OR = 1.51, 95% CI: 1.35, 1.70). Using a large pooled data set, we found a modest association between first-trimester passive smoking and oral clefts that was consistent across populations, diverse study designs, and cleft subtypes. While this association may reflect subtle confounding or bias, we cannot rule out the possibility that passive smoke exposure during pregnancy is teratogenic.

Hospitalisations up to adulthood for children born with orofacial clefts

AIM

The aim of this study was to compare hospital admissions from infancy to adulthood, between children born with orofacial clefts (OFC) and those without OFC.

METHODS

The method used was a cohort study using record-linked administrative datasets. Participants included all children liveborn in Western Australia (WA) between 1980 and 2010 diagnosed with OFC, who were frequency matched by year of birth to randomly selected liveborn children without OFC. We calculated rate ratios (RR) of hospital admission, number and reason of admissions, cumulative length of stay, for each cleft type (cleft lip only (CLO), cleft lip and palate (CL+P), cleft palate only (CPO), no OFC) and by age period (infancy, pre-school, primary and high school ages, and early adulthood).

RESULTS

Overall, 1396 children were diagnosed with an OFC and compared with 6566 children without OFC. Individuals born with OFC were up to three times more likely to be admitted to hospital, had more admissions and longer cumulative length of stay in all age periods. Children with OFC were also more likely to be admitted for ear and digestive system conditions (RR up to 30 and six times higher, respectively). Children with CL+P and CPO were more likely to be admitted for respiratory conditions (RR 1.3-2.0) and children with CPO were six times more likely to be admitted for care for other congenital anomalies.

CONCLUSIONS

Throughout childhood, individuals born with OFC were more likely to be admitted, and had more hospitalisations than those without OFC. Children born with CL+P or CPO had a higher hospitalisation burden than children born with CLO.

Psychosocial well-being of parents of children with oral clefts

BACKGROUND

Parents of children with oral clefts may be impacted psychosocially in several ways, but empirical evidence remains relatively sparse. The aim of this study was to identify predictors of psychosocial well-being of parents of affected children.

METHODS

The study included a total sample of 287 parents (171 mothers and 116 fathers) of children with oral clefts. Parents completed validated psychosocial instruments to measure social avoidance and distress, fear of negative evaluation scale, self-esteem and interpersonal support. Regression analysis was used to evaluate how selected child, parent and household characteristics relate to psychosocial outcomes focusing on child's cleft type, sex and age, differences between mothers and fathers, marital status and household income.

RESULTS

Fathers had higher self-esteem than mothers (P = 0.01) and lower concern of being negatively judged by others (P < 0.0001) but also had lower perception of having someone to talk to about their problems (P = 0.01). High household income was associated with greater self-esteem and perception of social support (<0.05). Parents of male affected children had greater perception of social support than parents of female affected children (P = 0.04). No significant differences in parental psychosocial status measures were found by cleft type. Similarly, there is little evidence of changes with child age, except for an increase in parental distress and decline in self-esteem during mid-adolescence (age 15-17 years).

CONCLUSIONS

The results indicate that mothers and fathers of children with oral clefts may differ in their psychosocial adjustment and that mothers may overall experience more psychosocial problems than fathers. Also, parents from less wealthy households may be at greater risk. Parental psychosocial status should be considered in holistic family-based treatment approaches to reduce burden on affected families and improve their well-being.

Description of total population hospital admissions for cleft lip and/or palate in Australia

BACKGROUND

Orofacial clefts are a group of frequently observed congenital malformations often requiring multiple hospital admissions over the lifespan of affected individuals. The aim of this study was to describe the total-population hospital admissions with principal diagnosis of cleft lip and/or palate in Australia over a 10 year period.

METHODS

Data for admissions to hospitals were obtained from the Australian Institute of Health and Welfare National Hospital Morbidity Database (July 2000 to June 2010). The outcome variable was a hospital separation with the principal diagnosis of cleft palate, cleft lip or cleft lip and palate (ICD-10-AM diagnosis codes Q35-Q37 respectively). Trends in rates of admission and length of stay by age, gender and cleft type were investigated.

RESULTS

A total of 11, 618 admissions were identified; cleft palate (4,454; 0.22 per 10,000 people per year), cleft lip (2,251; 0.11) and cleft lip and palate (4,913; 0.25). Admission age ranged from birth to 79 years with males more frequently admitted. Most admissions occurred prior to adolescence in cleft palate and cleft lip and through to late teens in cleft lip and palate, declining for all groups after 25 years.

CONCLUSIONS

This study identified population level trends in hospital separations for orofacial cleft diagnosis in Australia.

Long-term effects of oral clefts on health care utilization: a sibling comparison

Oral clefts are among the most common birth defects affecting thousands of newborns each year, but little is known about their potential long-term consequences. In this paper, we explore the impact of oral clefts on health care utilization over most of the lifespan. To account for time-invariant unobservable parental characteristics, we compare affected individuals with their own unaffected siblings. The analysis is based on unique data comprising the entire cohort of individuals born with oral clefts in Denmark tracked until adulthood in administrative register data. We find that children with oral clefts use more health services than their unaffected siblings. Additional results show that the effects are driven primarily by congenital malformation-related hospitalizations and intake of anti-infectives. Although the absolute differences in most health care utilization diminish over time, affected individuals have slightly higher utilization of some health care services in adulthood (particularly for diseases of the nervous and respiratory system). These results have important implications for affected individuals, their families, and their health professionals.

Comparing the Visual Analogue Scale and the Pediatric Quality of Life Inventory for measuring health-related quality of life in children with oral clefts

Objectives: To evaluate the performance of the Visual Analogue Scale (VAS), in measuring overall health-related Quality of Life (HRQoL) in children with oral clefts relative to the Pediatric Quality of Life Inventory 4.0 (PedsQL^TM) Generic Core Scales, one of the most validated and commonly used methods to measure pediatric HRQoL. Methods: The study included a population-based sample of 307 children aged 5 to 10 years who were born in Iowa, New York, and Arkansas with non-syndromic oral clefts. Data on HRQoL were obtained using a VAS and PedsQL^TM via self-administered interviews with the parents. We evaluated the correlations between the VAS and PedsQL^TM total scores, and the correlations of each of these two scales with a series of child health and wellbeing indicators. Results: The VAS and PedsQL^TM scores were well-correlated (r = 0.67). There were no prominent differences between the correlations of VAS and PedsQL^TM with the selected indicators of child health and wellbeing; differences in correlations were less than 0.1. Differences in HRQoL by cleft type were more pronounced on the PedsQL^TM. Conclusions: Our study finds the VAS to perform relatively well in measuring overall HRQoL among children with oral clefts. The VAS may be useful as a screening tool to identify children with oral clefts at risk of low HRQoL for referral into more comprehensive evaluations and for measuring average HRQoL across a sample of children.

Fetal health shocks and early inequalities in health capital accumulation

Several studies report socioeconomic inequalities in child health and consequences of early disease. However, not much is known about inequalities in health capital accumulation in the womb in response to fetal health shocks, which is essential for finding the earliest sensitive periods for interventions to reduce inequalities. We identify inequalities in birth weight accumulation as a result of fetal health shocks from the occurrence of one of the most common birth defects, oral clefts, within the first 9 weeks of pregnancy, using quantile regression and two datasets from South America and the USA. Infants born at lower birth weight quantiles are significantly more adversely affected by the health shock compared with those born at higher birth weight quantiles, with overall comparable results between the South American and US samples. These results suggest that fetal health shocks increase child health disparities by widening the spread of the birth weight distribution and that health inequalities begin in the womb, requiring interventions before pregnancy.

Oral cleft recurrence risk and subsequent maternal fertility preferences and behavior in Brazil

BACKGROUND

Oral clefts are among the most common birth defects with numerous impacts on affected individuals and families. However, little is known about how being at a greater risk of having an affected child affects subsequent maternal fertility decisions. We investigated differences in fertility preferences and behavior between mothers who are themselves affected with cleft lip with/without cleft palate but have had no affected children and unaffected mothers of an affected child. We also compared these outcomes between unaffected mothers of a first versus another affected child.

METHODS

The sample included 1475 Brazilian women interviewed between 2004 and 2009. The outcomes were wanting more children, contraceptive use and type, and maternal age at first child. Comparisons between the various maternal groups were performed using regression analysis adjusting for conceptually relevant demographic, socioeconomic, and geographic factors.

RESULTS

Affected mothers of unaffected children were less likely to use contraceptives than unaffected mothers of affected children by 31% (95% confidence interval, 1-53%). Among unaffected mothers, those who had a first affected child were 67% (95% confidence interval, 15-144%) more likely to use contraceptives.

CONCLUSION

The results suggest that having an affected child represents a stronger signal of recurrence risk to the mother than her own cleft status, and that cleft status of the first child is especially important in influencing subsequent maternal fertility decisions in affected families. These findings highlight the importance of adequate counseling of at-risk women about recurrence risks and available care resources and policies that improve access to quality cleft care.

Hospital care of children with a cleft in England

OBJECTIVE

To analyse hospital admissions in the first 2 years of life among children with cleft lip and/or palate in England.

DESIGN

Analysis of national administrative data of hospital admissions.

SETTING

National Health Service hospitals.

PATIENTS

Patients born alive between 1997 and 2008 who underwent surgical cleft repair.

OUTCOME MEASURES

Number of admissions, including the birth episode, and days spent in hospital were examined. Children were analysed according to cleft type and whether or not they had additional congenital anomalies.

RESULTS

10 892 children were included. In their first 2 years, children without additional anomalies (n=8482) had on average 3.2 admissions and 13.2 days in hospital, which varied from 2.6 admissions and 9.2 days with cleft lip to 4.7 admissions and 19.7 days with bilateral cleft lip and palate (BCLP). Children with additional anomalies (n=2410) had on average 6.7 admissions and 51.4 days in hospital, which varied from 6.4 admissions and 48.5 days with cleft palate to 8.8 admissions and 67.5 days with BCLP. The mean number and duration of cleft-related admissions was similar in children without (1.6 admissions and 6.4 days) and in those with additional anomalies (1.5 admissions and 8.5 days). 35.2% of children without additional anomalies had at least one emergency admission, whereas the corresponding figure was 67.3% with additional anomalies.

CONCLUSIONS

The burden of hospital care in the first 2 years of life varied according to cleft type and presence of additional anomalies. However, cleft-specific hospital care did not differ between children with and without additional anomalies.

Separation Anxiety in Children Ages 4 through 9 with Oral Clefts

Background

Psychosocial research on children with oral clefts (OCs), i.e., clefts of the lip, palate, or lip and palate, has suggested that these children may have higher rates of anxiety in general, but overall results have been equivocal. In this study we estimated the prevalence of separation anxiety disorder (SAD) in a population-based sample of children with OCs and identified associated risk factors.

Methods

Parents of 279 children with OCs, identified through three state birth defect registries, responded to a postal survey that included the Separation Anxiety subscale of the Screen for Child Anxiety-Related Emotional Disorders (SCARED) and items regarding the child's OC and its sequelae, parent and child health, parent mental health, family structure, and socioeconomic status indicators. Associations with SA were evaluated using bivariate and multivariate statistics.

Results

One quarter (24%) of the children screened positive for SAD, which was substantially higher than the U.S. child population estimates of 3% to 5%. OC-related impairments in speaking and eating more than doubled the risk of SAD, as did lower socioeconomic status and lower maternal health rating. Maternal mental health and marital status remained in the logistic model but were not significant.

Conclusions

Children with OCs appear to be at increased risk for SAD as measured by the SCARED instrument. OC-related problems with speech and eating more than doubled the risk of SAD. The use of targeted screening tools may help refine our understanding of psychosocial adjustment in children with OCs.

X-linked markers in the Duchenne muscular dystrophy gene associated with oral clefts

As part of an international consortium, case-parent trios were collected for a genome-wide association study of isolated, non-syndromic oral clefts, including cleft lip (CL), cleft palate (CP), and cleft lip and palate (CLP). Non-syndromic oral clefts have a complex and heterogeneous etiology. Risk is influenced by genes and environmental factors, and differs markedly by gender. Family-based association tests (FBAT) were used on 14,486 single nucleotide polymorphisms (SNPs) spanning the X chromosome, stratified by type of cleft and racial group. Significant results, even after multiple-comparisons correction, were obtained for the Duchenne muscular dystrophy (DMD) gene, the largest single gene in the human genome, among CL/P (i.e., both CL and CLP combined) trios. When stratified into groups of European and Asian ancestry, stronger signals were obtained for Asian subjects. Although conventional sliding-window haplotype analysis showed no increase in significance, selected combinations of the 25 most significant SNPs in the DMD gene identified four SNPs together that attained genome-wide significance among Asian CL/P trios, raising the possibility of interaction between distant SNPs within the DMD gene.

High dosage folic acid supplementation, oral cleft recurrence and fetal growth

OBJECTIVES

To evaluate the effects of folic acid supplementation on isolated oral cleft recurrence and fetal growth.

PATIENTS AND METHODS

The study included 2,508 women who were at-risk for oral cleft recurrence and randomized into two folic acid supplementation groups: 0.4 and 4 mg per day before pregnancy and throughout the first trimester. The infant outcome data were based on 234 live births. In addition to oral cleft recurrence, several secondary outcomes were compared between the two folic acid groups. Cleft recurrence rates were also compared to historic recurrence rates.

RESULTS

The oral cleft recurrence rates were 2.9% and 2.5% in the 0.4 and 4 mg groups, respectively. The recurrence rates in the two folic acid groups both separately and combined were significantly different from the 6.3% historic recurrence rate post the folic acid fortification program for this population (p = 0.0009 when combining the two folic acid groups). The rate of cleft lip with palate recurrence was 2.9% in the 0.4 mg group and 0.8% in the 4 mg group. There were no elevated fetal growth complications in the 4 mg group compared to the 0.4 mg group.

CONCLUSIONS

The study is the first double-blinded randomized clinical trial (RCT) to study the effect of high dosage folic acid supplementation on isolated oral cleft recurrence. The recurrence rates were similar between the two folic acid groups. However, the results are suggestive of a decrease in oral cleft recurrence compared to the historic recurrence rate. A RCT is still needed to identify the effect of folic acid on oral cleft recurrence given these suggestive results and the supportive results from previous interventional and observational studies, and the study offers suggestions for such future studies. The results also suggest that high dosage folic acid does not compromise fetal growth.