Ten-year experience of more than 35,000 orofacial clefts in Africa

Cleft Lip Surgery in Sudan: Clinical Presentations, Early Outcomes, and Patient and Professional Satisfaction: A sub-Saharan African experience

Background

Cleft lip and palate are the most common congenital craniofacial anomalies. They account for approximately 13% of all congenital anomalies.

Objectives

To study the presentation of cleft lip and the early results of surgical repair among patients who presented to our centers.

Methods

This was a hospital-based prospective cohort study of 72 patients who underwent cleft lip repair in Sudan.

Results

The commonest age group was between 10-18 months. The male-to-female ratio was 2:1, and a family history of cleft lip was found in 2.8% of patients. The cleft lip was complete in 81.9%, incomplete in 12.5%, and hybrid in 5.6% of patients. Associated cleft palate was observed in 54 patients. Associated syndromes were found in 10 patients. The surgery was carried out in most patients at 9 months or less; in 4 patients, it was more than 18 months. Achievement of reasonable lip repair was moderate (50% collectively). High achievement was observed for criteria, such as accurate union (90.3%), and sub-moderate achievement in even vermillion border and cupid's bow (44%), low nose symmetry (30.6%), and quality of scar (18.1%). Early complications were reported at the rate of 13.9%. Patient satisfaction was 59.7%; however, the professionals showed higher satisfaction levels (66.7%). The anthropometric measurements of normal infants were moderately similar to those of the infants who underwent surgery.

Conclusion

The patients with cleft lip showed early presentation, with a predominance of the male gender and left side pattern. The preliminary outcome of cleft lip repair was moderate, with variations in different criteria. Patient and professional satisfaction were above average.

Perspectives on the state of cleft lip and cleft palate patient care in Africa

PURPOSE OF REVIEW

Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa.

RECENT FINDINGS

To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources.

SUMMARY

The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

Cleft Lip and Palate Surgery at a Rural African Hospital: A 13-Year Experience From Western Kenya

INTRODUCTION

Most studies on the treatment of cleft lip and palate (CLP) in low-income and middle-income countries have reported on the experience of urban centers or surgical mission trips to rural locations. There is a paucity of literature on the experience of local teams providing orofacial cleft surgery in rural Sub-Saharan Africa. This study reports the efficacy and cost-effectiveness of cleft surgery performed by an all-local team in rural Kenya.

METHODS

A retrospective chart review was performed on all patients who received CLP repair at Kapsowar Hospital between 2011 and 2023. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. For the most recent year of study (2023), the authors performed a financial audit of all costs related to the performance of unilateral cleft lip surgery. Descriptive statistics were performed.

RESULTS

The authors identified 381 CLP surgeries performed on 311 patients (197 male, 63.3%). The most common etiology of the cleft was left unilateral (28.3%). The average age of primary lip repair decreased from 46.3 months in 2008 to 2009 to 20.2 months in 2022 to 2023 ( P <0.001). The average age of primary cleft palate repair decreased from 38.0 months in 2008 to 2009 to 25.3 months in 2022 to 2023 ( P <0.001). Patients traveled from 23 districts to receive treatment. Age of treatment was not different when distinguished by sex, county poverty level, or travel time from the hospital. The total costs associated with cleft lip repair was $201.6.

CONCLUSIONS

Adequately staffed hospitals in rural locations can meaningfully address a regional CLP backlog more cost-effectively than surgical mission trips.

The Pattern and Profile of Orofacial Clefts in Somaliland: A Review of 40 Consecutive Cleft Lip and Palate Surgical Camps

INTRODUCTION

Somaliland is an autonomously run country that is not internationally recognized. As such, it has been largely excluded by global health development programs despite being the world's fourth poorest country. The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate from this nation.

METHODS

The authors performed a retrospective chart review on all patients who received cleft lip and palate repair by a single surgeon in 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland, between 2011 and 2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location was retrieved. Descriptive statistical analysis was performed.

RESULTS

A total of 767 patients (495 male, 64.5%) received 787 surgical procedures. The average age of primary surgery was 73.7 months. The most common chief complaint was left cleft lip with cleft palate (316, 41.2%). Males received primary surgery 19.2 months later than did females (73.7 and 54.6 mo, respectively, P <0.001). Patients residing in Hargeisa received their initial procedure an average of 17.8 months younger than those who lived elsewhere in Somaliland (62.9 and 80.7 mo, respectively, P =0.004).

CONCLUSIONS

In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural sex expectations. Patients from rural locations were especially vulnerable to receiving delayed treatment. Further efforts to decrease the burden of craniofacial deformities in Somaliland should be pursued in earnest.

Barriers in Cleft Service Access in Sub-Saharan Africa: A Thematic Analysis of Practical Needs of Rural Families

OBJECTIVE

To explore the experiences and perceptions of barriers of parents and family members of patients with cleft lip and palate in accessing cleft services in remote northwest Nigeria.

DESIGN

Face-to-face semi-structured audio recorded interviews were used to obtained qualitative textual data. Thematic analysis using interpretative descriptive techniques was employed to understand the participants' lived experiences with barriers and accessibility to cleft services.

SETTING

Participants were from Sokoto, Kebbi and Zamfara states in remote northwest, Nigeria.

PARTICIPANTS

Consisted of 22 caregivers (17 parents and 5 extended family members) were purposively sampled between 2017 and 2020.

MAIN OUTCOME MEASURES

Barriers experienced while accessing cleft services were identified during thematic analysis.

RESULT

Over three quarter of the respondents had patients with both cleft lip and palate and without any previous family history (n = 20). About two-thirds of the participants (n = 15) were females. Most of the interviews were conducted before the surgeries (n = 15).

FIVE THEMES EMERGED

lack of information, financial difficulty, misrepresentation from health workers, multiple transportation and previous disappointment.

CONCLUSIONS

Areas of poor awareness, misinformation from primary health care workers, financial hurdles, multiple transportation logistics and others were identified. Aggressive broadcasting of information through radio, timely treatment and collaboration with influential religious leaders were emphasized. Support, grants and subsidies from government and voluntary agencies are encouraged to mitigate the huge out of pocket cost of cleft care in the region.

Perceptions and beliefs of community gatekeepers about genomic risk information in African cleft research

BACKGROUND

A fundamental ethical issue in African genomics research is how socio-cultural factors impact perspectives, acceptance, and utility of genomic information, especially in stigmatizing conditions like orofacial clefts (OFCs). Previous research has shown that gatekeepers (e.g., religious, political, family or community leaders) wield considerable influence on the decision-making capabilities of their members, including health issues. Thus, their perspectives can inform the design of engagement strategies and increase exposure to the benefits of genomics testing/research. This is especially important for Africans underrepresented in genomic research. Our study aims to investigate the perspectives of gatekeepers concerning genomic risk information (GRI) in the presence of OFCs in a sub-Saharan African cohort.

METHODS

Twenty-five focus group discussions (FGDs) consisting of 214 gatekeepers (religious, community, ethnic leaders, and traditional birth attendants) in Lagos, Nigeria, explored the opinions of participants on genomic risk information (GRI), OFC experience, and the possibility of involvement in collaborative decision-making in Lagos, Nigeria. Transcripts generated from audio recordings were coded and analyzed in NVivo using thematic analysis.

RESULTS

Three main themes-knowledge, beliefs, and willingness to act-emerged from exploring the perspective of gatekeepers about GRI in this group. We observed mixed opinions regarding the acceptance of GRI. Many participants believed their role is to guide and support members when they receive results; this is based on the level of trust their members have in them. However, participants felt they would need to be trained by medical experts to do this. Also, religious and cultural beliefs were crucial to determining participants' understanding of OFCs and the acceptance and utilization of GRI.

CONCLUSIONS

Incorporating cultural sensitivity into public engagement could help develop appropriate strategies to manage conflicting ideologies surrounding genomic information in African communities. This will allow for more widespread access to the advances in genomics research in underrepresented populations. We also recommend a synergistic relationship between community health specialists/scientists, and community leaders, including spiritual providers to better understand and utilize GRI.

Outcomes of Short-Term Surgical Trips in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

This scoping review aims to explore the current body of literature to characterize how short-term surgical trips (STSTs) in Otolaryngology-Head and Neck Surgery (OtoHNS) contribute to surgical, educational, and sustainability-based outcomes in low- and middle-income countries (LMICs). We aim to use these data to synthesize aspects of STSTs that are successful with the hopes of shaping future global efforts.

DATA SOURCES

Data sources included Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

REVIEW METHODS

A comprehensive search was conducted on several databases from inception to October 14, 2021. We included primary studies exploring any surgical or educational outcomes of global short-term surgical endeavors within LMICs. Data were then extracted to evaluate the heterogenous body of literature that exists, characterizing the surgical, educational, and sustainability-based outcomes.

RESULTS

Forty-Seven studies were included in the final analysis. Most publications were focused on surgical interventions (39 of 47; 82.9%); 13 (27.7%) studies included education as the primary aim and 12 (25.5%) considered sustainability a significant aim. Of the 94 first and last authors, there were zero first authors and only one last author with an LMIC affiliation. Twenty-six studies (55%) mentioned that any patients were seen in follow-up, ranging from one day to five years.

CONCLUSION

Our scoping review demonstrates that most STSTs have focused primarily on surgical procedures with a lack of appropriate long-term follow-up. However, the available outcome-based information presented helps identify factors that characterize a strong short-term global surgical program.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:32-39, 2024.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

Investigation of Flaviviruses Emerging in Brazil as Etiology Factor in Nonsyndromic Orofacial Cleft

Brazil has one of the largest forest areas on the planet and the potential for the emergence of new diseases. In turn, orofacial clefts, especially cleft lip and or palate (CL/P), are characterized as congenital malformations and may be associated with genetic and environmental factors. The present study aimed to investigate in silico the flavivirus's potential to emerge in Brazil as an etiology of CL/P. A scoring method was created based on literature and nucleotide similarity analysis. An integrative analysis of the literature was performed to answer the questions through the databases PubMed/MEDLINE, SciELO, LILACS, and Google Scholar to have a more significant number of results. The software Basic Local Alignment Search Tool-BLAST 2.12.0, through the Genomic + Transcript Databases (Human Genomic plus Transcript Human G+T), was selected to find similarities with human sequences associated with CL/P. The viral sequences used were obtained from the National Center for Biotechnology Information Virus-NCBI Virus, in which only complete and referential genomes were selected. The flavivirus that emerged in Brazil and presented a high potential to cause CL/P was the Iguape virus strain (species Aroa virus), followed by the Cacipacore virus and the Rocio virus strain (species Ilheus virus) with medium potential to cause CL/P. In conclusion, we suggest among the virus evaluated that the Iguape virus presented a high potential of causing CL/P. As prevention, the control of arthropods and the hospital diffusion on viral dynamics, mainly in the CL/P context and other congenital malformations, are indicated.

Prevalence and outcomes of pediatric surgical conditions at Connaught Hospital in Freetown: a retrospective study

Background

Sub-Saharan Africa experiences a disproportionate amount of pediatric surgical disease, with 80% of children lacking access to timely, affordable, and safe surgical care. This study aims to characterize the burden of disease and outcomes of pediatric surgical conditions at Connaught Hospital, the main pediatric referral hospital in Sierra Leone.

Methods

This retrospective and hospital-based study included children up to 15 years old who were operated on between 2015 and June 2016 at Connaught Hospital in Freetown, Sierra Leone. Descriptive and inferential statistics were used to characterize the distribution of disease and compare all variables against age category and mortality.

Findings

A total of 215 patients were included in this study of which 72.5% (n=132) were male and 27.5% (n=50) were female. Most of the patients were diagnosed with congenital anomalies (60.9%; n=131). However, infection was the leading diagnosis (60.5%; n=23) among patients aged 5-10 years (n=38). Inguinal hernia was the leading condition (65.0%; n=85) among patients presenting with a congenital anomaly. The condition with the highest mortality was infections (17.0%; n=8), followed by other conditions (9.1%; n=2) and congenital anomalies (3.1%; n=4). Based on the results of this study, over 7000 children with inguinal hernias remain untreated annually in Freetown, Sierra Leone.

Conclusion

This study quantifies the burden of surgical disease among children, a foundational step toward the prioritization of pediatric surgical care in national health agendas, the development of evidence-based interventions, and the strategic allocation of resources in Sierra Leone.

Epidemiology of Clefts in Kwazulu Natal: Comparison With Systematic Review Analysis, Similarities, and Differences

PREAMBLE

The incidence and accuracy of cleft epidemiology is variable depending on geographical region, population group, and country being assessed. Confounding factors are rendered more accurate if consecutive patients seen in a unit over a prolonged period are reported.

MATERIALS AND METHODS

Plastic surgery charts at Inkosi Albert Luthuli Central Hospital (IALCH) were reviewed from 2003 to 2019. Appropriate International Classification of Diseases (ICD) cleft codes were used to obtain a cleft database of all cleft patients. The review revealed 1487 cleft patients. Data extracted included sex, race, extent of cleft lip or palate, laterality, and birth month.

RESULTS

Overall, there was an almost equivalent sex distribution with 745 females and 742 males. There were 390 cleft lip only (26%), 505 cleft lip with palate (CLP) (34%), and 592 cleft palate only (40%). In the cleft lip only group, Black females were affected in 54% and males in 46%, whereas in the Asian group, females were affected in 33% and males in 67% ( P =0.022). In the CLP group, Asian and Colored females were affected more (56% and 60%, respectively), while in the Black and White groups, females were less affected (40% and 26%, respectively). Cleft palate only was the most common category in Black (44%) and Colored (55%), while the CLP category was most common in Asian (49%) and White (42%).

CONCLUSIONS

Demographics of cleft lip and palate in KwaZulu Natal is different from other series in certain aspects. In addition, there are differences in the race groups when analyzing certain aspects. The differences may be based on genetic or environmental factors and warrants further investigation.

Systematic Review of Clinical Practice Guidelines for Oral Health in Children With Cleft Lip and Palate

OBJECTIVE

Clinical practice guidelines (CPGs) exist to present recommendations and policies aimed at optimizing the oral health of children and adolescents born with cleft lip and/or palate. The aim of this review is to identify and assess the scope, quality, adequacy, and consistency of CPGs related to oral health in children and adolescents with clefts, along with reporting any differences and shortcomings.

METHODS

A systematic review of the literature of CPGs following Preferred Reporting Items for Systematic Reviews guidelines was conducted. Assessment of selected CPGs was performed using the Appraisal of Guidelines for Research & Evaluation II methodological quality instrument.

RESULTS

Only 7 CPGs fulfilled the criteria. Of these, 4 were from the American Cleft Palate-Craniofacial Association, and 1 each from the American Academy of Pediatrics, the Academy of Breastfeeding Medicine, and the American Academy of Pediatric Dentistry. The lowest overall mean scores were in the domain "Rigor of Development" (mean 29.58%, SD 17.11), revealing lower quality in methodology of the guideline. The domain "Clarity of Presentation" (mean 73.80%, SD 7.87) revealed the best score.

CONCLUSIONS

Our review results reveal a lack of integrated high-quality CPGs that can be used as universal guidelines by health workers in a range of disciplines for improving oral health in children and adolescents with cleft problems.

Epidemiology of Rare Craniofacial Anomalies: Retrospective Western Australian Population Data Linkage Study

OBJECTIVE

To describe birth prevalence of rare craniofacial anomalies and associations with antenatal and perinatal factors.

STUDY DESIGN

All live and stillbirths in Western Australia between 1980 and 2010 were identified from the Western Australian Birth Registrations and the Midwives Notification System (also provides information on antenatal and perinatal factors). Rare craniofacial anomalies (craniosynostosis, craniofacial microsomia, and others [Pierre Robin, Van der Woude, and Treacher Collins syndrome]) were ascertained from the Western Australian Register of Developmental Anomalies and linked to other data sources. Trends in prevalence, adjusted for sex and Indigenous status, were investigated by Poisson regression and presented as annual percent change (APC). Strengths of association of related factors were assessed using multivariable log-binomial regression adjusted for sex, Indigenous status, birth year, socioeconomic disadvantage, and remoteness and reported as risk ratios with 95% CIs.

RESULTS

There was a temporal increase in prevalence of metopic synostosis (APC 5.59 [2.32-8.96]) and craniofacial microsomia (Goldenhar syndrome) (APC 4.43 [1.94-6.98]). Rare craniofacial anomalies were more likely among infants born preterm, as twins or greater-order multiples, with growth restriction, to older parents, to mothers undertaking fertility treatments, and with pre-existing medical conditions, specifically epilepsy, diabetes, or hypothyroidism. Prenatal identification of rare craniofacial anomalies was uncommon (0.6%).

CONCLUSIONS

Our findings indicate a steady increase over time in prevalence of metopic synostosis and craniofacial microsomia (Goldenhar syndrome). Possible associations of fertility treatments and pre-existing maternal medical conditions with rare craniofacial anomalies require further investigation.

Pattern of Orofacial Clefts at A Tertiary Care Hospital in Ethiopia

Background

Clefts of the lip and/or palate are the most common craniofacial birth defects. The worldwide birth prevalence is 1/700 live births. There are varying reports from Africa. This study investigated the patterns of orofacial clefts at a tertiary care hospital in Addis Ababa.

Methods

A retrospective descriptive study was performed to assess the patterns of Orofacial clefts at the main cleft care center in Ethiopia. The Data of cleft patients operated at the main cleft care center in Ethiopia from January 2007 to April 2020 with the support of Smile Train was used for this study. Their demographic and clinical data was retrieved from the Smile Train data base and analyzed using Stata version 16.

Results

A total of 1919 patients' data was retrieved, excluding 16 patients' data (.83%). The data of 1903 (99.17%) patients were enrolled in this study. Cleft lip and palate were found in 53.0% of the patients. Cleft lip only was found in 731 (38.4%) and cleft palate only in 166 (8.6%) patients. The commonest surgery performed was primary unilateral lip nose repair. Most patients were operated after the age of five years old.

Conclusion

Many were operated after the age of five years, which is not in line with international recommendations. This needs improvement: establish more cleft care centers, distribute health care information and education.

The Current State of Cleft Care in Sub-Saharan Africa: A Narrative Review

OBJECTIVE

To identify practices and limitations of cleft care in sub-Saharan Africa (SSA).

DESIGN

A retrospective narrative nonsystematic literature review was performed.

SETTING

Literature exploring the management practices of cleft lip and/or palate across regions in SSA was included.

PARTICIPANTS

Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles written and published in English between 1966 and February 1, 2021, were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases.

MAIN OUTCOME MEASURES

Qualitative themes identified in analysis were clinical practice patterns, current infrastructure and limitations of cleft repair, training and interdisciplinary teams, economic analyses, and international partnerships.

RESULTS

Significant barriers to care identified in SSA include lack of hospital resources, craniofacial training, access to multidisciplinary specialists, and public awareness. These problems make the entire care journey difficult for patients. Increasing public education has the power to diminish late presentations to hospitals. Providing adequate hospital resources and craniofacial training through international and organizational partnerships can ensure that more patients will receive care. Increasing the availability and number of multidisciplinary specialists is crucial to follow up care which aims at improving functional outcomes.

CONCLUSION

This narrative review highlights current practices and limitations in cleft care, emphasizing the importance of effective and timely repair of clefts in SSA. Targeted efforts aimed at establishing sustainable infrastructure for cleft care in SSA can have significant individual and community health and economic benefits.

Biomechanical behavior of an alveolar graft under maxillary therapies

Cleft lip and palate is a congenital defect that affects the oral cavity. Depending on its severity, alveolar graft surgery and maxillary orthopedic therapies must be carried out as a part of the treatment. It is widely accepted that the therapies should be performed before grafting. Nevertheless, some authors have suggested that mechanical stimuli such as those from the maxillary therapies could improve the success rate of the graft. The aim of this study is to computationally determine the effect of maxillary therapies loads on the biomechanical response of an alveolar graft with different degrees of ossification. We also explore how the transverse width of the cleft affects the graft behavior and compare results with a non-cleft skull. Results suggest that stresses increase within the graft as it ossifies and are greater if maxillary expansion therapy is applied. This has consequences in the bone remodeling processes that are necessary for the graft osseointegration. Maxillary orthopedic therapies after graft surgery could be considered as a part of the treatment since they seem to act as a positive extra stimulus that can benefit the graft.

Interprofessional collaboration among health professionals in cleft lip and palate treatment and care in the public health sector of South Africa

BACKGROUND

Collaboration among different categories of health professionals is essential for quality patient care, especially for individuals with cleft lip and palate (CLP). This study examined interprofessional collaboration (IPC) among health professionals in all CLP specialised centres in South Africa's public health sector.

METHODS

During 2017, a survey was conducted among health professionals at all the specialised CLP centres in South Africa's public health sector. Following informed consent, each member of the CLP team completed a self-administered questionnaire on IPC, using the Interprofessional Competency Framework Self-Assessment Tool. The IPC questionnaire consists of seven domains with 51 items: care expertise (8 items); shared power (4 items); collaborative leadership (10 items); shared decision-making (2 items); optimising professional role and scope (10 items); effective group function (9 items); and competent communication (8 items). STATA®13 was used to analyse the data. Descriptive analysis of participants and overall mean scores were computed for each domain and analysed using ANOVA. All statistical tests were conducted at 5% significance level.

RESULTS

We obtained an 87% response rate, and 52 participants completed the questionnaire. The majority of participants were female 52% (n = 27); with a mean age of 41.9 years (range 22-72). Plastic surgeons accounted for 38.5% of all study participants, followed by speech therapists (23.1%), and professional nurses (9.6%). The lowest mean score of 2.55 was obtained for effective group function (SD + -0.50), and the highest mean score of 2.92 for care expertise (SD + -0.37). Explanatory factor analysis showed that gender did not influence IPC, but category of health professional predicted scores on the five categories of shared power (p = 0.01), collaborative leadership (p = 0.04), optimising professional role and scope (p = 0.03), effective group function (p = 0.01) and effective communication (p = 0.04).

CONCLUSION

The seven IPC categories could be used as a guide to develop specific strategies to enhance IPC among CLP teams. Institutional support and leadership combined with patient-centred, continuing professional development in multi-disciplinary meetings will also enrich IPC.

A Retrospective Cohort Study to Evaluate the Association Between Types of Nonsyndromic Oral Clefts and a Child's Gender and Maternal Age

Aims

To evaluate the association between nonsyndromic cleft lip with or without cleft palate (NSCL±P) anomaly and the affected child's gender and maternal age.

Materials and Methods

Records of 141 newborns received at the orthodontic craniofacial clinic of the Jordanian Royal Rehabilitation Center between 2017 and 2019 were retrospectively analyzed. Two variables were paid attention to: child's gender and maternal age. Five cleft types were considered: unilateral CLP (right; URCLP and left; ULCLP), bilateral CLP (BCLP), isolated cleft palate (CP) and isolated cleft lip (CL). Maternal age was classified into four subgroups: "26-30" years, "31-35" years, "36-40" years, and "above 40" years. Chi-square test and multinomial logistic regression analysis were used to analyze the resultant data.

Results

A significant occurrence of the NSCL±P in females was found compared with males. The different cleft types were found to be significantly associated with the different maternal age groups investigated. The ULCLP was the most prevalent cleft type for affected children among all maternal age groups except the "31-35" group, at which the BCLP exceeded.

Conclusions

The children's gender and the maternal age have a significant impact on defining the developing oral cleft types.

Management of Orofacial Cleft in Nigeria - A Retrospective Study

Introduction

Orofacial clefts (OFCs) are among the most common craniofacial developmental abnormalities worldwide and a significant cause of childhood morbidity and mortality. This study aimed to identify patterns of patient presentation, treatment approaches, and changes in our overall cleft care service between 2007 and 2019.

Methods and Methodology

A retrospective review of patients managed at a tertiary health facility in Nigeria of all OFC cases operated between 2007 and 2019 was done using the postintervention data retrieved from the Smile Train database. Data of all OFC cases operated within the period were analyzed using the Statistical Package for the Social Sciences. Descriptive statistics were performed using the Statistical Package for the Social Sciences version 20.0.

Results

A total number of 740 OFC surgeries were performed in 565 patients, consisting of 269 females (48.2%) and 289 males (51.8%). The majority (63%) of the patients presented before the age of 2 years. Thirty-seven percent presented with cleft lip and alveolus, 27.1% with cleft palate only, and 36.7% with cleft lip, alveolus, and palate. Primary cleft lip repair was the most performed surgery (n = 320, 43.2%), the mean age at repair was 2.1 years. Since 2017, additional services such as speech therapy, mixed dentition orthodontics, and nutritional support were added to services provided to our cleft patients. Fifteen patients have undergone speech assessment and three have completed speech treatment. Eight patients have undergone mixed dentition stage orthodontic treatment.

Discussion

Our services have evolved from simply providing surgical care to comprehensive care with a multidisciplinary team approach and provision of a wide range of services including nutritional counseling, pediatric care, orthodontic services, and speech therapy. We believe these will improve the overall well-being of our patients while we continue to improve on services based on clinical research outcomes.

The Tale of the Unrepaired Cleft-Retrospective Evaluation of Cases Encountered by an Indigenous Mission in a Northern Nigerian Community

OBJECTIVE

This study aims to document the experience of an indigenous surgical mission on the occurrence of unrepaired cleft in 2 visits to Minna, North-Central Nigeria.

DESIGN

This retrospective study involved participants with orofacial cleft anomaly at 2 surgical outreaches held in Minna in 2011 and 2017. Baseline data were initially obtained from case files of patients at both programs. Data collected were analyzed employing appropriate statistical tests for continuous and categorical variables.

SETTING

Two outreach programs in Minna, North-Central Nigeria by Cleft and Facial Deformity Foundation in 2011 and 2017.

RESULTS

A total of 117 participants with cleft anomaly were encountered at both surgical outreach programs. The sample prevalence of unrepaired cleft was 61.5% with an overall mean age (standard deviation) of 10 (13.2) years. Most participants presented with unilateral complete cleft lip (70.8%) which was more common on the left side and had no family history of orofacial cleft (54.2%). Information on the surgical program was mostly obtained via friends and relatives in 32.6% and lack of wherewithal to offset the expense of cleft surgery and supportive treatment represented the most common reason for the delay of surgical repair (50%).

CONCLUSION

We found a high proportion of patients with unrepaired cleft in our sample which may mirror happenings in other developing world centers. We advocate continued collaborations between indigenous missions and international funding agencies to further encourage continued repair of unrepaired cleft in developing centers.

Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology

BACKGROUND

Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques.

METHODS

Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns.

RESULTS

Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip.

CONCLUSIONS

The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

Surgical Repair of Orofacial Clefts in North Kivu Province of Eastern Democratic Republic of Congo (DRC)

BACKGROUND

There is a high prevalence of orofacial clefts in low- and middle-income countries with significant unmet need, despite having 50% of the population younger than 18 years in countries such as the Democratic Republic of Congo (DRC). The purpose of this article is to report on the experience of general surgeons with orofacial clefts at a single institution.

METHODS

This is a retrospective study of patients treated for cleft lip/palate in the province of North Kivu, DRC between 2008 and 2017.

RESULTS

A total of 1112 procedures (122/year) were performed. All procedures were performed by general surgeons following training by an international nongovernmental aid organization. A total of 59.2% of patients were male and the median age was 3.4 years (interquartile range: 0.7-13 years). Average distance from surgical center to patient location was 242.6 km (range: 2-1375 km) with outreach performed for distances >200 kms. A majority (82.1%) of patients received general anesthesia (GA) with significant differences in use of GA, age, weight, and length of stay by major orofacial cleft category. Of the 1112 patients, 86.1% were reported to have cleft lip alone, 10.5% had cleft lip and palate, and 3.4% cleft palate alone. Despite this, only 5.3% of patients underwent surgical repair of cleft palate.

CONCLUSIONS

Multiple factors including malnutrition, risk of bleeding, procedural complexity, and cosmetic results may contribute to the distribution of procedures performed where most cleft palates are not treated. Based on previously published estimates, unmet needs and social burden of cleft lip and palate are high in the DRC.

Six2 regulates Pax9 expression, palatogenesis and craniofacial bone formation

In this study, we investigated the role of the transcription factor Six2 in palate development. Six2 was selected using the SysFACE tool to predict genes from the 2p21 locus, a region associated with clefting in humans by GWAS, that are likely to be involved in palatogenesis. We functionally validated the predicted role of Six2 in palatogenesis by showing that 22% of Six2 null embryos develop cleft palate. Six2 contributes to palatogenesis by promoting mesenchymal cell proliferation and regulating bone formation. The clefting phenotype in Six2^-/- embryos is similar to Pax9 null embryos, so we examined the functional relationship of these two genes. Mechanistically, SIX2 binds to a PAX9 5' upstream regulatory element and activates PAX9 expression. In addition, we identified a human SIX2 coding variant (p.Gly264Glu) in a proband with cleft palate. We show this missense mutation affects the stability of the SIX2 protein and leads to decreased PAX9 expression. The low penetrance of clefting in the Six2 null mouse combined with the mutation in one patient with cleft palate underscores the potential combinatorial interactions of other genes in clefting. Our study demonstrates that Six2 interacts with the developmental gene regulatory network in the developing palate.

Establishing cleft services in developing countries: Complications of cleft lip and palate surgery in rural areas of Indonesia

BACKGROUND

Cleft treatment is frequently performed in Indonesia, mostly in charity missions, but without a postoperative protocol it is difficult to establish the risks and complications of cleft treatment. The present study was designed to give an overview of current cleft lip and palate treatment strategies in Indonesia and to assess the complication rates during and after surgery.

METHODS

This prospective study evaluated anesthetic, intraoperative surgical, and short-term postoperative complications in patients undergoing primary, secondary, or corrective surgery for cleft lip and palate deformities. The population consisted of 98 non-syndromic cleft patients. The main anesthetic complication that occurred during general anesthesia was high blood pressure, whereas the main intraoperative surgical complication was excessive bleeding and the main early postoperative complication was extremely poor wound hygiene.

RESULTS

In this study, there were no cases of perioperative or postoperative mortality. However, in 23 (23.4%) of the 98 operations performed, at least one perioperative complication related to anesthesia occurred. The intraoperative and early postoperative complications following cleft lip and/or palate were assessed. There was a significant difference in the complication rate between procedure types (χ2=0.02; P<0.05). However, no relationship was found between perioperative complications related to anesthesia and the occurrence of postoperative complications (χ2=1.00; P>0.05). Nonetheless, a significant difference was found between procedure types regarding perioperative complications and the occurrence of postoperative complications (χ2=0.031; P<0.05).

CONCLUSIONS

Further evaluation of these outcomes would help direct patient management toward decreasing the complication rate.

Epidemiology and clinical profile of individuals with cleft lip and palate utilising specialised academic treatment centres in South Africa

OBJECTIVE

The study was conducted to determine the epidemiology and clinical profile of individuals with cleft lip and/or palate (CLP) utilizing specialized academic treatment centres in South Africa's public health sector.

MATERIALS AND METHODS

The Human Research Ethics Committee of the University of the Witwatersrand in Johannesburg provided ethical approval for the study. We conducted a retrospective record review of all cases of CLP treated at the specialised academic centres for the two-year period from 1 January 2013 until 31 December 2014. We used a structured, pre-tested record review form to obtain demographic, clinical and treatment information on each CLP case. We used Stata 13 to analyse the data and conducted statistical tests at 5% significance level.

RESULTS

We analysed 699 records of individuals with CLP. The estimated prevalence of CLP in the South African public health sector was 0.3 per 1000 live births, with provincial variation of 0.1/1000 to 1.2/1000. The distribution of clefts was: 35.3% cleft palate; 34.6% cleft lip and palate; 19.0% cleft lip and other cleft anomalies at 2%. Of the total number of CLP, 47.5% were male and 52.5% female, and this difference was statistically significant (p<0.001). The majority of clefts occurred on the left for males (35.5%) and palate for females (43.4%), with a male predominance of unilateral cleft lip and palate (53.3%).

CONCLUSION

The study findings should inform the implementation of South Africa's planned birth defect surveillance system and health service planning for individuals with CLP.

Impact of short-term reconstructive surgical missions: a systematic review

Introduction

Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.

Methods

A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.

Results

Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.

Conclusions

Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.

PROSPERO registration number

CRD42018099285.

Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries

BACKGROUND

The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs).

METHODS

We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes.

RESULTS

The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases).

CONCLUSION

These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need.

TYPE OF STUDY

Retrospective study and review article LEVEL OF EVIDENCE: III.

STATE DISTRIBUTION OF NEW PATIENTS PRESENTING WITH CLEFT LIP AND PALATE TO THE UNIVERSITY COLLEGE HOSPITAL: A PILOT STUDY

BACKGROUND

The UCH/Smile Train partnership, which offers free cleft surgeries to patients provides succor.

OBJECTIVE

The objective of the study was to determine the state distribution of new patients presenting with cleft lip and palate, to The UCH.

METHODS

A retrospective review of all new cleft patients presenting to The UCH between January 2012 and June 2015. The data obtained were their local government area of residence, age of the patients, gender of the patients and the type of cleft. Descriptive statistics was used to analyze the distribution of patients seen while Chi square test was used to analyze the influence of gender and laterality on the type of cleft.

RESULTS

Sixty-seven eligible patients were seen within the study period. Majority (83.6%) of patients seen were from 14 of the 33 Local Government Areas (LGA's) in Oyo state. Patients were seen from LGA's in proximity to UCH. A few (16.4%) of the patients came from outside the state. Iwajowa, the LGA with the least number of patients (1.8%) was furthest from UCH. Left sided clefts were significantly more than bilateral or right-sided clefts (p=0.001). Most of the patients from Oluyole LGA had CP while no patient with CP was seen from Lagelu and Akinyele LGA's.

CONCLUSION

There is the need to intensify cleft awareness programs. Further studies into the health habits, cultural beliefs and genetic profile of communities may explain some regional distribution of cleft types seen.

"People look and ask lots of questions": caregivers' perceptions of healthcare provision and support for children born with cleft lip and palate

BACKGROUND

Clefting of the lip and/or palate (CL/P) is amongst the five most common birth defects reported in South Africa. The emotional impact on parents at the birth of their new-born with CL/P could affect parent-child relationships. In light of insufficient scholarly attention parental experiences and perceptions, this study reports on caregivers' perceptions of health service provision and support for children born with cleft lip and palate in South Africa.

METHODS

The study setting consisted of 11 academic hospital centres situated in six of South Africa's nine provinces. At each of the academic centres cleft clinic, five to ten parents or caregivers were selected purposively. Participants were interviewed, using a semi-structured interview schedule that elicited socio-demographic information, explored the family experiences of having a child with CL/P, and their perceptions of care provision and support services available. The interviews were analysed using thematic content analysis.

RESULTS

Seventy-nine participants were interviewed. Their mean age was 33.3 years (range 17-68 years). The majority of the parents were black African (72%), unemployed (72%), single (67%) and with only primary school education (58%). The majority of the children were male, with a mean age of 3.8 (SD = ±4.3) years. Five broad themes emerged from the interviews: emotional experiences following the birth of a child with cleft lip and palate; reactions from family, friends or the public; the burden of care provision; health system responsiveness; and social support services. Caregivers reported feelings of shock, anxiety, and sadness, exacerbated by the burden of care provision, health system deficiencies, lack of public awareness and insufficient social support services.

CONCLUSIONS

The findings have implications for the integrated management of children with cleft lip and/or palate, including information to parents, the education and training of healthcare providers, raising public awareness of birth defects, and social support.

Descriptive Epidemiology of Orofacial Clefts in Ethiopia

BACKGROUND

The prevalence of birth defects including orofacial clefts (OFC) in Ethiopia is not known and there is no established birth defects registration system.

OBJECTIVES

To investigate the prevalence and incidence of OFC in Ethiopia.

DESIGN

Retrospective hospital-based descriptive study.

METHODS

The authors obtained data from the Smile Train database on Ethiopian patients with OFC who underwent surgical treatment from June 2007 to December 2013 at 31 hospitals distributed throughout the country. Data related to live births in Ethiopia during the mentioned period were obtained from the Federal Ministry of Health database for estimates of the incidence and prevalence rates.

RESULTS

The total number of life births during the study period was 18,811,316. During this same period, 18,073 cleft patients approximately ranging from 1 to 75 years old were examined and treated at the hospitals mentioned earlier. The incidence rate estimated from the total number of affected children during the study period (N = 8232) is 0.44/1000 live births. The prevalence rate is 0.20/1000 and this was estimated using the number of total population in 2013 (N = 88,703,914). There is a significant difference in frequency between bilateral clefts of the lip and/or palate (CLP) (26.9%) versus unilateral CLP (73.1%) (P < 0.0001). There is also a significant difference in frequency between bilateral cleft lips only (15.4%) versus unilateral cleft lip only (84.6%), P < 0001.

CONCLUSION

It is obvious that the findings in this study cannot be representative of the true picture but provides a previously unavailable national estimate of incidence and prevalence of OFC in Ethiopia. It can also be used as comparison for future community-based studies.

Interaction Effect of RsaI and BamHI Polymorphisms of TGFα, BMP2 and BMP4 on the Occurrence of Non-Syndromic Cleft Lip and Palate in Iranian Patients

BACKGROUND

Orofacial cleft is the most common congenital defect of the maxillofacial region. Its non-syndromic type is multi-factorial, and several genes are involved in its occurrence. This study aimed to assess the interaction effect of Rsal and BamHI polymorphisms of Transforming Growth Factor-alpha (TGFα) gene and Bone Morphogenetic Protein-2 (BMP2) and BMP4 variants on the occurrence of Non-Syndromic Cleft Lip and Palate (NSCLP) in the Iranian population.

METHODS

This case-control study was conducted on 120 children with NSCLP and 215 healthy children. Genotyping of the TGFA/BamHI (rs11466297), TGFA/RsaI (rs37322-48), BMP4 (rs17563) and BMP2 (rs235768) was performed by Polymerase Chain Reaction (PCR) and Restriction Fragment Length Polymorphism (RFLP) methods. Logistic regression was applied to determine the effective factors and the interaction effect of different variants on the occurrence of NSCLP.

RESULTS

Gender of patients had no significant association with the occurrence of NSCLP (p=0.335). Multiple logistic regression showed that the interaction effect of the aforementioned polymorphisms on the occurrence of NSCLP was not statistically significant (p=1.000).

CONCLUSION

Although the individual effect of each of the BMP4, BMP2, RsaI and BamHI variants on the occurrence of NSCLP in the Iranian population has been previously confirmed, their interaction does not play a role in this respect.

A comparative study of quality of life of families with children born with cleft lip and/or palate before and after surgical treatment

Objectives

The aim of this study was to compare the quality of life (QoL) of parents/caregivers of children with cleft lip and/or palate before and after surgical repair of an orofacial cleft.

Materials and Methods

Families of subjects who required either primary or secondary orofacial cleft repair who satisfied the inclusion criteria were recruited. A preoperative and postoperative health-related QoL questionnaire, the ‘Impact on Family Scale’ (IOFS), was applied in order to detect the subjectively perceived QoL in the affected family before and after surgical intervention. The mean pre- and postoperative total scores were compared using paired t-test. Pre- and postoperative mean scores were also compared across the 5 domains of the IOFS.

Results

The proportion of families whose QoL was affected before surgery was 95.7%. The domains with the greatest impact preoperatively were the financial domain and social domains. Families having children with bilateral cleft lip showed QoL effects mostly in the social domain and 'impact on sibling' domain. Postoperatively, the mean total QoL score was significantly lower than the mean preoperative QoL score, indicating significant improvement in QoL (P<0.001). The mean postoperative QoL score was also significantly lower than the mean preoperative QoL score in all domains. Only 3.2% of the families reported affectation of their QoL after surgery. The domains of mastery (61.3%) with a mean of 7.4±1.8 and finance (45.1%) with a mean score of 7.2±1.6 were those showing the greatest postoperative impact. The proportion of families whose QoL was affected by orofacial cleft was markedly different after treatment (95.7% preoperative and 3.2% postoperative).

Conclusion

Caring for children with orofacial clefts significantly reduces the QoL of parents/caregivers in all domains. However, surgical intervention significantly improves the QoL of the parents/caregivers of these children.

Reconstructive Surgery in Times of Conflict

BACKGROUND

Smile Train is a charitable organization that partners with and trains surgeons in developing countries to provide surgical care to patients with cleft lip/palate deformities. The organization supports surgeries in several countries that experience high levels of regional conflict and violence. Nigeria, a country where Smile Train is very active, has undergone numerous periods of extreme violence over the past 12 years. The purpose of the present study is to analyze how local violence and conflict have impacted the ability of surgeons partnered with Smile Train to provide care in Nigeria.

METHODS

The authors retrospectively reviewed Smile Train Express, the organization's database, from 2003 to 2015 for cleft lip/palate repairs performed in Nigeria. The data was chronologically mapped against a detailed timeline of incidents of violence in Nigeria to compare how violence affected the work of Smile Train-affiliated surgeons.

RESULTS

Smile Train-affiliates facilitated 11,499 surgeries in Nigeria from 2003 to 2015. During the same period, 46,370 people were killed in Nigeria in acts of terrorism and violence. Major drops in the frequency of cleft surgeries were preceded by spikes in violence.

CONCLUSIONS

Violence in Nigeria has had a clear impact on the ability of Smile Train-affiliated surgeons to provide adequate cleft care. The international medical community needs to take steps in an attempt to continue to provide essential medical care in areas of conflict and instability.

Pediatric surgery as an essential component of global child health

Recent initiatives in global health have emphasized universal coverage of essential health services. Surgical conditions play a critical role in child health in resource-poor areas. This article discusses (1) the spectrum of pediatric surgical conditions and their treatment; (2) relevance to recent advances in global surgery; (3) challenges to the prioritization of surgical care within child health, and possible solutions; (4) a case example from a resource-poor area (Uganda) illustrating some of these concepts; and (5) important child health initiatives with which surgical services should be integrated. Pediatric surgery providers must lead the effort to prioritize children's surgery in health systems development.