Weight, Length, and Body Mass Index Growth of Children Under 2 Years of Age With Cleft Lip and Palate

A Dedicated Multidisciplinary Growth and Feeding Clinic for Infants with Cleft Lip and/or Palate Demonstrates Need for Intervention

OBJECTIVE

A Growth and Feeding Clinic (GFC) focused on early intervention around feeding routines in patients with cleft lip and/or palate (CL/P) was implemented.

DESIGN

This study assessed the effect of preoperative feeding interventions provided by the GFC.

SETTING

Tertiary academic center.

METHODS

This study evaluated patients with CL/P who were cared for by the GFC and a control group of patients with CL/P. Weight-for-age (WFA) Z-score of less than -2.00 was used as a cutoff to classify patients who were underweight during the preoperative period.

MAIN OUTCOME MEASURE

The number of underweight patients who were able to reach normal weight by the time of their cleft lip repair was used as the primary outcome measure.

RESULTS

Within both the GFC and control groups, 25% of patients with CL/P were underweight as determined by WFA Z-score. GFC patients who were underweight received more clinic visits (P < .001) and GFC interventions (P < .001) compared to GFC patients who were normal weight. At the time of cleft lip surgery, 64.1% of GFC underweight patients were normal weight compared to 31.8% of control group underweight patients (P = .0187).

CONCLUSION

This study showed that multidisciplinary care provided by the GFC was able to target preoperative nutritional interventions to the highest-risk patients, resulting in double the percentage of patients who were of normal weight at the time of their cleft lip repair. These results provide objective proof supporting the assertion that multidisciplinary team care of the infant with cleft leads to measurable improvement in outcomes.

Comparison of two Specialized Cleft Palate Feeders

OBJECTIVE

To evaluate feeding efficiency and weight gain in infants with cleft palate fed using 1 of the 2 specialty feeders.

DESIGN

Retrospective cohort study.

SETTING

Cleft palate clinic in a tertiary pediatric hospital.

PARTICIPANTS

Infants with cleft palate (with or without cleft lip) fed using the Medela SpecialNeeds® Feeder (n = 39) or the Dr. Brown's® Specialty Feeding System (n = 16) and who had documented feeding and growth data available from the time of initial assessment in the first month of life and at subsequent follow-up between 2 and 4 months.

PRIMARY OUTCOME MEASURE

Feeding velocity (mL/min).

SECONDARY OUTCOMES MEASURES

Calorie velocity (kcal/min), weight gain, and complications associated with poor feeding.

RESULTS

No statistically significant differences in feeding or calorie velocities were identified between infants with cleft palate fed with the Medela SpecialNeeds® feeder and those fed with the Dr. Brown's® feeder. Mean weight z-scores by month did not differ significantly between the 2 bottle groups at the time of initial assessment (P = .84) and follow-up (P = .20). Mean weight z-scores by month for the infants included in this study fell below the 50th percentile. The proportion of infants who developed otitis media, reflux requiring treatment, or who required hospital admission for nasogastric (NG) feeds did not differ significantly between the 2 groups.

CONCLUSIONS

Despite being adequately powered for the primary outcome, no significant differences were identified between infants fed with the Medela or the Dr. Brown's feeders in terms of feeding velocity, calorie velocity, weight gain, or complications.

Prenatal Consultation Outcomes for Infants With Cleft Lip With and Without Cleft Palate

To assess the clinical impacts of prenatal consultation with a multidisciplinary cleft team on infants with cleft lip with or without cleft palate (CL ± P).

Retrospective cases series.

Tertiary pediatric hospital.

Infants with CL ± P whose mothers received prenatal consultation with a pediatric otolaryngology team from June 2005 to December 2019 were identified. A random sample of infants with CL ± P without prenatal consultation from June 2005 to December 2019 was also identified.

The primary outcomes were the length of hospitalization during the first 12 weeks of life, timing of surgical repair, length of postsurgical hospitalization, and number of unplanned clinic visits and phone calls for feeding evaluation.

Time to cleft lip repair differed significantly between the 2 groups with repair performed at 13.4 (±0.9) weeks for the prenatal consultation group (n = 73) and 15.3 (±2.1) weeks for the control group (n = 80), (P < .05). If hospitalization was required for feeding difficulties during the first 12 weeks of life, length of stay was 4.9 (± 1.7) days for infants with prenatal consultation and 11.5 (± 7.2) days for control infants (P < .05). Unplanned clinic visits with a speech-language pathologist (SLP) for feeding difficulties were needed for 2.7% of prenatal consultation infants and 11.3% of control infants (P < .05).

Prenatal consultation regarding CL ± P resulted in infants with decreased duration of early hospitalizations, earlier cleft lip repair, and decreased engagement with the SLP feeding clinic for feeding difficulties when compared with infants without prenatal consultation.

Growth trajectories in children with cleft lip and/or palate

Introduction

Introduction: the nutritional status and growth of children with cleft lip and/or palate (CL/P) can be affected due to feeding difficulties caused by their anatomy and the surgical interventions. Objective: this retrospective longitudinal study aims to analyse the growth trajectories of a cohort of children with CL/P and compare them with a healthy representative cohort of children from Aragon (Spain). Methods: type of cleft, surgical technique and sequelae, and weight, length/height and body mass index (BMI) (weight/height2) at different ages (0-6 years) were recorded. Normalized age- and sex-specific anthropometric Z-scores values were calculated by World Health Organization (WHO) charts. Results: forty-one patients (21 male, 20 female) were finally included: 9.75 % cleft lip (n = 4/41), 41.46 % cleft palate (n = 17/41) and 48.78 % cleft lip and palate (n = 20/41). The worst nutritional status Z-scores were achieved at the age of three months (44.44 % and 50 % had a weight and a BMI lower than -1 Z-score, respectively). Mean weight and BMI Z-scores were both significantly lower than controls at one, three and six months of age, recovering from that moment until the age of one year. Conclusions: the highest nutritional risk in CL/P patients takes place at 3-6 months of age, but nutritional status and growth trajectories get recovered from one year of age compared to their counterparts. Nevertheless, the rate of thin subjects among CL/P patients is higher during childhood.

Rethinking the Rule of 10s: Early Cleft Lip Repair Improves Weight Gain

OBJECTIVE

This study compares patients undergoing early cleft lip repair (ECLR) (<3-months) and traditional lip repair (TLR) (3-6 months) with/without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms.

DESIGN

Retrospective review.

SETTING

Children's Hospital of Los Angeles, California.

PATIENT, PARTICIPANTS

A retrospective chart review evaluated patients who underwent ECLR or TLR ± NAM from November 2009 through January 2020.

INTERVENTIONS

No intervention was performed.

MAIN OUTCOME MEASURE(S)

Patient demographics, birth and medical history, perioperative variables, and complications were collected. Infant weights and age-based percentiles were recorded at birth, surgery, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcomes were weight change and weight percentile amongst ECLR and TLR ± NAM groups.

RESULTS

107 patients met inclusion criteria: ECLR, n = 51 (47.6%); TLR + NAM, n = 35 (32.7%); and TLR-NAM, n = 21 (19.6%). ECLR patients had significantly greater changes in weight from surgery to 8-weeks and from surgery to 24-months postoperatively compared with both TLR ± NAM (P < .05). Age-matched weights in the ECLR group were significantly greater than TLR ± NAM at multiple time points postoperatively (P < .05).

CONCLUSIONS

ECLR significantly increased patient weights 24-months postoperatively when compared to TLR ± NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutrition traditionally seen in patients with cleft lip.

Growth charts in FGFR2- and FGFR3-related faciocraniosynostoses

Objective

Faciocraniosynostoses (FCS) are malformations affecting the development of the bones of the skull and face, due to the premature closure of one or more craniofacial sutures, mostly secondary to activating Fibroblast Growth Factor Receptor (FGFR) 1–3 mutations. Gain-of-function FGFR3 mutations are also responsible for various conditions referred to as osteochondrodysplasia (OCD), characterized by structural and functional abnormalities of growth plate cartilages. We hypothesized that patients with FGFR-related faciocraniosynostoses may present extra-cranial growth anomalies.

Study design

We retrospectively collected height and weight data from a cohort of 70 patients. Included patients were admitted for FGFR-related FCS between 2000 and 2021 at the Craniofacial Unit of Necker – Enfants Malades University Hospital in Paris, France.

Results

We showed that FGFR-related faciocraniosynostoses had significantly reduced heights and weights relative to controls, and that two specific time periods (1–3 years and > 8 years of age) were associated with lower height and weight values. Four patients had received growth hormone treatment but remained below normal values for growth in height and weight.

Conclusions

Patients with FGFR-related faciocraniosynostoses have clinically significant extra-cranial anomalies which are not currently investigated and managed in usual protocols; these patients could benefit from a systematic pre-pubertal endocrine assessment. More generally, our results extend the scope of extracranial anomalies in FGFR-related faciocraniosynostoses and support the hypothesis that all conditions with activating FGFR mutations affect both membranous ossification and long bones.

•

FGFR mutations can cause syndromic faciocraniosynostoses (FCS) and are also responsible for osteochondrodysplasia.

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Patients with FCS present with significant delays in development compared to the standard French population.

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Patients with FCS could benefit from a systematic pre-pubertal endocrine assessment and hormonotherapy but more data is required to establish guidelines.

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FCS and achondroplasia both affect membranous and endochondral ossification processes.

Prevalence of malnutrition among children at primary cleft surgery: A cross-sectional analysis of a global database

Background

Orofacial clefts are common birth defects, affecting one newborn in every 700 live births globally. The condition requires prompt identification, feeding support, and timely surgery. While orofacial clefts benefit from a comprehensive, life-long care management in high-income countries, care provision is often lacking or inadequate in poor-resource settings. Data on the burden of orofacial clefts in children born in limited-resource settings remain scarce. The objective of this study was to estimate the prevalence of malnutrition in children using cleft surgery records collected by one large non-governmental cleft organization in low- and middle-income countries (LMICs).

Methods

The data set included clinical records of children ≤5 years who underwent primary cleft surgery between 2008 and 2018 in health care facilities across LMICs. Patients’ data included birth date, sex, weight at surgery, ethnicity, country of origin, and date of primary surgery and were analysed using descriptive statistics. The prevalence of malnutrition was estimated using weight-for-age z scores and the distribution described in relation to cleft type, sex, ethnic groups, and geography. Comparisons with prevalence estimates for underweight in children under-5 within countries were conducted using publicly available survey data.

Results

The analysis included 602 568 children. The prevalence of underweight in children with cleft varies with the epidemiology of cleft and the timing of primary surgery, and between ethnic groups and settings. The overall prevalence of underweight at the time of primary cleft surgery was 28.6% – a figure well above the global underweight prevalence in children under-5 without cleft estimated at 13.5%. We found a positive correlation between the prevalence of underweight among children with cleft and the prevalence of underweight in the DHS program (r_s = 0.6305; P < 0.0001). Within-country comparisons showed that, with only few exceptions, the prevalence of underweight was higher in children with clefts than in their peers born without clefts (P < 0.05).

Conclusions

Although orofacial cleft is not considered to be a life-threatening condition, our findings show a high burden of malnutrition among patients accessing surgeries in LMICs. Interventions prompting early identification and appropriate feeding management of this group of vulnerable children is essential to leave no one behind in the fight against malnutrition.

A nationwide cohort study on growth impairment by cleft lip with or without palate

There are very few nationwide studies discussing the height, weight, head circumference, and dental screening of children with cleft lip with or without palate (CL/P), with most reports on this subject based on a 1900s cohort. This study aimed to characterize CL/P children in the 2000s in terms of height, weight, head circumference, and dental screening. This nationwide population-based study evaluated the National Health Insurance Service-Infants and Children’s Health Screening (NHIS-INCHS), specifically the height, weight, and head circumference of millions of children. Dental screening data, including the status of each tooth and comprehensive dental judgment, were also evaluated. Syndromic and nonsyndromic CL/P children had lower height, weight, and head circumference than no CL/P children until the age of 66–71 months. Children with cleft palate only or both cleft lip and palate showed similar results. Regarding dental screening, the primary teeth of CL/P children erupted later and fell out faster than no CL/P children. Dental caries was also more common in CL/P children. Children with CL/P had inferior general growth, regardless of palatoplasty surgery. More aggressive dental treatment was required for CL/P children due to the instability of primary teeth and tendency for caries.

The effect of combined education on the knowledge and care and supportive performance of parents with children with cleft lip and palate: A clinical trial study

Cleft lip and palate is a major problem that disrupts the child's family life. The present study aimed to investigate the effect of combined education on the knowledge and care and supportive performance of parents with children with cleft lip and palate. This is a clinical trial study was conducted on 40 parents referring to hospitals. The data were collected using the demographic information questionnaire, the questionnaire of parental knowledge and care supportive performance questionnaire and analyzed using descriptive and analytical tests. After education the intervention group, the mean score of parents' care and supportive knowledge significantly increased in the intervention group as compared to the control group. There was also a significant difference in the mean score of parents' care-supportive performance between the two groups (P < 0.001). It is recommended to use the combined education as an effective method to increase knowledge and performance in parents of children with cleft lip and palate.

Parental Risk Factors and Child Birth Data in a Matched Year and Sex Group Cleft Population: A Case-Control Study

(1) Background: The etiology of orofacial cleft (OC) is not completely known but several genetic and environmental risk factors have been identified. Moreover, a knowledge gap still persists regarding neonatal characteristics. This study evaluated the effect of parental age and mothers’ body mass index on the risk of having an OC child, in a matched year and sex group (cleft/healthy control). Additionally, birth data were analyzed between groups. (2) Methods: 266 individuals born between 1995 to 2015 were evaluated: 133 OC individuals (85 males/48 females) and 133 control (85 males/48 females). A logistic model was used for the independent variables. ANOVA or Kruskal-Wallis tests were used for comparison between the OC phenotypes. (3) Results: Regarding statistically significant parental related factors, the probability of having a cleft child decreases for each maternal year increase (odds ratio = 0.903) and increases for each body mass index unit (kg/m²) increase (odds ratio = 1.14). On the child data birth, for each mass unit (kg) increase, the probability of having a cleft child decrease (odds ratio = 0.435). (4) Conclusions: In this study, only maternal body mass index and maternal age found statistical differences in the risk of having a cleft child. In the children’s initial data, the cleft group found a higher risk of having a lower birth weight but no relation was found regarding length and head circumference.

Long-term growth patterns in children born with cleft lip and/or palate. A systematic review

Introduction

Introduction: in children with cleft lip and/or palate nutritional status and growth may be impaired due to early life feeding difficulties. Objective: to review the existing literature on the nutritional prognosis during childhood of patients undergoing surgery for cleft lip and/or palate (CLP), their body composition and growth patterns from 2 to 10 years of age, and the possible effects of their early nutritional status on the long-term onset of overweight. Methods: a systematic search of growth and body composition parameters in 2-10 year-old CLP children, including cross-sectional and longitudinal studies, and using the Pubmed and Scopus databases. From the 2,983 retrieved articles, 6 were finally included. Results: two studies out of 6 were longitudinal and the other 4 were cross-sectional, including very heterogeneous samples. Weight and height were used as growth parameters in 2 studies; 2 studies used body mass index (BMI); and the remaining 2 used indexes of nutritional status derived from anthropometric measures. The studies showed discrepancies among results: 3 of them found growth differences between children with CLP and their counterparts, whereas the other 3 did not. The two longitudinal studies did not show any significant differences between the mean BMI z-scores or growth curves of cleft patients and their counterparts. When differences existed, the most affected group was that under 5 years, syndromic children, and adopted children with CL/P. Conclusions: the literature is scarce comparing growth patterns between children with CLP and controls, and results cannot confirm that children with CLP aged 2-10 years, excluding those with syndromes or belonging to vulnerable populations, have different growth patterns or a worse nutritional status than their counterparts.

Malnutrition as a Risk Factor in Cleft Lip and Palate Surgery

OBJECTIVES/HYPOTHESIS

To assess the prevalence of acute and chronic malnutrition at the time of surgery in patients with cleft lip and/or palate (CLP) at our institution, and to quantify nutrition as a risk factor for postsurgical complications following CLP surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective review of 855 children undergoing initial cleft lip or palate surgery, or revision surgery after fistula/dehiscence of initial cleft repair. We measured acute and chronic malnutrition using World Health Organization Z-scores of weight-for-age and height-for-age, respectively, and noted any postsurgical fistula or dehiscence.

RESULTS

Among patients with cleft lip, 22.3% were at least moderately chronically malnourished at the time of initial repair, and 17.5% were at least moderately acutely malnourished. Among patients undergoing initial repair of cleft palate, 20.9% were at least moderately chronically malnourished, and 8.1% were at least moderately acutely malnourished. Increasing nutritional status, as measured by height-for-age, predicts decreased odds of fistula (OR 0.78, P = .01) after cleft palate surgery.

CONCLUSIONS

Chronic malnutrition significantly increases the risk of fistula formation in patient with cleft palate. Preoperative strategies to manage this risk and influence surgical timing can avoid morbid and costly postoperative complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2060-E2065, 2021.

The Effect of Nursing Care Provided to Turkish Mothers of Infants Born With Cleft Lip and Palate on Maternal Attachment and Self-efficacy: A Quasi-Experimental Study

PURPOSE

The present study evaluated the effect of the nursing care provided to the mothers of the infants born with a cleft lip and palate (CLP) until the time of cleft palate (CP) repair surgery, on maternal attachment and self-efficacy.

DESIGN AND METHODS

The present study was designed as a quasi-experimental study with a pre-test and post-test control group design. The study included 32 mothers whose infants were born with CLP and had undergone CL repair surgery. Nursing care was provided to the mothers and the infants included in the study group through a total of seven home visits over a period of nine weeks. The data for the study were collected using a socio-demographic form, a home-care needs evaluation form, the Maternal Attachment Inventory (MAI), and the Parental Self-Efficacy Scale (PSE).

RESULTS

The scores for the mothers in the intervention group increased as the visits progressed, and it was observed that by the end of the ninth week, the difference between the mothers in the intervention group and those in the control group in terms of post-test MAI and PSE had become statistically significant.

CONCLUSIONS

Providing nine weeks of home-based nursing care to the mothers and the infants has the potential of reducing the problems experienced by the mothers of infants born with CLP.

PRACTICE IMPLICATIONS

Obtaining a better understanding of the barriers to the nursing care provided to the mothers of the infants born with CLP in-home setting would contribute immensely to the development of appropriate nursing-care practices.

Prevalence of Stunting in Syrian Refugee Children With Cleft Lip and/or Cleft Palate in Time of Crisis: A Call for Intervention

OBJECTIVE

Our study aims to compare the prevalence of stunted growth in Syrian refugee children with cleft lip and/or palate (CL±CP) to other children with CL±CP of similar socioeconomic status.

DESIGN

A retrospective medical chart review.

SETTING

Center for Cleft and Craniofacial Surgery at a tertiary care hospital in Lebanon in the period between January 2013 and May 2019.

PATIENTS, PARTICIPANTS

One hundred three Syrian refugee children and 70 Lebanese children <18 years of low socioeconomic status who have CL, CP, or both.

INTERVENTIONS

These patients underwent cleft repair surgeries at our center.

MAIN OUTCOME MEASURE(S)

Stunted growth measured by calculating the height-for-age z-score (HAZ).

RESULTS

Using a confidence interval of 95%, the prevalence of stunting is significantly higher among Syrian refugees (P < .003). The prevalence of stunting and age of presentation were positively correlated (P < .02). There was no difference in stunting between patients with CP and CL (P < .746). There was no difference in stunting between genders.

CONCLUSIONS

The majority of Syrian refugee patients with CL±CP fall on the malnourished side of the nutritional spectrum as reflected by the high percentage of stunting as well as a mean of -1 for the HAZ.

Weight Gain in Infants With Pierre Robin Sequence in the First Year of Life

OBJECTIVE

To compare growth trends among infants with Pierre Robin sequence (PRS) to normal World Health Organization (WHO) growth standards.

STUDY DESIGN

Case series with chart review.

SUBJECTS AND METHODS

Twenty-four infants with syndromic and nonsyndromic PRS (54% male) treated at an urban academic medical center between 2009 and 2017 were included. Infants with symptomatic hypoventilation underwent mandibular distraction osteogenesis (71%). Weights were recorded at roughly 1- to 3-month intervals from birth to 12 months, with ages adjusted for prematurity. The 50th percentile (P50) for this cohort was calculated and compared to WHO standards.

RESULTS

In total, 135 weight entries for 24 subjects were included. The birth weight P50 was similar to the WHO standard (females: 0.09 kg above WHO [95% CI, -0.25 to +0.43; z score = 0.19]; males: 0.38 kg below WHO [95% CI, -0.77 to 0.00; z score = -0.79]). A slower growth rate was noted among female and male infants with PRS: in month 5, the PRS P50 among females was 1.42 kg below the WHO standard (95% CI, -1.77 to -1.07; z score = -1.64). Among males in month 3, the PRS P50 was 1.68 kg below the WHO standard (95% CI, -2.12 to -1.24; z score = -2.19). By month 12, weight deficiencies had resolved in both groups.

CONCLUSION

Newborns with and without PRS may have similar birth weights, but the growth rate among male and female infants with PRS may lag behind that of unaffected infants, even when upper airway obstruction has been addressed in early infancy.

Physical Growth Status and Feeding Methods of Chinese Infants With Cleft Lip With or Without Cleft Palate Under 1 Year of Age

Objectives: Malnutrition is a characteristic feature of cleft lip with or without palate (CL/P). This study aims to retrospectively quantify the physical growth status, evaluate the feeding methods, and identify the possible correlation of CL/P types with growth failure. Methods: The length and weight of 508 infants with CL/P and 118 healthy infants were recorded at the date of admission. The weight-for-age (W/A), length-for-age (L/A), and body mass index-for-age (BMI) of the infants were calculated. Results: The L/A values were significantly lower in the infants with cleft lip (CL, 123 cases) and cleft lip with palate (CLP, 122 cases) than those of the control infants (p < 0.01). The W/A values of the infants with CP (263 cases) and CLP were significantly lower than those of the control infants (p < 0.05). However, the BMI index was not significantly different between any of the studied groups and the controls. In the mixed feeding group, the infants with CL and CP showed significantly lower L/A (p < 0.05) and W/A (p < 0.05), respectively. Conclusion: Physical growth issues were more common in the infants with CP and CLP. Because this was a retrospective study, the foods supplied to the patients were not strictly uniform, therefore, a prospective study with unified food supplement may be needed to confirm these findings.

Body Mass Index and Association With Caries in School-Aged Children With Orofacial Cleft: A Case-Control Study

OBJECTIVE

Data on the association between body mass index (BMI) and dental caries in children with orofacial clefts are sparse. Therefore, studies on the impact of BMI on caries frequency in children with cleft lip and/or palate (CL/P) are of importance. The aim of the current study was to investigate the association between BMI and frequency of dental caries in children with and without CL/P. Height, weight, and BMI in children with CL/P were also compared to controls.

DESIGN

This study used a cross-sectional case-control design.

PARTICIPANTS

One hundred and thirty-nine 5- and 10-year-old children with CL/P and 299 age-matched controls.

MAIN OUTCOME MEASURES

Caries was recorded according to the International Caries Detection and Assessment System. Height and weight were recorded, and BMI was calculated as weight/height².

RESULTS

There was no correlation between BMI and caries frequency. Weight, height, and BMI were significantly lower in all children with CL/P compared to controls. After adjustment for international adoption, only BMI was significantly lower in CL/P children compared to controls. Non-adopted children with CL/P were significantly heavier and longer than adopted children with CL/P.

CONCLUSIONS

Five- and 10-year-old children with corrected CL/P seemed to have a lower BMI than controls, but there was no association between BMI and caries frequency. Internationally adopted children with CL/P were lighter and shorter than non-adopted CL/P children and controls.

Early Weight Gain in Infants With Cleft Lip and Palate Treated With and Without Nasoalveolar Molding: A Retrospective Study

OBJECTIVE

To assess weight gain of infants with cleft lip and/or palate (CL ± P) treated with nasoalveolar molding (NAM).

DESIGN

Retrospective, case-control chart review.

SETTING

Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.

PATIENTS, PARTICIPANTS

Infants with nonsyndromic CL ± P and noncleft controls.

INTERVENTIONS

Prior to primary lip surgery, NAM was either included (+NAM) or not included (-NAM) in the cleft treatment protocol.

MAIN OUTCOME MEASURE(S)

Weight gain and percentage weight gain relative to initial weight were compared among +NAM, -NAM, and control groups from birth to 7 months and from birth to 36 months.

RESULTS

Comparing +NAM and -NAM groups, no significant difference in weight or percentage weight gain was found in either time window. Compared to controls, from birth to 7 months, both CL ± P groups weighed less (P < .001), while percentage weight gain was greater for the +NAM (P < .001) and did not differ for -NAM. From birth to 36 months relative to controls, weight for +NAM showed no significant difference and -NAM weighed less (P < .01), while percentage weight gain was greater for both CL ± P groups (P < .001).

CONCLUSIONS

Comparisons of CL ± P infants treated with and without NAM showed that with the NAM appliance, despite its added complexity, there was no adverse impact on weight gain. Comparisons to noncleft, control infants suggests that NAM treatment may have a beneficial impact on weight gain.

Extraintestinal manifestations of celiac disease: 33-mer gliadin binding to glutamate receptor GRINA as a new explanation

We propose a biochemical mechanism for celiac disease and non-celiac gluten sensitivity that may rationalize many of the extradigestive disorders not explained by the current immunogenetic model. Our hypothesis is based on the homology between the 33-mer gliadin peptide and a component of the NMDA glutamate receptor ion channel - the human GRINA protein - using BLASTP software. Based on this homology the 33-mer may act as a natural antagonist interfering with the normal interactions of GRINA and its partners. The theory is supported by numerous independent data from the literature, and provides a mechanistic link with otherwise unrelated disorders, such as cleft lip and palate, thyroid dysfunction, restless legs syndrome, depression, ataxia, hearing loss, fibromyalgia, dermatitis herpetiformis, schizophrenia, toxoplasmosis, anemia, osteopenia, Fabry disease, Barret's adenocarcinoma, neuroblastoma, urinary incontinence, recurrent miscarriage, cardiac anomalies, reduced risk of breast cancer, stiff person syndrome, etc. The hypothesis also anticipates better animal models, and has the potential to open new avenues of research.