Should left- and right-sided unilateral cleft lip and palate patients be grouped together when reporting the outcomes?

OBJECTIVES

Investigate associations between cleft laterality in patients with non-syndromic unilateral cleft lip and palate (UCLP) and oral-health, dental-arch, speech, audiological, psychological and nasolabial-aesthetic outcomes.

METHODS

Secondary data analysis of the outcomes of 5-year-old children with non-syndromic complete UCLP identified from three studies: Cleft Collective (n = 155), Cleft Care UK (CCUK) (n = 266) and Clinical Standards Advisory Group (CSAG) study (n = 238). Outcome measures included occlusal assessment using the 5-year-old's index score, speech intelligibility rating using the CAPS-A Audit tool, audiological assessment using pure tone audiometry, nasolabial aesthetic assessment using the Asher-McDade tool, oral-health assessment using decayed, missing, filled teeth scores and parent-reported outcomes. Logistic regression with adjustment for age, sex and index-of-multiple-deprivation scores were performed.

RESULTS

No differences were found in patient-reported outcomes between the left and right clefts in the Cleft Collective study. From the CCUK study, right clefts had poorer speech (n = 236; 95% CI 1.09, 3.42; and P = .03) and hearing outcomes (n = 211; 95% CI 1.03, 3.43; P = .04). In the CSAG study, patients with left clefts were more likely to be teased (n = 213; 95% CI 0.26, 0.85; and P = .01).

CONCLUSION

Weak associations between cleft laterality, speech, hearing and psychological outcomes were found, however the findings were inconsistent across the studies. This study contributes to evidence of associations between laterality and outcomes in children born with UCLP.

Outcome measures for children with speech sound disorder: an umbrella review

OBJECTIVE

Speech sound disorder (SSD) describes a 'persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication'. There is a need to establish which care pathways are most effective and efficient for children with SSD. Comparison of care pathways requires clearly defined, evidence-based, interventions and agreement on how to measure the outcomes. At present, no definitive list of assessments, interventions or outcomes exists. The objective of this umbrella review paper is to provide a rigorous and detailed list of assessments, interventions and outcomes which target SSD in children.

DESIGN

In December 2022, a systematic search of Ovid Medline, OVID Embase, CINAHL, PsycInfo and Cochrane and a number of grey literature platforms were undertaken. 18 reviews were included, and subsequently 415 primary research articles were assessed for data related to assessments, interventions or outcomes. The AMSTAR (Assessing the Methodological Quality of Systematic Reviews) framework was used to assess the quality of the retained reviews.

SETTING

Reviews were retained which took place in any setting.

PARTICIPANTS

The population is children of any age with a diagnosis of SSD of unknown origin.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reviews reporting outcomes, assessment and interventions for children with SSD.

RESULTS

Extraction and analysis identified 37 assessments, 46 interventions and 30 outcome measures used in research reporting of SSD. Not all of the listed outcomes were linked to specific outcome measurement tools, but these were measurable through the use of one or more of the assessments extracted from the retained reviews.

CONCLUSIONS

The findings of this review will be used to develop a Core Outcome Set for children with SSD. The findings are part of a rigorous process essential for advancing healthcare research and practice in the specific area of speech and language therapy for children with SSD.

PROSPERO REGISTRATION NUMBER

CRD42022316284.

Association of Perioperative Antibiotics with the Prevention of Postoperative Fistula after Cleft Palate Repair

Background

There is debate amongst surgeons regarding the use of antibiotics to prevent fistulae after palatoplasty. Prescribing should be evidence based, as antibiotic stewardship is integral to reducing antibiotic resistance. Our aim was to determine whether differing perioperative regimens affect the prevalence of postoperative fistulae.

Methods

The sample comprised participants from the Cleft Collective who had undergone palatoplasty. Participants were recruited across all 16 UK cleft centers between 2013 and 2021. The exposure was perioperative antibiotic regimen prescribed at the time of palatoplasty. The primary outcome was the presence of palatal fistula.

Results

Fistula data were available for 167 participants when exploring antibiotic regimen and for 159 when exploring antibiotic agent. There was no evidence to suggest a difference in fistula rate between those receiving antibiotics on induction only versus as an inpatient or up to 7 days postoperatively (χ2 = 4.57; P = 0.10). There was no evidence to suggest a difference in fistula rate between those who received co-amoxiclav and those who had an alternative antibiotic (χ2 = 0.16; P = 0.69). Postoperative fistulae increased with the extent of the cleft (χ2 = 20.39; P < 0.001). When adjusting for cleft type, no evidence of an association between antibiotic regimen and fistulae was found (inpatient antibiotics: OR 1.36; 95% confidence interval, 0.53-3.51; antibiotics up to 7 days postoperatively: OR 0.68; 95% confidence interval, 0.26-1.80).

Conclusions

The choice of antibiotic and dosing regimen does not influence the formation of postoperative fistulae. These results should be supported by interventional trials.

Prevalence and Factors Associated with Behavioral Problems in 5-Year-Old Children Born with Cleft Lip and/or Palate from the Cleft Collective

OBJECTIVES

To determine the UK prevalence of behavioral problems in 5-year-old children born with isolated or syndromic cleft lip and/or palate (CL/P) compared to the general population and identify potentially associated factors.

DESIGN

Observational study using questionnaire data from the Cleft Collective 5-Year-Old Cohort study and three general population samples.

MAIN OUTCOME MEASURE

The Strengths and Difficulties Questionnaire (SDQ).

PARTICIPANTS

Mothers of children (age: 4.9-6.8 years) born with CL/P (n  =  325). UK general population cohorts for SDQ scores were: Millennium Cohort Study (MCS) (n  =  12  511), Office of National Statistics (ONS) normative school-age SDQ data (n  =  5855), and Avon Longitudinal Study of Parents and Children (ALSPAC) (n  =  9386).

RESULTS

By maternal report, 14.2% of children born with CL/P were above clinical cut-off for behavioral problems, which was more likely than in general population samples: 7.5% of MCS (OR  =  2.05 [1.49-2.82], P < 0.001), 9.8% of ONS (OR  =  1.52 [1.10-2.09], P  =  0.008), and 6.6% of ALSPAC (OR  =  2.34 [1.70-3.24], P < 0.001). Children in the Cleft Collective had higher odds for hyperactivity, emotional and peer problems, and less prosocial behaviors. Maternal stress, lower maternal health-related quality of life and family functioning, receiving government income support, and maternal smoking showed evidence of association (OR range: 4.41-10.13) with behavioral problems, along with maternal relationship status, younger age, and lower education (OR range: 2.34-3.73).

CONCLUSIONS

Findings suggest elevated levels of behavioral problems in children born with CL/P compared to the general population with several associated maternal factors similar to the general population.

Speech sound disorder or DLD (phonology)? Towards a consensus agreement on terminology

BACKGROUND

The publication of phase 2 of the CATALISE project in 2017 clarified terminology for children with developmental language disorder (DLD) or delay but unintentionally muddied the water for children with unintelligible speech. A diagnostic label of DLD (phonology) indicates poor prognosis and phonological disorder that persists into middle childhood. However, in contrast to other diagnostic labels that fall under the overarching term of speech sound disorder (SSD), DLD (phonology) does not elucidate the characteristics of the child's speech nor does it point us in the direction of appropriate intervention.

AIMS

The aim of this paper is to discuss terminology in SSD leading to an evidence-based model which builds on the model of DLD developed in CATALISE, supports descriptive diagnosis and signposts intervention.

METHODS

Following a focused review of literature proposing or describing terminology for SSD, an expert group of researchers in developmental SSD proposed a revised model of existing terminology. Groups of UK speech and language therapists (SLTs) who provide services for children with SSD were asked to comment on its acceptability and feasibility.

DISCUSSION

A three-level terminology model was developed. This comprised an overarching Level 1 term; Level 2 terms that differentiated SSD of unknown origin from SSD with associated or underlying conditions; and specific diagnostic terms at Level 3 to support further assessment and intervention decisions. Consulted SLTs generally expressed agreement with the proposed terminology and a willingness to adopt it in practice.

CONCLUSIONS

Existing terminology for childhood SSD provides a good basis for clinical decision-making. A modified version of Dodd's (2005) terminology was found to be acceptable to UK SLTs. There is an evident overlap of SSD with CATALISE terminology. However more detailed and specialist terminology than 'DLD (phonology)' is required to support clinical decision-making. It is proposed that endorsement by the UK Royal College of Speech and Language Therapists would obviate the need for a Delphi process.

WHAT THIS PAPER ADDS

What is already known on this subject Over nearly a hundred years, as our knowledge and understanding of speech sound disorder (SSD) has increased, so has the terminology that is used to describe those disorders. Current terminology not only describes subtypes of SSD but can also signpost us to effective interventions. With the publication, in 2017, of phase 2 of CATALISE a new term of 'developmental language disorder (DLD) (phonology)' was introduced with the unintentional consequence of challenging more specific descriptive terms for SSD. What this paper adds In the context of CATALISE and DLD (phonology), the history and nature of SSD terminology are reappraised. Building on the model of DLD developed in CATALISE, a tiered model that supports descriptive diagnosis and signposts intervention is proposed for discussion. Clinical implications of this study The proposed model of terminology for SSD provides descriptive and detailed labels that will support accuracy in differential diagnosis of developmental SSD by speech and language therapists. Furthermore, a decision-making tree for SSD demonstrates the pathway from diagnostic use of the terminology to the selection of evidence-based, effective interventions.

Patient Factors Influencing Speech Outcomes in Velopharyngeal Function Following Initial Cleft Palate Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

Identification of patient factors influencing velopharyngeal function for speech following initial cleft palate repair.

DESIGN

A literature search of relevant databases from inception until 2018 was performed using medical subject headings and keywords related to cleft palate, palatoplasty and speech assessment. Following three stage screening data extraction was performed.

SETTING

Systematic review and meta-analysis of relevant literature.

PATIENTS/PARTICIPANTS

Three hundred and eighty-three studies met the inclusion criteria, comprising data on 47 658 participants.

INTERVENTIONS

Individuals undergoing initial palatoplasty.

MAIN OUTCOME MEASURES

Studies including participants undergoing initial cleft palate repair where the frequency of secondary speech surgery and/or velopharyngeal function for speech was recorded.

RESULTS

Patient factors reported included cleft phenotype (95% studies), biological sex (64%), syndrome diagnosis (44%), hearing loss (28%), developmental delay (16%), Robin Sequence (16%) and 22q11.2 microdeletion syndrome (11%). Meta-analysis provided strong evidence that rates of secondary surgery and velopharyngeal dysfunction varied according to cleft phenotype (Veau I best outcomes, Veau IV worst outcomes), Robin Sequence and syndrome diagnosis. There was no evidence that biological sex was associated with worse outcomes. Many studies were poor quality with minimal follow-up.

CONCLUSIONS

Meta-analysis demonstrated the association of certain patient factors with speech outcome, however the quality of the evidence was low. Uniform, prospective, multi-centre documentation of preoperative characteristics and speech outcomes is required to characterise risk factors for post-palatoplasty velopharyngeal insufficiency for speech.

SYSTEMATIC REVIEW REGISTRATION

Registered with PROSPERO CRD42017051624.

Exploring the Psychosocial Experiences of Individuals with Developmental Language Disorder During Childhood: A Qualitative Investigation

Children with Developmental Language Disorder (DLD) often experience co-occurring psychosocial difficulties, the developmental trajectories of which are still not fully understood. This study sought to explore the manifestation of such difficulties during childhood, through first-hand accounts of those with DLD and their close relatives. Individual semi-structured interviews were conducted with 11 mothers of children with DLD (aged 6-12 years old) and were analysed alongside the secondary data from interviews of five adults with DLD. Interviews were conducted online; all participants resided in Europe and were fluent in spoken and written English. A process of interpretive phenomenological analysis resulted in the development of five overall themes: experiencing anxiety, social frustrations, maintaining factors, childhood strengths and the parenting experience. Cognitive appraisals appeared particularly important during childhood in both escalating and maintaining anxiety, low self-esteem, emotion dysregulation and social frustrations. High levels of isolation and stress were experienced by all mothers. The findings suggest parents in the United Kingdom and Ireland require more support and guidance at the point of diagnosis than is currently provided. Emphasis was given to the link between children's experience of anxiety and social behaviours, such as withdrawal, as well as their intolerance of uncertainty. Internalising symptoms were a prioritisation for intervention during childhood by both parents and adults with DLD.

Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with Developmental Language Disorder

BACKGROUND

It is well-documented that children with Developmental Language Disorder (DLD) have a higher likelihood of experiencing anxiety, as well as other socio-emotional and behavioural (SEB) difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand the prevalence of broader SEB difficulties and anxiety, informing intervention development by understanding the relationships between them.

METHODS

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD ("DLD sample"; n = 57) or typically developing children ("typical sample"; n = 50), aged 6-12 years old. Binary SEB statements informed by previous qualitative work (e.g. "my child requires routine/sameness"; "my child has frequent tantrums") provided an insight into the prevalence of SEB difficulties in both DLD and typical samples. Validated measures of anxiety, emotion regulation, intolerance of uncertainty, insistence on sameness, family stress and coping mechanisms were also collected. Correlation and mediation analyses were run using these validated measures to understand the manifestation of anxiety in children with DLD in more detail. Qualitative interviews were then carried out with a select panel of survey respondents (n = 4).

RESULTS

The DLD sample scored significantly higher on all binary SEB statements than the typical sample: experiencing anxiety (80.7%, p < .05), requiring routine and sameness (75.4%, p < .001) and emotional dysregulation (75.4%; p < .001) were the most common difficulties reported for children with DLD. Using the validated scales, family stress and coping mechanisms were found to only correlate with the manifestation of anxiety in the typical group, not the DLD group. "Intolerance of uncertainty" and "insistence on sameness" were found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Parent's interviews provided contextual support for the analysis, as well as highlighting sensory sensitivities as a focus for future research.

CONCLUSIONS

Parents of children with DLD appear to cope well with their children's complex SEB needs. Intervention focussing on intolerance of uncertainty may help the management of difficulties with anxiety. Behaviours such as insistence on sameness should be investigated further, as potential indicators for anxiety amongst children with DLD.

The Association Between Atypical Speech Development and Adolescent Self-Harm

BACKGROUND

Adolescent self-harm is a major public health issue internationally. Various factors associated with adolescent self-harm have been identified, including being bullied and experiencing mental health problems. Stuttering and speech sound disorder are associated with both of these factors. It was hypothesized that both stuttering and speech sound disorder would be associated with self-harm. This is the first study to explore the relationship between communication disorders and adolescent self-harm.

METHOD

Secondary analysis of a large, longitudinal, prospective, community sample, the Avon Longitudinal Study of Parents and Children, was carried out. Clinicians identified children who stuttered or exhibited speech sound disorder at the age of 8 years. When the cohort members were 16 years old, they were asked to complete a questionnaire about self-harm. Multinomial logistic regression was used to examine the associations between stuttering and speech sound disorder and the self-harm outcomes, adjusting for other relevant factors.

RESULTS

Of 3,824 participants with data for both speech status and self-harm, 94 (2.5%; 95% confidence interval [CI; 2.0, 3.0]) stuttered at 8 years of age and 127 (3.3%; 95% CI [2.8, 3.9]) displayed speech sound disorder. Speech sound disorder at the age of 8 years was associated with self-harm with suicidal intent in both unadjusted and adjusted models. Differences between the adjusted and unadjusted models were small, suggesting that speech sound disorder is largely an independent risk factor for self-harm with suicidal intent. Stuttering at the age of 8 years was not associated with adolescent self-harm, and there was no association between speech sound disorder and self-harm without suicidal intent.

CONCLUSION

Compared with individuals without speech sound disorder, adolescents with speech sound disorder at the age of 8 years have twice the risk of reporting self-harm with suicidal intent, even when other important predictors are taken into account.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22573030.

The development of a digital story-retell elicitation and analysis tool through citizen science data collection, software development and machine learning

Background

In order to leverage the potential benefits of technology to speech and language therapy language assessment processes, large samples of naturalistic language data must be collected and analysed. These samples enable the development and testing of novel software applications with data relevant to their intended clinical application. However, the collection and analysis of such data can be costly and time-consuming. This paper describes the development of a novel application designed to elicit and analyse young children's story retell narratives to provide metrics regarding the child's use of grammatical structures (micro-structure) and story grammar (macro-structure elements). Key aspects for development were (1) methods to collect story retells, ensure accurate transcription and segmentation of utterances; (2) testing the reliability of the application to analyse micro-structure elements in children's story retells and (3) development of an algorithm to analyse narrative macro-structure elements.

Methods

A co-design process was used to design an app which would be used to gather story retell samples from children using mobile technology. A citizen science approach using mainstream marketing via online channels, the media and billboard ads was used to encourage participation from children across the United Kingdom. A stratified sampling framework was used to ensure a representative sample was obtained across age, gender and five bands of socio-economic disadvantage using partial postcodes and the relevant indices of deprivation. Trained Research Associates (RA) completed transcription and micro and macro-structure analysis of the language samples. Methods to improve transcriptions produced by automated speech recognition were developed to enable reliable analysis. RA micro-structure analyses were compared to those generated by the digital application to test its reliability using intra-class correlation (ICC). RA macro-structure analyses were used to train an algorithm to produce macro-structure metrics. Finally, results from the macro-structure algorithm were compared against a subset of RA macro-structure analyses not used in training to test its reliability using ICC.

Results

A total of 4,517 profiles were made in the app used in data collection and from these participants a final set of 599 were drawn which fulfilled the stratified sampling criteria. The story retells ranged from 35.66 s to 251.4 s in length and had word counts ranging from 37 to 496, with a mean of 148.29 words. ICC between the RA and application micro-structure analyses ranged from 0.213 to 1.0 with 41 out of a total of 44 comparisons reaching 'good' (0.70-0.90) or 'excellent' (>0.90) levels of reliability. ICC between the RA and application macro-structure features were completed for 85 samples not used in training the algorithm. ICC ranged from 0.5577 to 0.939 with 5 out of 7 metrics being 'good' or better.

Conclusion

Work to date has demonstrated the potential of semi-automated transcription and linguistic analyses to provide reliable, detailed and informative narrative language analysis for young children and for the use of citizen science based approaches using mobile technologies to collect representative and informative research data. Clinical evaluation of this new app is ongoing, so we do not yet have data documenting its developmental or clinical sensitivity and specificity.

Social, emotional and behavioural difficulties associated with persistent speech disorder in children: A prospective population study

Purpose

Social, emotional and behavioural difficulties (SEBD) in childhood are associated with negative consequences across the life course. Children with developmental language disorder have been identified as being at risk of developing SEBD but it is unclear whether a similar risk exists for children with speech sound disorder, a condition which impacts on children's ability to make themselves understood and has been shown to be associated with poor educational outcomes.

Methods

Participants were children who attended the 8-year-old clinic in the Avon Longitudinal Study of Parents and Children (N = 7390). Children with speech sound disorder that had persisted beyond the period of typical speech acquisition (persistent speech disorder [PSD]) at age 8 were identified from recordings and transcriptions of speech samples (N = 263). Parent-, teacher- and child-reported questionnaires and interviews including the Strengths and Difficulties Questionnaire, Short Moods and Feelings Questionnaire and measures for antisocial and risk-taking behaviour were used to provide outcome scores for SEBD at 10-14 years in a series of regression analyses.

Results

Following adjustment for biological sex, socio-economic status and Intelligence Quotient, children with PSD at age 8 were more likely to show peer problems at age 10-11 years compared with their peers, as reported by teachers and parents. Teachers were more likely to report problems with emotionality. Children with PSD were no more likely to report symptoms of depression than their peers. No associations were observed between PSD, risk of antisocial behaviour, trying alcohol at age 10 or smoking cigarettes at age 14.

Conclusions

Children with PSD may be at risk in terms of their peer relationships. This could impact on their wellbeing and, while not observed at this age, may lead to depressive symptoms in older childhood and adolescence. There is also the potential that these symptoms may impact on educational outcomes.

Outcome measures for children with speech sound disorder: an umbrella review protocol

INTRODUCTION

Speech sound disorder (SSD) describes a 'persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication'. There is a need to establish which care pathways are most effective and efficient for children with SSD. Comparison of care pathways requires clearly defined, evidence-based interventions and agreement on how to measure the outcomes. At present, no list of assessments, interventions or outcomes exists.The objective of this paper is to provide a rigorous and detailed protocol for an umbrella review of assessments, interventions and outcomes that target SSD in children. The protocol details the development of a search strategy and trial of an extraction tool.

METHODS AND ANALYSES

The umbrella review has been registered with PROSPERO (CRD42022316284). Papers included can use a review methodology of any sort but must include children of any age, with an SSD of unknown origin. In accordance with the Joanna Briggs Institute scoping review methods guidelines, an initial search of the Ovid Emcare and Ovid Medline databases was conducted. Following this, a final search strategy for these databases were produced. A draft extraction form was developed.

ETHICS AND DISSEMINATION

Ethical approval is not needed for an umbrella review protocol. Following the systematic development of an initial search strategy and extraction form, an umbrella review of this topic can take place. Dissemination of findings will be through peer-reviewed publications, social media, and patient and public engagement.

Syndromes associated with Robin sequence: a national prospective cohort study

OBJECTIVES

To determine the prevalence of syndromic Robin sequence (RS) in the UK and if this group of patients had an increased need for airway and feeding management compared with a non-syndromic RS cohort.

DESIGN

A prospective national multicentre study of cases submitted to the Cleft Collective cohort studies.

SETTING

Specialist cleft services in the UK.

PATIENTS

259 participants who fulfilled the diagnosis of RS. This group was compared with 548 participants with cleft palate only (CPO).

MAIN OUTCOME MEASURES

The primary outcome measure was the presence of a syndrome in patients with RS and CPO. Secondary outcome measures included the use of airway and feeding adjuncts.

RESULTS

An associated syndrome was seen in 28% of patients with RS and 14% of patients with CPO. The most common syndrome for the RS group was Stickler syndrome (27%). Syndromic status was significantly higher among patients with RS compared with those with CPO (OR 2.36, 95% CI 1.65 to 3.39; p<0.001). Patients with syndromic RS have an increased reliance on airway adjuncts compared with the patients without syndromic RS (OR 2.02, 95% CI 1.13 to 3.64; p=0.018). There was no evidence of a difference in the use of feeding adjuncts between syndromic and non-syndromic RS groups (OR 2.43, 95% CI 0.78 to 7.58; p=0.126).

CONCLUSION

The presence of a syndrome has implications for management of patients with RS. Early identification of a syndrome may help prevent the consequences of a missed syndromic diagnosis. Routine ophthalmological and genetic screening for Stickler syndrome should be mandatory for all patients with RS.

Parent/Caregiver Views of the Effectiveness of Speech-Language Pathology for Children Born With Cleft Palate Delivered via Telemedicine During COVID-19

PURPOSE

The purpose of this study was to describe and examine parent views of speech-language pathology (SLP) for children born with cleft palate delivered via telemedicine during the COVID-19 pandemic in the United Kingdom (UK).

METHOD

Parents were asked whether they found this method of delivery "very effective," "somewhat effective," or "not at all effective." Free text was then invited. There were 212 responses. Ordinal chi-square, Kruskal-Wallis, or Fisher's exact tests examined associations between parent views of effectiveness and biological variables and socioeconomic status. Free text responses were analyzed using qualitative content analysis.

RESULTS

One hundred and forty (66.0%) respondents reported that SLP delivered via telemedicine was "somewhat effective," 56 (26.4%) "very effective," and 16 (7.6%) "not at all effective." There was no evidence of an association between parent reported effectiveness and any of the explanatory variables. Parent-reported challenges impacting on effectiveness included technology issues and keeping their children engaged with sessions. Importantly, telemedicine was viewed as "better than nothing."

CONCLUSIONS

Most parents reported that they felt SLP delivered via telemedicine during the first few months of the COVID-19 pandemic in the UK was at least "somewhat effective." It is important to interpret this in the context of there being no other method of service delivery during this time and that this study only represents families who were able to access SLP delivered via telemedicine. Further work is needed to identify which children with cleft palate might benefit from SLP delivered via telemedicine to inform postpandemic service provision.

Current Surgical Practice for Children Born with a Cleft lip and/or Palate in the United Kingdom

OBJECTIVE

This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK).

DESIGN

Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires.

SETTING

Data were obtained from the Cleft Collective, a national longitudinal cohort study.

PATIENTS

Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children.

RESULTS

The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (P < .001) and a 5 to 7-day postoperative regime used more commonly for soft palatoplasties (P < .001). Perioperative steroids were used more commonly in palatoplasties than cheiloplasties (P < .001) but tranexamic acid use was equivalent (P = .73).

CONCLUSIONS

This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols.

Maternal Stressful Life Events During the Periconceptional Period and Orofacial Clefts: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess whether women who experience stressful life events during the periconceptional period are at higher risk of giving birth to a baby with an orofacial cleft (OFC).

DESIGN

Systematic review and meta-analysis of studies reporting the proportion of babies born with OFC to mothers exposed and unexposed to population-level or personal-level stressful life events during the periconceptional period. Six electronic databases were searched from inception to August 2020. Risk of bias was assessed using the Newcastle-Ottawa scale. Odds ratios (ORs) for the odds of OFC in babies of exposed mothers relative to unexposed controls were extracted and/or calculated. Random effects meta-analysis was undertaken, stratified by cleft subtype.

RESULTS

Of 12 eligible studies, 8 examined experience of personal events and 4 examined population-level events. Studies demonstrated low-moderate risk of bias and there was indication of publication bias. There was some evidence that personal stressful life events were associated with greater odds of cleft lip and/or palate (six studies, OR 1.63, 95% confidence interval (CI) 1.16, 2.30, P = 0.001) and cleft palate only (six studies, OR 1.45, 95% CI 1.02, 2.06, P = 0.04). Population-level events were associated with higher odds of OFC in studies that did not specify subtype (three studies, OR 1.64, 95% CI 1.19, 2.25, P = 0.002), but subtype stratified analyses were underpowered. Heterogeneity was high.

CONCLUSIONS

Limited evidence indicated a weak positive association between maternal stressful life events during the periconceptional period and risk of OFC in the offspring, but further studies with greater consistency in research design are needed.

A systematic review of early speech interventions for children with cleft palate

BACKGROUND

Children with cleft palate with or without cleft lip (CP±L) are at high risk of problems with early speech sound production, and these difficulties can persist into later childhood. Early intervention could help to reduce the number of children whose problems become persistent. However, much research in the field to date has focused on older children. There is a need to determine if providing intervention during the phase of early typical speech development leads to better outcomes.

AIMS

To review the evidence for the effectiveness of interventions targeting speech, delivered in the first 3 years of life for children with CP±L, and discuss factors such as intervention type, facilitator, dosage, outcome measures and the age of the child.

METHODS & PROCEDURES

The systematic review was registered with PROSPERO (CRD42019121964). Eight bibliographic databases including CINAHL and MEDLINE were searched in August 2018. Studies were included if participants received speech and language interventions before 37 months and if they reported outcomes for speech. Two reviewers independently completed inclusion reviews, quality analysis and data extraction.

OUTCOME & RESULTS

The review included seven papers: one pilot randomized controlled trial, one controlled trial, four cohort studies and one case series report. Interventions largely took a naturalistic approach, namely focused stimulation and milieu teaching. The findings provide preliminary support for naturalistic interventions and suggest that these interventions can be delivered by parents with suitable training. Studies included in the review provided low-strength evidence with variation in both the type of intervention, the manner of delivery and in the risk of bias in the designs used.

CONCLUSIONS & IMPLICATIONS

The papers included in this review suggest that early naturalistic interventions can have positive impacts on the speech development of children with CP±L. However, the reported methodological quality of the publications overall was weak, and the current evidence lacks clarity and specificity in terms of therapy technique, delivery and optimum age of delivery. Future research should use more robust methodological designs to determine whether early speech interventions are beneficial for children born with CP±L.

WHAT THIS PAPER ADDS

What is already known on the subject Children with CP±L show difficulties with early speech development and often have restricted speech sound inventories. They may reach the canonical babbling stage later than children without CP±L and studies have shown that 20% of children with CP±L have speech which is considered unintelligible or barely intelligible at age 5. It has been proposed that early intervention can lessen the impact of CP±L on speech development. However, currently, the evidence for early interventions for children with CP±L is limited, with the majority of studies focusing on children aged 3 years and older. What this paper adds to existing knowledge This paper reviews the evidence for different types of early interventions for speech provided to children born with CP±L and whether these interventions are effective in supporting speech sound development. In this review, early intervention is defined as intervention provided to children in the first 3 years of life. This review describes intervention approaches and how they are delivered for this population. What are the potential or actual clinical implications of this work? In the UK, children born with CP±L and their families are supported by National Health Service (NHS) services over a 20-year period and speech and language therapy sessions may take place over many weeks and months. If providing early intervention in the first 3 years of life is effective, there is the potential for improved speech outcomes in early childhood and a reduced burden of care on children, families and services. This review considers the evidence for early speech intervention for children with CP±L in the first 3 years of life and identifies areas for future research.

The Fluency Trust Residential Course for young people who stutter: A pragmatic feasibility study

INTRODUCTION

A feasibility study of The Fluency Trust Residential Course (FTRC) for adolescents who stutter was conducted. The study aimed to measure key areas of a feasibility trial, for example, recruitment and retention, outcome measure completion, outcome measure reliability, and acceptability of the intervention to inform future research into the FTRC.

METHODS

Quantitative and qualitative methods were used. Participants were 23 adolescents (12-17 years), 23 parents and 2 Speech-Language Pathologists (SLPs) from the FTRC. Data collection included: outcome measure collection via a pre-test post-test quasi-experimental design (including two baseline measures), intervention fidelity checklists, semi-structured interviews with adolescents to explore acceptability of the intervention and semi-structured interviews with SLPs to explore their experiences of research participation and views on a future trial.

RESULTS

Recruitment, retention and outcome measure completion levels were all 100%. Intervention fidelity was 95% and there were no adverse events. Outcome measures showed good test- re-test reliability: Progress Questionnaire Child Intraclass Correlation Coefficient (ICC) = 0.87 (95% CI = 0.69-0.94 sig< 0.001) and Progress Questionnaire Parent ICC = 0.88 (95% CI = 0.70-0.95 sig< 0.001). Descriptive statistics showed that group medians and means of all outcome measures shifted in a positive direction between pre and post-tests (9 weeks follow-up). Twenty-five percent of young people showed changes on the Progress Questionnaire Child that were above the minimal important difference. Seventy-five percent of parents showed changes on the Progress Questionnaire Parent that were above the minimal important difference. Acceptability of the intervention by adolescents was high. SLPs reported participation was manageable and they were pleased to be part of the research.

CONCLUSION

Quantitative and qualitative data suggest that a future definitive trial of the FTRC is indicated after additional development work and feasibility testing. Recommendations for further research are included.

The impact of changing cigarette smoking habits and smoke-free legislation on orofacial cleft incidence in the United Kingdom: Evidence from two time-series studies

BACKGROUND

Both active and passive cigarette smoking have previously been associated with orofacial cleft aetiology. We aimed to analyse the impact of declining active smoking prevalence and the implementation of smoke-free legislation on the incidence of children born with a cleft lip and/or palate within the United Kingdom.

METHODS AND FINDINGS

We conducted regression analysis using national administrative data in the United Kingdom between 2000-2018. The main outcome measure was orofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland. First, we conducted an ecological study with longitudinal time-series analysis using smoking prevalence data for females over 16 years of age. Second, we used a natural experiment design with interrupted time-series analysis to assess the impact of smoke-free legislation. Over the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2-16.2 in England, Wales and Northern Ireland and 13.4-18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (RR 0.92, 95%CI 0.85 to 0.99; P = 0.024) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation (RR 1.16, 95%CI 0.94 to 1.44; P = 0.173).

CONCLUSIONS

These two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.

Maternal Cigarette Smoking and Cleft Lip and Palate: A Systematic Review and Meta-Analysis

Objectives

A systematic review and meta-analysis to determine the association between active maternal smoking and cleft lip and palate etiology.

Data sources

Medline, Embase, Web of Science and the Cochrane Library from inception to November, 2020.

Study selection

Observational studies of cigarette smoking habits in pregnant women. Outcomes included cleft lip and/or palate, cleft lip  ±  palate and cleft palate only.

Data analysis

Publication bias analyses were performed and the Newcastle Ottawa scales were used to assess study quality. Fixed or random effect models were used in the meta-analysis, dependent on risk of statistical heterogeneity.

Results

Forty-five studies were eligible for inclusion of which 11 were cohort and 34 were case–control studies. Sixteen studies were of sufficient standard for inclusion in the meta-analysis. The summary odds ratio for the association between smoking and cleft lip and/or palate was 1.42 (95%CI 1.27-1.59) with a population attributable fraction of 4% (95%CI 3%-5%). There was limited evidence to show a dose–response effect of smoking.

Conclusions

This review reports a moderate association between maternal smoking and orofacial cleft but the overall quality of the conventional observational studies included was poor. There is a need for high quality and novel research strategies to further define the role of smoking in the etiology of cleft lip and palate.

Making the case for the collection of a minimal dataset for children with speech sound disorder

BACKGROUND

NHS case note data are a potential source of practice-based evidence which could be used to investigate the effectiveness of different interventions for individuals with a range of speech, language and communication needs. Consistency in pre- and post-intervention data as well as the collection of relevant variables would need to be demonstrated as a precursor to adopting this approach in future investigations of speech and language therapy intervention.

AIMS

To explore whether routine clinical data collection for children with speech sound disorder (SSD) could be a potential source for examining the effectiveness of intervention(s).

METHODS & PROCEDURES

We examined case notes from three UK NHS services, reviewing 174 sets of case notes and 234 blocks of therapy provided for school-age children with SSD.

MAIN CONTRIBUTION

We found there was significant variation in pre- and post-intervention data and variables collected by the services. The assessment data available in the case notes across all sites were insufficient to be used to compare the effectiveness of different interventions. Specific issues included lack of consistent reporting of pre- and post-intervention data, and use of a variety of both formal and informal assessment tools.

CONCLUSIONS & IMPLICATIONS

The case notes reviewed were from three sites and may not represent wider clinical practice, nevertheless the findings suggest the sample explored indicates the need for more consistent and contemporaneous collection of data for children with SSD to facilitate the investigation of different interventions in practice. Researchers should work with the clinical community to determine a minimal dataset that includes a core outcome set and potential variables. This should be feasible to collect in clinical practice and provide a dataset for future investigations of clinically relevant research questions. This would provide an invaluable resource to the clinical academic and research communities enabling research questions to be addressed that have the potential to lead to improved outcomes and more cost-effective services.

WHAT THIS PAPER ADDS

What is already known on the subject While there is some evidence for the efficacy of therapy for children with SSD, studies typically focus on very specific populations who meet strict selection criteria and take place in university clinics or laboratory-style settings which do not reflect typical clinical practice in the UK and elsewhere. An alternative approach to investigating the effectiveness of interventions would be to use NHS case note data. It is not clear from the existing literature whether case note data are sufficiently robust to facilitate such an analysis. What this paper adds to existing knowledge This study found that case note data, in particular assessment data, were highly variable across services and would be insufficient to compare different interventions for this population. Agreement on what should be included in a minimal dataset for children with SSD is required to maximize the potential for NHS clinical case notes to become a resource for future research. What are the actual or potential clinical implications of this work? This study indicates that current clinical practice in SLT for children with SSD is inconsistent with regards to the reporting of pre- and post-intervention assessment data and other important variables in case notes. We make the case for agreeing a minimal dataset with a need for clinicians to work with researchers to determine core outcomes and additional relevant data, which can be feasibly collected in clinical practice.

Exploring the relationship between conductive hearing loss and cleft speech characteristics in children born with cleft palate

BACKGROUND

Children with cleft palate are at high risk of both conductive hearing loss and cleft speech characteristics (CSCs) yet there is limited research to understand whether hearing loss impacts speech development in this population by contributing to the development of CSCs.

AIMS

This study used data from a large national cohort study in the UK (The Cleft Collective) to explore the relationship between those with a history of diagnosed hearing loss and presence of CSCs in children with cleft palate (+/- cleft lip) aged between 18 and 24 months.

METHOD

Speech and Language Therapists (SLTs) provided uniformed information from assessment for 123 participants who had been recruited to the Cleft Collective study. History of diagnosed hearing loss, intervention for hearing loss, and presence of CSCs were reported. A consonant inventory for each participant was completed. Statistical analysis of relationships between hearing loss and CSCs and analysis of consonant inventories was undertaken to provide information related to speech acquisition and its relationship with hearing.

RESULTS

There was a statistically significant relationship between history of diagnosed hearing loss and presence of CSCs (p < 0.05). Analysis of the consonant inventories highlighted that children with diagnosed hearing loss used fewer oral consonants compared to those with normal hearing (p < 0.05) CONCLUSION: This study provides some evidence that a conductive hearing loss can affect speech in children with cleft palate resulting in CSCs developing. Therefore, children with cleft palate should be closely monitored by audiology from birth to ensure that hearing is optimised for speech and language development. SLT services should also closely monitor the speech development of those children where a hearing loss has been identified, so that early intervention can be provided if appropriate. Continued data collection, with a large sample of children, will provide additional evidence regarding how this hearing loss is best managed. It will also allow increased knowledge of the long term impact of conductive hearing loss on speech development in children with cleft palate.

How many words make a sample? Determining the minimum number of word tokens needed in connected speech samples for child speech assessment

Connected speech (CS) is an important component of child speech assessment in both clinical practice and research. There is debate in the literature regarding what size sample of CS is required to facilitate reliable measures of speech output. The aim of this study was to identify the minimum number of word tokens required to obtain a reliable measure of CS across a range of measures. Participants were 776 5-year-olds from a longitudinal community population cohort study (Avon Longitudinal Study of Parents and Children, ALSPAC). Children's narratives from a story retell task were audio-recorded and phonetically transcribed. Automatic analysis of the transcribed speech samples was completed using an automated transcription and analysis system. Measures of speech performance extracted included: a range of profiles of percentage consonant correct; frequency of substitutions, omissions, distortions and additions (SODA); percentage of syllable and stress pattern matches; and a measure of whole word complexity (Phonological Mean Length of Utterance, pMLU). Statistical analyses compared these measures at different CS sample sizes in increments using averages and weighted moving averages, and investigated how measures performed between CS samples grouped into word tokens of at least 50, 75 and 100, and restricted to samples of 50-74, 75-99 and 100-125. Key findings showed that sample sizes of 75 word tokens and above showed minimal differences in most measures of speech output, suggesting that the minimum requirement for samples of CS is a word count of 75. The exception to this is in the case of pMLU and measures of substitutions and distortions when a word count of 100 is recommended.

Association between genes regulating neural pathways for quantitative traits of speech and language disorders

Speech sound disorders (SSD) manifest as difficulties in phonological memory and awareness, oral motor function, language, vocabulary, reading, and spelling. Families enriched for SSD are rare, and typically display a cluster of deficits. We conducted a genome-wide association study (GWAS) in 435 children from 148 families in the Cleveland Family Speech and Reading study (CFSRS), examining 16 variables representing 6 domains. Replication was conducted using the Avon Longitudinal Study of Parents and Children (ALSPAC). We identified 18 significant loci (combined p < 10-8) that we pursued bioinformatically. We prioritized 5 novel gene regions with likely functional repercussions on neural pathways, including those which colocalized with differentially methylated regions in our sample. Polygenic risk scores for receptive language, expressive vocabulary, phonological awareness, phonological memory, spelling, and reading decoding associated with increasing clinical severity. In summary, neural-genetic influence on SSD is primarily multigenic and acts on genomic regulatory elements, similar to other neurodevelopmental disorders.

Changes in the Transverse Dimension of the Maxillary Arch of 5-Year-Olds Born With UCLP Since the Introduction of Nationwide Guidance

Objective:

To determine whether the transverse dimensions of the maxillary arch of 5-year-old children with unilateral cleft lip and palate (UCLP) have changed following centralization of cleft services in the United Kingdom.

Design:

Retrospective cross-sectional study.

Setting:

Digital analysis of UCLP maxillary dental casts.

Participants:

All available maxillary dental casts from 5-year-old participants of the Clinical Standards Advisory Group (CSAG, N = 114) and Cleft Care UK (CCUK, N = 175) studies.

Interventions:

Quantitative measurements of the intercanine width (ICW), intermolar width (IMW), and the distance from the midline to the greater and lesser side canine (GC/LC) and greater side and lesser side second primary molar (GE/LE). Degree measurements of the greater and lesser arch form angles, arch length, anterior palatal depth (APD), and posterior palatal depth were also measured.

Main outcome:

Differences between the transverse dimensions of the maxillary arch for the CSAG and CCUK cohorts.

Results:

In 5 (ICW, IMW, LC, LE, and APD) of the 11 measurements, there was a statistically significant difference between the CSAG and CCUK cohorts. In all of these, the CCUK values were greater than CSAG.

Conclusions:

There have been small but positive improvements for the transverse maxillary dimensions since centralization of the UK cleft service.

Early Communication Behaviors in Infants With Cleft Palate With and Without Robin Sequence: A Preliminary Study

OBJECTIVE

To investigate the early communication behaviors in infants with nonsyndromic isolated cleft palate (iCP) and Robin sequence (RS).

DESIGN

Group comparison using parent report.

PARTICIPANTS

There were 106 participants included in this study. Two groups were selected from the UK Cleft Collective resource. Parents had completed the Language ENvironment Analysis Developmental Snapshot questionnaire when their child turned 13 months. There were 78 participants in the iCP group and 28 in the RS group.

MAIN OUTCOME MEASURE(S)

Total number of communication behaviors reported on the questionnaire. Subdomains for expressive and receptive language and social communication behaviors were also analyzed.

RESULTS

There were no statistically significant group differences. Parents of infants with RS reported fewer later communication behaviors compared to the iCP group. Infants in both groups had fewer communication behaviors compared to the normative sample. Across the whole sample, post hoc analysis revealed a significant correlation between severity of the cleft and social communication behaviors and expressive but not receptive language. Infants with a cleft of the hard and soft palate were more likely to be in the RS group (odds ratio: 7.04 [95% CI: 1.55-32.04]; P = .01).

CONCLUSIONS

Both groups reported similar levels of early communication. Some divergence of more complex language skills was seen, although there were no significant group differences. A relationship with the diagnosis of a cleft of the hard or soft palate with expressive language behaviors was found. Further study into the impact of cleft severity on early speech development and the relationship with later language skills is needed along with longitudinal follow-up of this population.

Speech input processing in children born with cleft palate: A systematic literature review with narrative synthesis

BACKGROUND

Speech development requires intact and adequately functioning oral anatomy and cognitive 'speech processing' skills. There is evidence that speech input processing skills are associated with speech output problems in children not born with a cleft. Children born with cleft palate ± lip (CP±L) are at high risk of developing disordered speech output. Less is known about their speech input processing skills and whether they are associated with cleft-related speech sound disorder (SSD).

AIMS

(1) To collate and evaluate studies reporting evidence regarding the speech input processing skills of children born with cleft palate in comparison with data from typically developing children or other comparison groups; and (2) to identify any available evidence regarding relationships between speech input processing skills and speech output in children born with CP±L.

METHODS & PROCEDURES

Potentially relevant studies published up to November 2019 were identified from the following databases: Medline via Ovid, Embase via Ovid, Cinahl via Ebscohost, PsycInfo via Ebscohost, BNI via ProQuest, AMED via Ovid, Cochrane Library and Scopus. Inclusion criteria were: peer-reviewed articles published in scientific journals, any design, published in English, participants born with a CP±L aged up to age 18 years who completed speech input processing assessments compared with normative data and/or a control or other comparison group. Critical Appraisal Skills Programme (CASP) checklists were used to quality appraise included studies.

OUTCOMES & RESULTS

Six studies were retained in the final review. There is some evidence that children born with CP±L perform less well than non-cleft controls on some speech input processing tasks and that specific input processing skills may be related to errors in the children's speech. Heterogeneity in relation to study groups and assessments used, as well as small sample sizes, limits generalization of findings.

CONCLUSION & IMPLICATIONS

There is limited evidence regarding the speech input processing skills of children born with CP±L. There are indications that children born with CP+/L may have difficulty in some aspects of speech input processing in comparison with children not born with a cleft, and that difficulties with some speech input processing tasks may be specific to errors in children's speech output. Further research is required to develop our understanding of these skills in this population and any associations with speech output.

WHAT THIS PAPER ADDS

What is already known on the subject Few studies have been published that examine aspects of speech input processing in children born with CP±L. Theoretical models of speech processing, and published studies, propose that speech input processing skills are associated with SSD in children who were not born with a cleft. However, it is less clear whether there is any association between speech input processing and cleft-related SSD. What this paper adds to existing knowledge This review systematically collates and evaluates the published, peer-reviewed evidence regarding speech input processing skills in children born with CP±L. The collated evidence indicates that some speech input processing skills differ between children with and without CP±L. There is some evidence, from a single study, that speech input processing of specific cleft speech characteristics (CSCs) may be associated with the presence of these CSCs in the speech output of some children born with CP±L. What are the potential or actual clinical implications of this work? While the evidence is currently limited, increasing our knowledge of speech input processing skills in children born with CP±L contributes to our clinical understanding of the nature of cleft-related SSD. The current evidence suggests that speech and language therapists should consider speech input processing skills when assessing children with cleft-related SSD to support intervention planning. Considering these skills in relation to literacy development in these children may also be important.

Exploring the Relationship Between Palatal Cleft Type and Width With the Use of Relieving Incisions in Primary Repair

OBJECTIVE

The mainstay of palatal repair in the United Kingdom is the intravelar veloplasty (IVVP). It is not always possible to align the oral mucosa in the midline to achieve tension-free repair. The addition of lateral relieving incisions may aid transposition of the oral mucosa to allow closure. The aim of this study was to explore cleft features that may predispose to a requirement for relieving incisions in order to allow palate closure.

DESIGN

We performed a national multiinstitutional retrospective study using data from the UK Cleft Collective cohort study.

PATIENTS

The study sample consisted of 474 patients who had undergone IVVP at the time of palatal closure across all 16 of the UK cleft units.

RESULTS

We found strong evidence for the requirement for relieving incisions in patients with an increased degree of clefting per the Veau classification (P < .001), increasing palatal soft-edge width (P < .001) and moderate evidence of an associated use in patients with Pierre Robin sequence (P = .015). Insufficient data were available to explore the relationship between intertuberosity distance and the presence of fistula formation with the use of relieving incisions.

CONCLUSIONS

The results of this study identify cleft features that increase the likelihood for requiring lateral relieving incisions to allow palatal closure. The degree to which the addition of relieving incisions to IVVP affects maxillary growth and speech outcomes is unknown. Further study is required to answer this important question.

Cleft lip/palate and educational attainment: cause, consequence or correlation? A Mendelian randomization study

BACKGROUND

Previous studies have found that children born with a non-syndromic orofacial cleft have lower-than-average educational attainment. Differences could be due to a genetic predisposition to low intelligence and academic performance, factors arising due to the cleft phenotype (such as social stigmatization, impaired speech/language development) or confounding by the prenatal environment. A clearer understanding of this mechanism will inform interventions to improve educational attainment in individuals born with a cleft, which could substantially improve their quality of life. We assessed evidence for the hypothesis that common variant genetic liability to non-syndromic cleft lip with or without cleft palate (nsCL/P) influences educational attainment.

METHODS

We performed a genome-wide association study (GWAS) meta-analysis of nsCL/P with 1692 nsCL/P cases and 4259 parental and unrelated controls. Using GWAS summary statistics, we performed Linkage Disequilibrium (LD)-score regression to estimate the genetic correlation between nsCL/P, educational attainment (GWAS n = 766 345) and intelligence (GWAS n = 257 828). We used two-sample Mendelian randomization to evaluate the causal effects of genetic liability to nsCL/P on educational attainment and intelligence.

RESULTS

There was limited evidence for shared genetic aetiology or causal relationships between nsCL/P and educational attainment [genetic correlation (rg) -0.05, 95% confidence interval (CI) -0.12 to 0.01, P 0.13; MR estimate (βMR) -0.002, 95% CI -0.009 to 0.006, P 0.679) or intelligence (rg -0.04, 95% CI -0.13 to 0.04, P 0.34; βMR -0.009, 95% CI -0.02 to 0.002, P 0.11).

CONCLUSIONS

Common variants are unlikely to predispose individuals born with nsCL/P to low educational attainment or intelligence. This is an important first step towards understanding the aetiology of low educational attainment in this group.

Educational outcomes associated with persistent speech disorder

BACKGROUND

Children with persistent speech disorder (PSD) are at higher risk of difficulties with literacy, with some evidence suggesting an association with poorer educational attainment. However, studies to date have either used small clinical samples, which exclude children who have not been referred to clinical services, or relied on parent-teacher report of children's speech development. There is a need for an inclusive study to investigate the impact of PSD on educational outcomes using a population-based sample and robust measures of speech development.

AIM

Using a large prospective UK population-based study-the Avon Longitudinal Study of Parents and Children (ALSPAC)-this study investigated: (1) how children identified with PSD at age 8 years perform on educational attainment tests at ages 10-11 and 13-14 years in comparison with children without PSD; and (2) whether children identified with PSD at age 8 years are more likely to receive a label of special educational needs (SEN) in secondary school.

METHODS & PROCEDURES

We examined the data for 263 children with PSD and 6399 controls who had speech assessed at age 8 years in a research clinic. Educational attainment was measured using data from English school standard attainment tests. Data on SEN categorization were obtained between 11 and 13 years of age. Children with PSD and controls were compared using regression analyses adjusted for biological sex, maternal age, verbal, performance and full-scale IQ.

OUTCOMES & RESULTS

Children with PSD at age 8 years were more likely to achieve lower attainment scores at ages 10-11 years in English and mathematics and across all three subjects of English, mathematics and science at ages 13-14 years after controlling for biological sex and maternal education; score below target levels for English at both time points after controlling for verbal IQ, and at ages 13-14 years after controlling for performance IQ; and receive a label of SEN (typically for the category of cognition and learning needs or communication and interaction needs) in secondary school.

CONCLUSIONS & IMPLICATIONS

PSD identified at age 8 years is associated with poor educational attainment at ages 10-11 and 13-14 years in the core subjects of English, mathematics and science. Children with PSD at age 8 years are more likely to be identified with SEN at ages 11-13 years, particularly cognition and learning needs, and communication and interaction needs. We need to be aware of the potential for the long-term impact of PSD on educational attainment in providing appropriate and effective support throughout school. What this paper adds What is already known on the subject Speech-sound disorder is associated with reading and spelling difficulties, with some evidence to suggest that PSD is associated with a higher risk of literacy difficulties. Limited evidence also suggests that speech-sound disorder may be associated with poorer educational attainment. However, studies to date have used small clinical samples or parent-teacher report of speech development and there is a need to determine whether the association is observed in larger and more inclusive population-based samples. What this paper adds to existing knowledge This prospective, longitudinal study of a large community-based sample of English children has shown that PSD is associated with poorer educational attainment at the end of primary school and at ages 13-14 years. Children with PSD are also more likely to be identified as having SEN in secondary school, especially communication and interaction needs but also including cognition and learning needs. What are the potential or actual clinical implications of this work? Understanding the long-term implications of PSD on educational attainment highlights the importance of ongoing monitoring and support to enable children to reach their potential throughout primary and secondary school. The identification of children with a history of PSD during transition to secondary school will enable effective support to be put in place. The intervention for children with PSD should involve close collaboration between speech and language therapists and education professionals.

Intelligibility in 3-Year-Olds With Cleft Lip and/or Palate Using the Intelligibility in Context Scale: Findings from the Cleft Collective Cohort Study

Objective:

To provide comparison data on the Intelligibility in Context Scale (ICS) for a sample of 3-year-old English-speaking children born with any cleft type.

Design:

Questionnaire data from the Cleft Collective Cohort Study were used. Descriptive and inferential statistics were carried out to determine difference according to children’s cleft type and syndromic status.

Participants:

A total of 412 children born with cleft lip and/or palate whose mothers had completed the ICS when their child was 3 years old.

Main Outcome Measure(s):

Mothers’ rating of their children’s intelligibility using the ICS.

Results:

The average ICS score for the total sample was 3.75 ( sometimes-usually intelligible; standard deviation [SD] = 0.76, 95% CIs = 3.68-3.83) of a possible score of 5 ( always intelligible). Children’s speech was reported to be most intelligible to their mothers (mean = 4.33, SD = 0.61, 95% CIs = 4.27-4.39) and least intelligible to strangers (mean = 3.36, SD = 1.00, 95% CIs = 3.26-3.45). There was strong evidence ( P < .001) for a difference in intelligibility between children with cleft lip only (n = 104, mean = 4.13, SD = 0.62, 95% CIs = 4.01-4.25) and children with any form of cleft palate (n = 308, mean = 3.63, SD = 0.76, 95% CIs = 3.52-3.71). Children born with cleft palate with or without cleft lip and an identified syndrome were rated as less intelligible (n = 63, mean = 3.28, SD = 0.85, 95% CIs = 3.06-3.49) compared to children who did not have a syndrome (n = 245, mean = 3.72, SD = 0.71, 95% CIs = 3.63-3.81).

Conclusions:

These results provide preliminary comparative data for clinical services using the outcome measures recommended by the International Consortium for Health Outcomes Measurement.

Cleft lip and palate: Care configuration, national registration, and research strategies

A child born with a cleft lip and palate will face 20 years or more of hospital care and surgery. This is a global problem with approximately 10 million people affected worldwide. Various models of care exist around the condition, and the best configurations of services within an economy need to be optimized. We provide examples of how centralized care can improve outcomes and provide an opportunity to establish national registries, and then emphasize the opportunities for building research platforms of relevance. The default of any cleft service should be to centralize care and enable cleft teams with a sufficient volume of patients to develop proficiency and measure the quality of outcomes. The latter needs to be benchmarked against the better centers in Europe. Two areas of concern for those with cleft are morbidity/mortality and educational attainment. These two issues are placed in context within the literature and wider approaches using population genetics. Orthodontists have always played a key role in developing these initiatives and are core members of cleft teams with major responsibilities for these children and their families.

•

Cleft lip and palate affects about 10 million people worldwide.

•

Centralised care can improve outcome and establish national registries.

•

Orthodontists have played a key role in developing these initiatives.

•

No strong evidence of an association between clefting and cancer.

•

Proper care can positively influence lives of children born with a cleft.

Educational Attainment of Children Born with Unilateral Cleft Lip and Palate in the United Kingdom

Objective:

This study evaluated association between functional outcomes in children born with unilateral cleft lip and palate (UCLP) and educational attainment.

Design:

Cleft Care UK (CCUK) was a United Kingdom (UK) wide cross-sectional study.

Setting:

UK Cleft Teams (data collected from all UK sites providing centralized cleft services).

Patients, Participants:

Five-year olds born with nonsyndromic UCLP (n = 268).

Main Outcome Measure(s):

National tests for educational attainment Key Stage 1 (KS1) undertaken by children at age 7 were linked to CCUK data to describe differences in educational attainment. Associations between functional outcomes and KS1 results were evaluated using regression analysis. We adjusted for birth month, gender, and an area-based measure of socioeconomic status.

Results:

Data were available for 205 children with UCLP. These children scored lower than national average (NA) scores across all subject areas, with a 0.62 lower score observed in the Average Point Score (APS; P = .01). There was association between being in a lower category for a cleft related outcomes and poorer KS1 results, with a trend for poorer attainment with higher numbers of poor functional outcomes. Those with 3 or more poor outcomes had a −2.26 (−3.55 to −0.97) lower APS compared to those with 0 to 1 poor outcomes.

Conclusions:

Children born with UCLP have poorer educational attainment at age 7 across all subject areas though differences were modest. Children with poor functional outcomes at age 5 had worse educational outcomes age 7. Improvements in functional outcomes could enhance educational outcomes.

An Exploratory Study of Speech and Language Therapy Intervention for Children Born With Cleft Palate ± Lip

INTRODUCTION

Children born with a cleft palate ± lip are at risk of developing speech and language difficulties, which may require intervention from a speech and language therapist (SLT). To date, there is no strong evidence to support one approach to intervention over another, neither is it clear which approaches or methods of provision are commonly used.

OBJECTIVES

To describe the range of speech and language therapy interventions being used with children born with cleft palate in the United Kingdom up to 5 years of age. To explore the different ways, interventions are being delivered.

DESIGN

A prospective study to conduct 9 semi-structured focus groups. Iterative content analysis was completed.

SETTING

Regional Cleft Lip and Palate Centers in the United Kingdom.

PARTICIPANTS

Sixty-two speech and language therapy professionals from specialist cleft teams and community services.

RESULTS

Four main codes were identified: "intervention approaches," "service delivery models," "decision-making and rationale," and "patient-centered care." Participants frequently discussed how they adopt an eclectic style when delivering intervention, the importance of an individualized approach for each child and service delivery constraints, such as a lack of resources.

CONCLUSION

Insight into the multitude of intervention approaches used by SLTs, aspects which influence their decision-making and the variability of service delivery models were gained. Uncertainty regarding which intervention approaches and methods for delivery are most effective provides rationale for future research, to improve the effectiveness of speech and language intervention for children with cleft palate ± lip.

Linguistic comprehension and narrative skills predict reading ability: A 9-year longitudinal study

BACKGROUND

Linguistic comprehension and narrative skills encapsulate a complex array of grammatical and semantic skills that underpin complex reading comprehension processes. However, most research in this area has focused on children with reading difficulties and not on typically developing children. Also the research has mostly focused on short-term effects of these skills on reading during the primary school years. Therefore, it remains unclear what specific role linguistic comprehension and narrative skills play in typically developing children's reading beyond the primary school years.

AIMS

With this 9-year prospective longitudinal study, we sought to clarify the independent effects of linguistic comprehension and narrative skill (at 5 years of age) on children's reading ability at 10 and 14 years of age.

SAMPLE

We examined the data from 716 children (M_Age  = 67 months, SD = 2.13 months), which were drawn from a major population cohort study, the Avon Longitudinal Study of Parents and Children.

METHODS

Children's language skills were assessed at 5 and word reading and reading comprehension skills at 10 years of age. The reading achievement scores at 14 years of age were based on national curriculum test results.

RESULTS

Linguistic comprehension and narrative skills at 5 years of age made unique and direct contributions to reading comprehension skills and reading achievement after accounting for general cognitive ability, memory, phonological skills, and mother's education. Moreover, listening comprehension predicted reading achievement even when prior reading skills were taken into account.

CONCLUSIONS

Linguistic comprehension and narrative skills are related but distinct oral language skills that continue to influence children's reading development beyond the primary school years.

Non-Interventional Factors Influencing Velopharyngeal Function For Speech In Initial Cleft Palate Repair: A Systematic Review Protocol

BACKGROUND

This systematic review aims to inform the development of a screening tool which pre-operatively predicts which children are likely to develop velopharyngeal insufficiency, one of the causes of poor speech outcomes, following cleft palate repair. This would be highly beneficial as it would inform pre-operative counselling of parents, allow targeted speech and language therapy, and enable meaningful comparison of outcomes between surgeons, techniques, and institutions. Currently, it is unclear which factors influence speech outcomes. A systematic review investigating the non-interventional factors which potentially influence speech outcomes following cleft palate repair is warranted. This may be illuminating in itself or provide foundations for future studies.

METHODS

A systematic review will be carried out according to Cochrane methodology and reported according to PRISMA guidelines (PLoS Med 6: e1000097, 2009). Systematic review software will be used to facilitate three-stage screening by two independent reviewers experienced in cleft lip and palate. Thereafter, data extraction and GRADE assessment will be performed in duplicate by five independent reviewers experienced in cleft lip and palate. Studies reporting the proportion of patients who were recommended or underwent secondary speech surgery for velopharyngeal insufficiency following primary surgery for cleft palate will be included. The study findings will be tabulated and summarised. The primary outcome measure will be further speech surgery (either recommended or performed). The secondary outcome measure will be perceptual speech assessment for the presence of velopharyngeal insufficiency. A meta-analysis is planned. However, if this is not possible, due to the anticipated marked heterogeneity of study characteristics, pre-operative assessment, and the recorded outcome measures, a narrative synthesis will be undertaken.

DISCUSSION

This systematic review may provide sufficient data to inform the development of a screening tool to predict the risk of velopharyngeal insufficiency prior to cleft palate repair. However, it is anticipated that these findings will provide the foundation for future studies in this area.

SYSTEMATIC REVIEW REGISTRATION

Registered on 19 December 2016 with PROSPERO CRD42017051624.

'It depends': Characterizing speech and language therapy for preschool children with developmental speech and language disorders

BACKGROUND

Several studies have suggested that practitioners hold speech and language therapy (SLT) practice as tacit and consequently it is difficult for the therapist to describe. The current study uses a range of knowledge elicitation (KE) approaches, a technique not used before in SLT, as a way of accessing this tacit knowledge. There is currently no agreed framework that establishes key factors underpinning practice for preschool children with speech and language disorders. This paper attempts to address that gap.

AIMS

To develop a framework of SLTs' practice when working with preschool children with developmental speech and language disorders (DS&LD).

METHODS & PROCEDURES

A mixed-methods approach was adopted for this study. Data were collected iteratively, from 245 SLTs with experience of working with preschool children with DS&LD across sites in England, by means of focus groups and national events. There were three stages of data collection: local sites, specific-interest groups and two national events. KE techniques were used to gather data, with initial data being collected in local site focus groups. Findings from groups were taken to subsequent larger groups where a combination of concept mapping, teach-back and sorting exercises generated a more detailed description of practice, using discussion of consensus and disagreement to stimulate further exploration and definition and provide validatory evidence.

OUTCOMES & RESULTS

This paper provides a high-level framework of therapy for preschool children with DS&LD that makes practice explicit in this area. The framework proposes that therapists' aims for this group of children fall into three categories: addressing children's areas of impairment and skills; achieving functionally meaningful skills and carryover; and supporting adults to provide a supportive communication environment. The exact configuration is shaped by the child's context and needs.

CONCLUSIONS & IMPLICATIONS

The framework highlights themes that are well researched in the literature (e.g., speech) and others that have been little studied (e.g., adult understanding), indicating a disconnect between research evidence and practice. The research also highlights the complex nature of interventions for preschool children with DS&LD and the importance therapists attribute to tailoring therapy to individual needs. The framework provides a scaffold upon which SLTs can focus their clinical practice and encourages the profession to understand and explore better the gaps between research evidence and clinical practice for preschool children with DS&LD.

Using Free Text From Medical Notes To Enrich a Longitudinal Cohort Study

IntroductionThe Cleft Collective Cohort study is the world's largest multidisciplinary cleft lip/palate research programme. Despite being one of the most common birth anomalies, the causes of clefting are unknown. Treatment involves a considerable burden of care from birth onwards, together with a variety of social and psychological challenges. Objectives and ApproachOur aim is to create the infrastructure and resources necessary to gain important new knowledge that will advance our understanding of the causes of cleft lip/palate, inform treatment and improve the lives of people born with cleft; data linkage is a key aspect of this. There are challenges associated with linking to multiple data sources (NHS Digital, Cleft National Registry). However, using the consent obtained, we are also able to link directly to the participant’s medical notes held by their NHS cleft team; enabling us to access a variety of data, including free text. ResultsThe study already collects social and demographic data via questionnaires and genetic data from biological samples. Data linkage enriches this but also enables us to validate and address missing data problems. However, linkage to external sources brings many challenges, including, governance, costs, access issues. By gaining direct access to cleft team medical notes these issues are significantly reduced and provide us with rich phenotype data that cannot be obtained elsewhere, for example, via ‘read codes’ within electronic medical records. By tailoring our own data collection tool we can collect specific cleft data to enhance the resource and allow for subtype analyses. This process can be repeated throughout the duration of this longitudinal study for subsequent data. Conclusion/ImplicationsData linkage is a valuable resource but comes with many challenges. One route to overcome many of these issues is by accessing free text data directly from participants medical notes. The richness of these data allows for more in depth phenotypic analyses.

Preschool children's communication, motor and social development: Parents' and educators' concerns

PURPOSE

During early childhood, it is important to identify which children require intervention before they face the increased demands of school. This study aimed to: (1) compare parents' and educators' concerns, (2) examine inter-rater reliability between parents' and educators' concerns and (3) determine the group difference between level of concern and children's performance on clinical testing.

METHOD

Parents and educators of 1205 4- to 5-year-old children in the Sound Start Study completed the Parents' Evaluation of Developmental Status. Children whose parents/educators were concerned about speech and language underwent direct assessment measuring speech accuracy (n = 275), receptive vocabulary (n = 131) and language (n = 274).

RESULT

More parents/educators were concerned about children's speech and expressive language, than behaviour, social-emotional, school readiness, receptive language, self-help, fine motor and gross motor skills. Parents' and educators' responses were significantly correlated (except gross motor). Parents' and educators' level of concern about expressive speech and language was significantly correlated with speech accuracy on direct assessment. Educators' level of concern was significantly correlated with a screening measure of language. Scores on a test of receptive vocabulary significantly differed between those with concern and those without.

CONCLUSION

Children's communication skills concerned more parents and educators than other aspects of development and these concerns generally aligned with clinical testing.

Setting up a cohort study in speech and language therapy: lessons from The UK Cleft Collective Speech and Language (CC-SL) study

BACKGROUND

Efforts to increase the evidence base in speech and language therapy are often limited by methodological factors that have restricted the strength of the evidence to the lower levels of the evidence hierarchy. Where higher graded studies, such as randomized controlled trials, have been carried out, it has sometimes been difficult to obtain sufficient power to detect a potential effect of intervention owing to small sample sizes or heterogeneity in the participants. With certain clinical groups such as cleft lip and palate, systematic reviews of intervention studies have shown that there is no robust evidence to support the efficacy of any one intervention protocol over another.

AIMS

To describe the setting up of an observational clinical cohort study and to present this as an alternative design for answering research questions relating to prevalence, risk factors and outcomes from intervention.

METHODS

The Cleft Collective Speech and Language (CC-SL) study is a national cohort study of children born with cleft palate. Working in partnership with regional clinical cleft centres, a sample size of over 600 children and 600 parents is being recruited and followed up from birth to age 5 years. Variables being collected include demographic, psychological, surgical, hearing, and speech and language data.

MAIN CONTRIBUTION

The process of setting up the study has led to the creation of a unique, large-scale data set which is available for researchers to access now and in future. As well as exploring predictive factors, the data can be used to explore the impact of interventions in relation to individual differences. Findings from these investigations can be used to provide information on sample criteria and definitions of intervention and dosage which can be used in future trials.

CONCLUSIONS

The observational cohort study is a useful alternative design to explore questions around prevalence, risk factors and intervention for clinical groups where robust research data are not yet available. Findings from such a study can be used to guide service-delivery decisions and to determine power for future clinical trials.

A systematic review and classification of interventions for speech-sound disorder in preschool children

BACKGROUND

Multiple interventions have been developed to address speech sound disorder (SSD) in children. Many of these have been evaluated but the evidence for these has not been considered within a model which categorizes types of intervention. The opportunity to carry out a systematic review of interventions for SSD arose as part of a larger scale study of interventions for primary speech and language impairment in preschool children.

AIMS

To review systematically the evidence for interventions for SSD in preschool children and to categorize them within a classification of interventions for SSD.

METHODS & PROCEDURES

Relevant search terms were used to identify intervention studies published up to 2012, with the following inclusion criteria: participants were aged between 2 years and 5 years, 11 months; they exhibited speech, language and communication needs; and a primary outcome measure of speech was used. Studies that met inclusion criteria were quality appraised using the single case experimental design (SCED) or PEDro-P, depending on their methodology. Those judged to be high quality were classified according to the primary focus of intervention.

OUTCOMES & RESULTS

The final review included 26 studies. Case series was the most common research design. Categorization to the classification system for interventions showed that cognitive-linguistic and production approaches to intervention were the most frequently reported. The highest graded evidence was for three studies within the auditory-perceptual and integrated categories.

CONCLUSIONS & IMPLICATIONS

The evidence for intervention for preschool children with SSD is focused on seven out of 11 subcategories of interventions. Although all the studies included in the review were good quality as defined by quality appraisal checklists, they mostly represented lower-graded evidence. Higher-graded studies are needed to understand clearly the strength of evidence for different interventions.

Cluster-Randomized Controlled Trial Evaluating the Effectiveness of Computer-Assisted Intervention Delivered by Educators for Children With Speech Sound Disorders

PURPOSE

The aim was to evaluate the effectiveness of computer-assisted input-based intervention for children with speech sound disorders (SSD).

METHOD

The Sound Start Study was a cluster-randomized controlled trial. Seventy-nine early childhood centers were invited to participate, 45 were recruited, and 1,205 parents and educators of 4- and 5-year-old children returned questionnaires. Children whose parents and educators had concerns about speech were assessed (n = 275); 132 children who were identified with phonological pattern-based errors underwent additional assessment. Children with SSD and no difficulties with receptive language or hearing, typical nonverbal intelligence, and English as their primary language were eligible; 123 were randomized into two groups (intervention n = 65; control n = 58), and 3 withdrew. The intervention group involved Phoneme Factory Sound Sorter software (Wren & Roulstone, 2013) administered by educators over 9 weeks; the control group involved typical classroom practices. Participants were reassessed twice by a speech-language pathologist who was unaware of the initial assessment and intervention conditions.

RESULTS

For the primary outcome variable (percentage of consonants correct), the significant mean change from pre- to postintervention for the intervention group (mean change = +6.15, p < .001) was comparable in magnitude to the significant change for the control group (mean change = +5.43, p < .001) with a small between-groups effect size for change (Cohen's d = 0.08). Similar results occurred for measures of emergent literacy, phonological processing, participation, and well-being.

CONCLUSION

Computer-assisted input-based intervention administered by educators did not result in greater improvement than typical classroom practices.