Speech Disorders Associated with Cleft Lip and Palate

How Does Cleft Palate Lead to Speech Disorders?

Cleft palate causes structural abnormalities in one or more areas, including the lip, hard palate, soft palate, teeth, and nose, preventing these organs from performing the movements required for articulation in a proper manner.

What is the Incidence of Cleft Lip and Palate?

According to a study conducted in our country, cleft lip and palate is observed in 1 out of every 1,000 births (Tunçbilek, 1973; as cited in Aras, 1996).

What is the Role of the Speech and Language Therapist in Infants with Cleft Lip and Palate?

Infants with isolated cleft lip usually do not experience significant difficulties regarding feeding or speech. For this reason, the information provided below has been prepared to highlight the role of the speech and language therapist in clefts that involve only the palate or the palate along with the lip.

Feeding from Birth to 12 Months

The most serious problem encountered in a newborn with a cleft palate is "feeding." Although lip surgeries are performed around 2.5 to 3 months of age, palate surgeries are generally not conducted before 12 months. During this period, it is vital to meet the infant's nutritional needs so they can continue their normal development.

The presence of an open palate has led to the development of specialized bottles for this condition (such as Mead Johnson and Haberman). Parents who struggle to feed their infant due to the inability to generate negative pressure use whichever bottle they find more practical. Mothers assist in feeding the infant—who cannot perform the sucking action—by squeezing the bottle made of soft material into the mouth. Families in Turkey who face difficulties finding these specialized bottles may choose alternative methods, such as spoon-feeding.

During the feeding process, it is critical for the child to be held vertically at an angle of 45–60 degrees, rather than horizontally. Vertical feeding prevents food from entering the nose. The parent should monitor the child continuously and stop feeding the moment they sense the child is uncomfortable.

Other points to consider during feeding include:

• Pausing approximately every 8 minutes to burp the child,

• Not feeding for more than half an hour,

• Feeding at frequent intervals,

• Seeking assistance from a speech therapist if problems arise,

• Consulting a physician if the child experiences weight loss.

Communication Evaluation and Guidance

In some clinics, contact is established with specialists as early as the pregnancy stage, and these specialists inform parents about what to expect. The speech therapist is one of these professionals. Apart from this general orientation, the speech therapist should evaluate the communication skills of the infant between 6 and 12 months of age. They should provide guidance to the family on how to develop receptive and expressive language skills and how to reinforce the production of specific speech sounds.

Speech Between 12 Months and 3 Years of Age

During this stage, rather than working one-on-one with the child, the speech therapist should still work with the families and provide the necessary guidance.

50% to 60% of children with cleft lip and/or palate do not experience speech problems. Therefore, it should be explicitly explained to the family that they should not treat their child any differently than a typically developing child. At the same time, the family should be informed about speech problems that may arise. The differences between the concepts of language and speech should be explained, the number of words in the child's sentences should be monitored, and whether they understand sentences containing 2–3 commands should be checked. Furthermore, families should be encouraged to pay closer attention to whether there are errors in the sounds the child uses when pronouncing words.

One of the important parameters affecting language and speech is hearing. It must be ensured that the child's hearing is routinely checked by an ENT physician and an audiologist. The family should be warned that recurrent middle ear infections (otitis media) can lead to permanent hearing problems.

After 3 Years of Age

Active speech and language therapy with children with cleft palate begins after three years of age. This period is required for the child to participate in desk-based activities and to act in accordance with the given instructions.

Speech and Language Disorders in Children with Cleft Lip and Palate

In therapy, the child's language development is evaluated before their speech. Kuehn and Henne (2003) stated that even though cleft palate negatively affects a child's speech development, it does not significantly impact language development, except in cases accompanied by additional disorders. It is essential for children with language development delays to be evaluated by pediatric neurology, particularly in terms of cognitive skills and syndromes.

Children whose language development is not age-appropriate are not admitted to articulation therapy. The priority is for the child to possess the language skills necessary to form sentences using an adequate number of words, to use inflections and suffixes correctly within sentences, and in short, to express their thoughts easily. While children with weak language development receive language therapy, children who do not experience issues in this area can be started on articulation therapy.

What is Hypernasality?

Hypernasality occurs when the acoustic energy required for speech escapes into the nose during sounds that should normally exit through the mouth, thereby disrupting the resonance of speech. Since hypernasality frequently accompanies cleft palate, it can cause various articulation problems. Some of these problems are compensatory processes developed by the child to make up for the palate deformity, which can be corrected with speech therapy. Others are obligatory disorders that arise necessarily due to structural issues (such as hypernasality or dental/jaw anomalies). During the evaluation, the speech therapist determines which of these disorders are obligatory and which are compensatory. For structural defects, they should refer the patient to physicians or orthodontists, while for compensatory processes, they should initiate speech therapy.

What Are Compensatory Speech Processes?

Compensatory speech processes specific to cleft palate usually involve backing processes, where sounds expected to be produced at the front of the mouth, such as /t/ and /d/, are converted into velar consonants like /k/ and /g/.

Speech Therapy in Cleft Lip and Palate

The success of speech therapy depends on the success achieved through teamwork. The plastic surgeon, ear, nose, and throat (ENT) specialist, geneticist, pediatric neurologist, speech therapist, orthodontist, audiologist, psychologist, and social worker are all parts of this team. This multidisciplinary teamwork is crucial for the child with a cleft palate to form a positive self-perception.