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PAPERS: Kaare Christensen, Knud Juel, Anne Maria Herskind, and Jeffrey C Murray Long term follow up study of survival associated with cleft lip and palate at birth BMJ 2004; 328: 1405 [Abstract] [Full text]

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Cleft palate, premature death and learning disabilities

Woody Caan   (11 June 2004)

Possible confounders in CLP and survival

Rachel Myr   (16 June 2004)

Cleft lip and palate, look out for sleep apnoea

Eric Yat Tung Chan   (23 June 2004)

Cleft palate, premature death and learning disabilities 11 June 2004
Woody Caan, professor of public health Department of public and family health, APU, Chelmsford, Essex CM1 1SQ, UK Send response to journal: Re: Cleft palate, premature death and learning disabilities	Christensen and colleagues (1) have produced a fine example of the long term health consequences of congenital anomolies, just at the time when the National Congenital Anomaly System in the UK 'is currently being reviewed' (2). It is no surprise that risk of suicide is elevated, given that having a cleft in childhood can 'attract hostility and bullying' (3). A subtler point came up during our national study of speech therapy in relation to clefts (4): professionals were unanimous about the need for expertise 'across a range of presenting problems'. What Christensen et al (Online version) allude to as 'cognitive impairments' are quite common in the UK, i.e. cleft palate and co-morbid learning disabilities. Given that premature death is especially common in the population with learning disabilities (5), could this sub-group have accounted for most of the 143 excess deaths aged 0-55 in the Danish sample of 5331 births? 1 Christensen K, Juel K, Herskind AM, Murray JC. Long term follow up study of survival associated with cleft lip and palate at birth. BMJ 2004; 328: 1405-10. 2 National Statistics. The health of children and young people. London: ONS, 2004. 3 Caan W. Your shout. Department of Health: Mental Health Promotion Update 2002; 3: 16-17. 4 Caan W. Diploma Evaluation for CLeft Advanced Roles and Education (the DECLARE project). Report for the Royal College of Speech and Language Therapists (London), 1999. 5 Caan W. Epilepsy, early death and learning disabilities. http://bmj.bmjjournals.com/cgi/eletters/326/7385/349 19 February 2003. Competing interests: None declared
Possible confounders in CLP and survival 16 June 2004
Rachel Myr, midwife, breastfeeding specialist Sørlandet Sykehus Kristiansand, 4604 Kristiansand Send response to journal: Re: Possible confounders in CLP and survival	A recent study from the US showed increased mortality in the first year of life in children who were artifically fed. It is much more challenging to nourish a child with a cleft at the breast, and most of these babies are fed on breastmilk for a shorter time than their peers without clefts, because of the extra work involved expressing milk to be fed by other means. The cleft predisposes to feeding difficulties, notably slow growth or failure to thrive, and to respiratory tract infections. Use of artificial baby milks adds to both problems as it is noxious if aspirated, unlike breastmilk, and it increases the risk of GI infection; lack of immune support normally gotten in breast milk magnifies the effect. Surgery poses an added risk of infection. In Norway parents are not strongly encouraged to provide breastmilk for babies with clefts; it is presented as a nice thing, but not essential, as if we are afraid of adding to their burden if we emphasize the real difference it makes to these particular babies if they get mother's milk. Clefts are not repaired for months, obturators to help with feeding are not available and local support for dealing with the known practical problems of breastfeeding, or providing breastmilk for, a baby with a cleft is sketchy and haphazard. No one knows the effect of losing out on one of the newborn's great sensory experiences, cuddling and suckling at the breast. I don't know what the situation is in Denmark but I doubt it is very different. It would be interesting to know the feeding practices for the babies in this study, to see if they differ significantly from the total population, especially in duration and proportion of breastmilk in their diets. Generally, the more vulnerable the baby, the bigger the danger of being artificially fed. If we are shortchanging families of children with cleft lip and/or palate by inadequate support, we should find out. Competing interests: None declared
Cleft lip and palate, look out for sleep apnoea 23 June 2004
Eric Yat Tung Chan, MO Kwong Wah Hospital Send response to journal: Re: Cleft lip and palate, look out for sleep apnoea	There is a anatomical defect of upper airway in patients with cleft palate. Even after operation, the dynamics of the upper airway is disturbed. Patient with pharyngeal flap done was suggested to have higher chance of obstructive sleep apnoea(1) Although patient with Furlow palatoplasty was suggested to have only transient and mild OSA, but I think that a longterm follow up is required to look for recurrence. It would be good if the study had subset of mortality datas on patients, ie, type of operation done, any sleep symptoms. In the future, regular assessment of sleep symptoms should be done in CLP patient. Ref. (1)Cleft Palate Craniofac J. 2004 Mar;41(2):152-6. Competing interests: None declared