A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.

METHOD

Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.

RESULTS

Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.

CONCLUSION

The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.

TRIAL REGISTRATION

ISRCTN29932826.

Attention to infants in the first year

The time spent by 158 infants in contact with their carers at 6, 13, 26 and 52 weeks was reviewed prospectively. Periods of contact in the categories of (1) physical care, (2) holding the crying or sleeping infant, and (3) playing and interacting with the infant were recorded using 24-h log diaries completed by the mother. The mean total carer contact time over a 24-h day did not change significantly in the first year, varying between 6.5 and 73 h. Between 6 and 52 weeks, time spent by the mother in physical care declined significantly from 207 to 143 min and in holding the crying or sleeping infant from 61 to 17 min (P < 0.05 and 0.0001 respectively). There were no significant changes in the amount of time spent in playing and interacting with the infant over the first year by the mother and father, the time being on average 52.7 and 25.0 min respectively. Play and interaction with a non-parental carer increased significantly from 14 to 69 min (P < 0.0001). Relationships between infant size and holding became weaker as the infant became older. Infant gender, socioeconomic status and duration of breast-feeding did not influence infant contact time.

Assisted feeding is more reliable for infants with clefts--a randomized trial

OBJECTIVE

To compare the effectiveness of squeezable and rigid feeding bottles for infants with clefts.

DESIGN

Patients were randomly assigned at birth to feeding with a squeezable bottle (assisted feeding) or to feeding with a rigid bottle and were followed for 1 year. The data were analyzed on the basis of intention to treat.

SETTING

The trial was conducted within the existing arrangements for hospital and home care for children with clefts within the National Health Service in the north of England.

PATIENTS

The patients were 101 consecutively born children with cleft lip and/or palate who were otherwise healthy. All patients completed the trial. Two were excluded from the analysis when unrelated developmental problems became apparent.

MAIN OUTCOME MEASURES

Anthropometric measures-nude weight, crown-heel length (CHL), and occipito-frontal circumference (OFC)-were recorded.

RESULTS

There were statistically significant differences between the two groups in weight at 12 months (p = .038, with an adjusted mean difference of 0.43 kg) and in head circumference (p = .004 with an adjusted mean difference of 0.77 cm), indicating increased growth in the squeezable bottle group. The difference in CHL was not significant at conventional levels (p = .082). Whereas 25 of 52 (48%) rigid bottles required modification by the health visitor, this was needed for only 4 of 49 (8%) squeezable bottles. There was a highly significant difference when numbers of modifications for each method were compared (p < .0001). Despite modifications, six infants feeding with a rigid bottle (11%) were transferred to a squeezable bottle due to problems with feeding, but none were transferred from squeezable to rigid bottles. Thus, the squeezable bottle generally appeared to be a more satisfactory method, requiring less support or intervention after initial instruction.

CONCLUSIONS

Both feeding methods achieved similar anthropometric outcomes, with a beneficial effect on head circumference and weight in the assisted feeding group. We recommend that this last observation be treated with caution. The squeezable bottles were easier to use, and we recommend that they be routinely prescribed.

Fetal and postnatal growth to age 2 years by mother's country of birth

The objective of this study was to measure the physical growth of fetuses and infants in an inner city health district in the north of England and to compare their growth profiles according to mother's country of birth (British Isles or Indian subcontinent). The study was part of the Central Manchester Child Growth Project, a prospective longitudinal study of fetal and postnatal growth and development in a sample from the geographically-defined Central Manchester Health District. Data were collected from the beginning of the second trimester of pregnancy to the age of 2 years. One-hundred seventy-four singleton infants born at term ( > or = 37 weeks) had serial antenatal cephalometry every 3 weeks from the beginning of the second trimester and had serial head, length and weight measurements at birth and at the ages of 6, 13, 26, 52 and 104 weeks. Infants of Indian-born mothers tended to be lighter at birth than those of locally-born mothers, but the difference was not due to lower accumulation of soft tissue. Body length from 6 to 52 weeks in both groups of infants was similar. The major finding was the reduced head size in infants of Indian-born mothers, the difference being significant among boys, evident from mid-pregnancy and persisting postnatally to age 2 years. Reduced fetal growth is associated with the development of cardiovascular disease in adulthood, mortality from ischaemic heart disease being specifically linked with head size at birth. The reduced head size of boys of Indian-born mothers is of interest because male immigrants from the Indian subcontinent who live in England have an increased incidence of non-insulin dependent diabetes and a substantial excess mortality (standardised mortality ratio 313 at ages 20-29) from ischaemic heart disease.

Duration and pattern of crying in the first year of life

In a prospective study of fetal and postnatal growth and development in a group of babies whose mothers were residents of an inner-city health district in the north of England, the total amount of crying of 157 infants was recorded at four periods during the first year of life by means of a 24-hour log. The mean number of crying episodes reduced from 4.4 at six weeks to 1.5 at one year. Early crying predicted later crying. It was not possible to predict which babies would cry a lot except that breast-fed infants tended to cry less. Mothers' perceptions of whether their babies cried a lot correlated with their perception of sleep difficulties. Rapid response to crying was associated with significantly less crying overall.

Sleep in the first year of life

The sleep patterns of 174 infants were recorded on one typical day at six, 13, 26 and 52 weeks of age, using a 24-hour log. During the first year of life the number of episodes of sleep was reduced by about 50 per cent, but total sleep time was reduced by only two hours. A circadian rhythm was established by six weeks of age. Smaller infants slept more than larger ones in the first months of life. Sex or birth-order of the child did not affect the duration or number of sleep episodes, but sleep pattern related significantly to whether or not mothers found their infants difficult to feed. Introduction of weaning food at an early stage reduced the number of sleep episodes, but increased the average length of each episode. Socio-economic status showed no significant relationship with number of episodes or total length of sleep.