Cleft Lip & Palate

The face and mouth form between the 5th and 12th weeks of pregnancy, when separate blocks of tissue grow towards the midline and fuse. If some of these do not join completely, a cleft results.

• Cleft lip: A gap in the upper lip. It may be unilateral (one side) or bilateral (both sides), and range from a small notch to a wide split extending up to the nose.
• Cleft palate: A gap in the roof of the mouth, which can involve the hard palate at the front, the soft palate at the back, or both.
• Cleft lip and palate together: The most common combination.
• Isolated cleft palate: A cleft of the palate alone, without a cleft lip. This is harder to see before birth and is more often part of a wider (syndromic) picture, so it is looked for particularly carefully.

A cleft is a difference in structure only — it does not cause pain, and it says nothing about a baby's intelligence.

Most clefts occur with no clear cause, but several factors can increase the chance:

• Family history: A cleft in a parent or sibling raises the likelihood.
• Genetic and syndromic causes: Some clefts are part of a wider condition (syndromic), which is more likely when there are other structural findings. This is why we offer detailed scanning and, in selected cases, microarray or genetic testing.
• Certain medications and exposures: Some anti-epileptic drugs and heavy smoking or alcohol in early pregnancy are associated with a higher risk.
• Folic acid: Adequate folic acid before and in early pregnancy may reduce the risk, which is one reason it is routinely recommended.

It is important to know that in the great majority of cases, parents have done nothing to cause a cleft.

Diagnosis begins with ultrasound and, when needed, extends to genetic testing.

• Anomaly scan: A cleft lip is usually visible at the 18–22 week detailed scan when the face is examined in profile and front-on. An isolated cleft palate, hidden inside the mouth, is much harder to see and is sometimes only diagnosed after birth.
• Detailed fetal assessment: Once a cleft is seen, we perform a careful survey of the whole baby — including a detailed heart scan — because associated anomalies make a syndromic cause more likely.
• Isolated versus syndromic: If the cleft appears isolated and all else is normal, the outlook is excellent. If other findings are present, we offer chromosomal microarray via amniocentesis to look for a genetic cause, together with clinical genetics counselling.
• After birth: A newborn examination confirms the extent of the cleft, and a cleft team assessment is arranged to plan feeding and surgery.

Care is delivered by a specialist multidisciplinary cleft team and is planned around the baby's growth.

• Feeding first: A baby with a cleft lip alone can often breastfeed. With a cleft palate, a baby cannot create suction, so specially designed bottles and teats are used; a feeding specialist supports parents from the first days. Babies feed and gain weight well with the right technique.
• Staged surgical repair (typical timeline):
• Cleft lip repair: usually around 3–6 months of age.
• Cleft palate repair: usually around 6–12 months, timed to support speech development.
• Later procedures: some children need further surgery in childhood — for example a bone graft to the gum around 8–11 years, and occasionally speech or nasal surgery in the teenage years.
• The wider team: speech and language therapists, audiologists (glue ear and hearing are monitored), orthodontists and dentists, and psychological support all contribute over the years to an excellent overall result.

The long-term outlook for children with a cleft is excellent.

• Appearance: Modern surgical techniques produce very good cosmetic results, with a small, well-healed scar after lip repair.
• Speech: With timely palate repair and speech therapy, most children develop normal or near-normal speech.
• Hearing: Middle-ear fluid ('glue ear') is more common, so hearing is monitored and treated (for example with grommets) to protect speech and learning.
• Development and intelligence: For an isolated cleft, development and intelligence are entirely unaffected.
• Overall: Children who have completed cleft care grow up to lead full, normal lives — going to school, working, and forming relationships like anyone else.

Referral to the MFM Unit is appropriate when:

• A cleft lip, cleft palate, or both is suspected or seen on ultrasound.
• There is a family history of clefting and detailed assessment is wanted.
• Other structural findings are present alongside a cleft, raising the possibility of a syndrome.

At the MFM Unit, Dr. Ali Al Ibrahim and the fetal medicine team confirm the diagnosis, perform detailed scanning to distinguish isolated from syndromic clefts, arrange microarray and genetic counselling where indicated, and connect families with the paediatric cleft surgical team so that a clear plan is in place before the baby arrives.