There is no one cause of cleft lip and palate. However, most cases are thought to result from multifactorial inheritance—an interaction between the person's genes (genetic predisposition) and specific environmental factors (see, e.g., Beaty et al., 2011). Clefting can also be caused by chromosomal differences in individuals born with genetic syndromes.

Risk factors that increase the likelihood of cleft lip and palate include the following:

• Strong family history of cleft lip and palate (e.g., Grosen et al., 2010; Natsume, Kawai, Ogi, & Yoshida, 2000; Sivertsen et al., 2008).
• Race—cleft lip and palate are more common in Asians and Native Americans than in African Americans (see Incidence and Prevalence section).
• Sex—males are more likely to have cleft lip with or without cleft palate; females are more likely to have cleft palate without cleft lip (see Incidence and Prevalence section).
• Exposure to certain environmental substances, such as tobacco and alcohol, prescription drugs, and illegal drugs (e.g., Arpino et al., 2000; DeRoo, Wilcox, Drevon, & Lie, 2008; Källén, 2003; Li et al., 2010; Little, Cardy, & Munger, 2004; van Gelder, Reefhuis, Caton, & Werler, 2009).

A cleft is the result of failure or interruption in growth or fusion of the normal craniofacial process (Leslie & Marazita, 2013). Clefts originate between the 4th and 10th week of embryologic development (Peterson-Falzone et al., 2010). There is no one cause of cleft lip and palate. Most cases are thought to result from multifactorial inheritance—an interaction between the person’s genes (genetic predisposition) and specific environmental factors (see, e.g., Beaty et al., 2011). Syndromic cleft refers to a cleft that co-occurs with a syndrome or a disorder as a result of a genetic or chromosomal difference.

Risk factors that increase the likelihood of cleft lip and palate include

• strong family history of cleft lip and palate (e.g., Grosen et al., 2010; Natsume et al., 2000; Sivertsen et al., 2008);
• maternal exposure to substances during pregnancy, such as tobacco and alcohol, prescription drugs, and illegal drugs (e.g., Arpino et al., 2000; DeRoo et al., 2008; Källén, 2003; Li et al., 2010; Little et al., 2004; van Gelder et al., 2009); and
• other maternal factors such as pregestational diabetes, obesity during pregnancy, and poor maternal nutrition (World Health Organization, 2020, 2022).

Cleft lip and cleft palate can be associated with a large number of craniofacial and genetic sequences or syndromes, some of which are rare. Some examples include the following:

• 22q11.2 deletion syndrome (also known as velocardiofacial syndrome and DiGeorge sequence)
• Stickler syndrome
• Pierre Robin sequence
• Van der Woude syndrome
• Treacher Collins syndrome
• oculo-auriculo-vertebral spectrum, hemifacial microsomia, Goldenhar syndrome
• neonatal abstinence syndrome, which includes fetal alcohol spectrum disorder and neonatal opioid withdrawal syndrome

For more information on rare diseases, please visit rarediseases.org.

Cultural beliefs may impact individuals’ determination of the cause of craniofacial differences (Loh & Ascoli, 2011; Mednick et al., 2013; Turlapati et al., 2021). This may influence a family’s decisions about seeking treatment (Loh & Ascoli, 2011; Louw et al., 2006; Mednick et al., 2013). For example, individuals who believe that clefting is fate or God’s will may not seek treatment, so as not to interfere with the spiritual world (Loh & Ascoli, 2011).

SLPs practice cultural sensitivity when providing education about the causes of cleft lip and palate to individuals and their caregivers. Please see the Counseling and Education Regarding Cleft Lip and Palate section as well as ASHA’s Practice Portal page on Cultural Responsiveness.

Screening

Speech screening for the child with a cleft lip and/or palate or suspected velopharyngeal dysfunction (VPD) may be completed by an SLP in a variety of settings, including cleft palate–craniofacial team visits, school, and early intervention.

The SLP attends to signs of

• anatomical/structural differences (e.g., malocclusion, submucous cleft, fistula, or bifid uvula);
• resonance disorders and presence of nasal emission;
• articulation errors that may be characterized as obligatory errors (due to structural differences) or as compensatory (learned) errors; and
• articulation errors that may be characterized as developmental or phonologic in nature.

The screening protocol includes a hearing screening and screening of expressive and receptive language skills. Screening may result in recommendations for additional assessments by the team, such as a comprehensive, audiologic, more in-depth speech and language assessment or instrumental assessment.

Comprehensive Assessment

See Comprehensive Assessment for Cleft Lip and Palate and Resonance. Specific components of an assessment will depend on the individual’s age and stage of development. Assessment and treatment of clefts may require use of appropriate personal protective equipment.

An SLP conducts a comprehensive speech and language assessment using both standardized and nonstandardized measures. See ASHA’s resource on assessment tools, techniques, and data sources.

Infants and toddlers: Some infants and toddlers with clefts may be evaluated by an SLP in an early intervention program to identify language delays, articulatory errors, and voice and swallowing disorders even before they are seen by a team. An understanding of the speech and language characteristics of these children is essential for accurate assessment. For children who are not yet talking, the assessment includes measures of vocalization diversity and complexity, vocalization rate, and use of communicative gestures (Scherer, 2017). For more information, see the Early Speech and Language Characteristics section of this Practice Portal page as well as ASHA’s Practice Portal pages on Late Language Emergence and Early Intervention.

School-age children: Assessment may be conducted by the school SLP, the medical team SLP, or an SLP in another outpatient or private clinic. Collaboration between the team SLP and other SLPs involved in service delivery for a child with a history of cleft lip and palate is encouraged (American Cleft Palate Craniofacial Association, 2022).

Adolescents: Assessment may be conducted by the school SLP and team SLP. Assessments should include perceptual measures of speech, self-reports about speech, and of the impact of speech on activities and participation (e.g., being understood by others, presenting in the classroom, engaging in clubs and sports).

Adults: Using the International Classification of Functioning, Disability and Health (ICF; World Health Organization [WHO], 2001) as a framework, SLPs conduct perceptual speech assessments and seek information about the person’s perception of speech and the impact of speech on quality of life. The SLP can be helpful in connecting adults with appropriate service providers.

Due to the likelihood of transient or permanent hearing loss in this population, the comprehensive assessment typically includes an audiologic assessment by an audiologist and otologic examination by an otolaryngologist. The audiologist monitors middle ear function and hearing sensitivity, and the otolaryngologist assesses and manages otologic concerns. Based on the findings, recommendations to enhance hearing are made, which may include listening devices and/or medical/surgical intervention.

The assessment is conducted in the language(s) used by the child and their family, with the use of interpretation services as necessary (see ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators). Assessment considers speech and language characteristics unique to the linguistic background of the individual and the cultural variables that affect communication (see ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology).

Consistent with the WHO’s ICF framework (WHO, 2001), comprehensive assessment is conducted to identify and describe

• impairments in body structure and function, including underlying strengths and weaknesses in speech sound production and oral/non-oral communication;
• comorbid deficits or conditions, such as developmental disabilities or syndromes;
• limitations in activity and participation, including functional communication, interpersonal interactions with family and peers, and learning;
• contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
• the impact of communication impairments on quality of life of the child and family.

See ASHA’s Person-Centered Focus on Function: Cleft Lip and Cleft Palate [PDF] for an example of assessment data consistent with the ICF framework. Also see Neumann and Romonath (2012) for a discussion of the application of the ICF framework to cleft lip and palate.

Assessment may result in

• the diagnosis of a speech, language, resonance, voice, and/or feeding and swallowing disorder;
• a determination of the type, severity, and possible cause of the disorder;
• a recommendation for therapy, as needed (seeTreatment Decision Tree for Managing Speech Problems Associated With Cleft Palate and VPD [PDF] [Trost-Cardamone, 2013]);
• the identification of speech errors that would benefit from coaching or counseling rather than from direct remediation (see ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology);
• the identification of barriers to child, adolescent, or adult participation in everyday situations;
• a referral for surgical, prosthetic, or other medical or dental intervention; and/or
• a referral for genetic testing to identify co-occurring syndromes or conditions.

Cultural Considerations

Spiritual, religious, and cultural beliefs may influence individuals’ perception of the cause of cleft lip and/or palate. For instance, some individuals may believe that cleft lip and/or palate occur because of evil spirits or as a punishment for a past sin. It is the clinician’s responsibility to exercise cultural sensitivity, which helps develop trust. Professionals need to be aware of beliefs—including differences in cultural reactions to the birth of a child with clefting—and communicate respectfully when providing care (Black et al., 2009; Strauss, 1997). Using ethnographic interviewing techniques can be an effective strategy for gathering information about cultural beliefs and concerns.

For more information, see ASHA’s Practice Portal page on Cultural Responsiveness and ASHA’s resource on cultural competence check-ins.

Team Approach to Treatment

Treatment for children with clefts, other craniofacial conditions, and even noncleft velopharyngeal insufficiency (VPI) is best done through a cleft palate–craniofacial team. The team typically includes a patient care coordinator, nurse, or social worker who facilitates team function and efficiency, assists families, and coordinates care for individuals and families. Based on standards developed by the American Cleft Palate Craniofacial Association (ACPA, 2022), a cleft palate team must have, as a minimum, a surgeon, an orthodontist, and an SLP.

Comprehensive teams may also include or have access to professionals in other fields, such as audiology, otolaryngology, ophthalmology, dentistry, genetics, nursing, psychology, and social work. Others may include oral maxillofacial surgeons, developmental pediatricians, geneticists, and plastic and craniofacial surgeons. Additional members vary depending on the individual’s developmental, medical, and psychological needs. See Standards for Approval of Cleft Palate and Craniofacial Teams [PDF] (ACPA, 2022) for essential characteristics of quality for team composition and functioning.

See also the American Speech-Language-Hearing Association’s (ASHA’s) web page, Interprofessional Education/Interprofessional Practice (IPE/IPP).

Components of Treatment

Treatment of children affected by clefts or other craniofacial conditions involves normalizing structure through physical management (surgical or orthodontic) and normalizing function through therapy. Treatment may also include early feeding intervention, dental care and orthodontics, audiologic care and monitoring of hearing status, and psychological services. See Parameters for Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Differences (ACPA, 2018).

In addition to speech therapy for compensatory productions secondary to cleft lip/palate, treatment may also be needed for unrelated articulation/phonology disorders and language disorders, if present. See ASHA’s Practice Portal pages on Speech Sound Disorders – Articulation and Phonology, Late Language Emergence, Spoken Language Disorders, and Written Language Disorders.

Feeding and Swallowing

Feeding disorders are among the first concerns following the birth of a child with cleft lip and palate. The goal of feeding intervention is to ensure adequate and efficient intake for appropriate hydration and nutrition, for growth and development, and for adequate medical status prior to surgery.

An important additional goal is to ensure that feeding is a low-stress experience for the infant and their family (Reid, 2004). Health care providers (e.g., SLPs, nurses, or lactation consultants) instruct mothers in feeding techniques and reassure them that successful feeding can be accomplished with the least amount of stress for the infant and family (Goyal et al., 2014). Please see ASHA’s Practice Portal page on Pediatric Feeding and Swallowing for further information.

Prior to Cleft Palate Surgery

A number of strategies and techniques can be used to facilitate feeding success prior to surgery, including

• placing the baby in an upright position while feeding to help prevent nasal regurgitation;
• providing jaw and cheek support, as needed;
• using the appropriate nipple size;
• positioning the nipple optimally (e.g., away from the side of cleft, if unilateral);
• pacing the flow rate and providing fluid in rhythm with the baby’s cues (e.g., movements and reactions);
• burping frequently to counter excessive air intake; and
• limiting feeding time (e.g., no more than 30 minutes) to avoid fatigue (Dailey, 2013; Peterson-Falzone et al., 2010, 2016).

Some cleft palate centers offer nasoalveolar molding (NAM) for infants with cleft lip and palate before surgery. NAM is a presurgical appliance that is used prior to surgery to align maxillary segments; however, a secondary benefit is that the appliance can function as a dental plate. Some parents report improved feeding with a NAM appliance (Zajac & Vallino, 2017b).

A feeding obturator is a prosthetic appliance that can be used in the first few months of life to assist the infant with cleft palate in feeding. Some craniofacial centers use feeding obturators routinely, believing that the appliance improves the ability of the infant to compress the nipple. Most craniofacial centers do not routinely use these appliances because they feel that with modifications of the nipple or bottle, correct positioning, and appropriate feeding techniques, the obturator simply is not necessary (Miller & Kummer, 2020).

Bottle-Feeding

Most babies who have cleft palate with or without cleft lip require a modified bottle to feed successfully. Nipples can vary in shape, size, and pliability to accommodate each baby’s unique needs.

Other frequently used modifications include the following:

• Nipples with a wide base to help the baby achieve adequate lip seal despite a wide cleft lip.
• Nipples with a one-way valve at the base. This valve allows milk to flow into the nipple but not back into the bottle when the nipple is compressed; milk in the nipple flows into the baby’s mouth on compression. Specialized feeding options for drinking milk include, but are not limited to, SpecialNeeds Feeder, Pigeon Bottle, and Dr. Brown’s Standard Specialty Feeding System.
• Soft, squeezable bottles that allow the feeder to express milk into the baby’s mouth by compressing the bottle in sync with each sucking motion (e.g., Mead Johnson Cleft Lip/Palate Nurser).
• Nipples with enlarged (e.g., cross-cut) holes that allow milk to flow into the baby’s mouth via force of gravity; the feeder must monitor the baby’s cues and control the rate of flow to avoid compromising the baby’s suck–swallow–breathe coordination.

See the ACPA’s Feeding Your Baby for demonstrations of feeding using various bottle and nipple types.

Breastfeeding

Families interested in breastfeeding should be supported and given all necessary guidance in their efforts. Consultation with a lactation consultant or feeding specialist is often recommended, and the baby’s weight gain should be closely monitored. If breastfeeding is not sustainable for maintaining adequate nutrition and hydration, families who are interested in bonding with their babies during nonnutritive times at the breast after feeding should be supported.

The type and severity of the cleft affects the degree of success with breastfeeding. Babies with an isolated cleft lip, small soft palate clefts, or submucous clefts may have less difficulty than babies with larger clefts of the lip. Babies with cleft palate are usually unable to achieve adequate nutrition through breastfeeding alone. Expressing milk and using a bottle for delivery is usually needed (see, e.g., Arvedson & Brodsky, 2001; Clarren et al., 1987; Garcez & Giugliani, 2005; Grady, 1977; Mei et al., 2009; Miller, 2011).

As with bottle-feeding, making modifications to the feeding position and providing cheek and lip support can help make breastfeeding successful. Often, the baby is unable to completely empty the breast; however, milk can be expressed and placed into a bottle to complete the feeding or to store for a later feeding.

After Surgery

Decisions about the timing and methods of feeding after surgical cleft repair vary and depend on several factors, including

• the type (e.g., lip or palate, unilateral or bilateral) and size of the original cleft;
• the particular surgical procedure (e.g., primary lip repair or primary palate repair); and
• the preferences of the surgeon and the cleft–craniofacial team.

Some babies are able to feed from bottle or breast immediately after surgery, whereas others will use alternate methods (e.g., syringe or spoon-feeding) for the first month or so following surgery (see, e.g., Cohen et al., 1992; Darzi et al., 1996; Peterson-Falzone et al., 2016).

Feeding Considerations: Babies With Clefts Related to Craniofacial and Genetic Sequences or Syndromes

Cleft palate only (without cleft lip) is often associated with a craniofacial syndrome. Many syndromes include features that place the child at risk for airway compromise during feeding, such as structural anomalies (e.g., anatomically smaller airway, glossoptosis) or neurological deficits (e.g., weakened muscles due to hypotonia).

Assessment for potential airway compromise during feeding should be done for these at-risk infants. The infant’s nutritional needs might necessitate alternate feeding methods (e.g., tube feeding).

See ASHA’s Practice Portal page on Pediatric Feeding and Swallowing for assessment and treatment considerations.

Approaches to Treating Cleft-Type Speech

Approaches to treatment for articulation disorders associated with cleft palate or velopharyngeal dysfunction (VPD) will depend on whether speech deviations are obligatory (i.e., related to atypical anatomy and/or structural defects) or learned.

• Obligatory speech distortions that are related to VPI or other structural anomalies (i.e., fistula, dental anomalies, malocclusion) are not responsive to speech therapy and will likely require surgical intervention or other physical management for correction.
• Learned articulation errors (e.g., compensatory errors and phoneme-specific nasal air emission) should be responsive to speech therapy.

Surgical Intervention and Other Physical Management

Surgical intervention or other physical management is needed to manage speech disorders resulting from

• VPD (e.g., hypernasality);
• hyponasality due to enlarged adenoids or enlarged turbinates;
• pervasive nasal air emission (and/or weak pressure on oral consonants); and
• malocclusion (e.g., orthognathic surgery to correct a Class II or Class III malocclusion).

Presurgical orthopedics during infancy may be used to move cleft segments closer together and into better alignment prior to surgical repair. These include

• lip taping,
• lip adhesion,
• NAM appliances, and
• premaxillary orthopedics (devices that force alignment of premaxilla with the lateral maxillary segments).

Surgeries can include one or more of the following:

• repair of cleft lip (usually performed within the first 6 months of life)
• repair of cleft palate (usually by 12 months of age in children with no significant co-occurring diagnosis, airway obstruction, or conditions that would cause surgery to be delayed or postponed)
• mandibular distraction using osteogenesis in infants with severe retrognathia and airway compromise
• repair of submucous cleft palate
• procedures to correct noncleft VPD or to correct postoperative VPI (e.g., bilateral buccal flap revision palatoplasty, pharyngeal flap; sphincter pharyngoplasty; furlow, Z-plasty velar lengthening; posterior pharyngeal wall augmentation and bilateral buccal flaps)
• tonsillectomy and/or adenoidectomy (may be needed prior to pharyngeal flap or other pharyngoplasty)
• secondary surgeries to repair palatal fistulae (if symptomatic)
• alveolar bone grafting (determined by the stage of dental development and in collaboration with the dentist)
• surgical treatment of malocclusion (e.g., maxillary advancement—typically done in adolescence or in young adults after bone growth is completed)

For more information about presurgical and surgical intervention, see Peterson-Falzone et al. (2010), Pearson and Kirschner (2011), and Zajac and Vallino (2017d). See also Parameters for Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Differences (ACPA, 2018).

Other physical management approaches may include the following:

• Orthodontics—to correct malocclusions and other dental misalignments.
• Prosthodontics—to improve velopharyngeal (VP) function. Prosthetic management can include palatal obturators, speech bulb obturators (to close off a portion of the pharynx when the velum is very short), and palatal lifts (to elevate the velum when there is VPI).

Speech Therapy for Cleft Palate Speech Errors

Direct speech therapy is appropriate for treatable articulation disorders, including compensatory misarticulations and phoneme-specific nasal air emission due to a pharyngeal placement on sibilants.

The objectives of therapy are to

• correct abnormal placements for consonant misarticulations (e.g., bring backed oral articulations forward, teach correct oral place, and establish oral pressure buildup and release) and
• establish oral pathway/direction of airflow and appropriate valving of airflow at target place during production of oral sounds (Golding-Kushner, 2001; Ruscello, 2017; Trost-Cardamone, 2013).

Therapy can be diagnostic. Progress can help inform the cleft palate team about VP function and the possible need for (further) surgical intervention (see Treatment Decision Tree for Managing Speech Problems Associated With Cleft Palate and VPD [Trost-Cardamone, 2013]).

Treatment Strategies

Therapy typically targets the elimination of compensatory misarticulations first, as these tend to have greater impact on intelligibility and VP function than do other types of speech sound errors. Later therapy addresses developmental articulation or phonological errors if present.

Initial Therapy Targets

Initial therapy targets for children with compensatory misarticulations may include

• sounds for which the child is stimulable (i.e., can articulate, given a model);
• nasal and low-pressure consonants, if they are produced or co-produced with glottal stops;
• high-pressure consonants that are not in the inventory, are age appropriate, or have high impact on intelligibility/understandability; and
• anterior consonants that are visible (e.g., /p, b, t, d, f/), given that children often compensate with posterior placement.

Strategies and Techniques

Strategies and techniques used in therapy include the following:

• Using phonetic placement techniques, typically starting with bilabials and then moving to alveolars.
• Introducing gentle whispering or using sustained /h/ to break the glottal pattern and to teach easy oral airflow with open glottis.
• Inserting /h/ after oral stop consonants to discourage the use of glottal stops prior to vowel onset (e.g., p(h)op for “pop”).
• Teaching auditory discrimination between the correct target and the compensatory error to facilitate self-monitoring.
• Providing visual cues, including
  • using a lateral diagram or a model of the mouth for visual placement cues;
  • pointing to lips/tongue to cue placement;
  • using visual airflow cues (e.g., using a feather); and
  • using mirrors for observing articulatory positioning—sit side by side—so that the child can view the reflection of themselves and the therapist.
• Providing verbal cues, such as instructions for correct placement and manner or airstream.
• Providing tactile cues, such as
  • feeling one’s neck musculature to help identify incorrect placement for glottal stops and for pharyngeal stops and fricatives,
  • feeling a released puff of air on one’s hand during the production of plosives,
  • using one’s finger to feel bilabial closure and oral air pressure on plosives, and
  • using nose plugging/pinching (nasal occlusion) to provide the individual with the sensation of oral pressure and to discourage nasal airflow errors.
• Using established speech therapy procedures and techniques (e.g., minimal pairs, traditional shaping hierarchy). See ASHA’s Practice Portal page on Speech Sound Disorders – Articulation and Phonology.

(Golding-Kushner, 2001; Kummer, 2020b; Peterson-Falzone et al., 2016; Trost-Cardamone, 2013.)

Nonspeech oral motor therapy involves the use of oral motor training prior to teaching sound or as a supplement to speech sound instruction. Such approaches are controversial in the treatment of cleft lip and palate (Kummer, 2020b; Ruscello & Vallino, 2020). Consult systematic reviews of this treatment to help guide clinical decision making (see, e.g., Lee & Gibbon, 2015; McCauley et al., 2009). See also the Treatment section of the Speech Sound Disorders Evidence Map filtered for Oral Motor Exercises as well as ASHA’s Practice Portal page on Speech Sound Disorders – Articulation and Phonology.

Use of Technology in Speech Therapy

Performance feedback is integral to speech improvement and helps improve outcomes. This feedback can be provided in several forms and may include instrumentation. A number of technologies can be used in speech therapy to provide feedback. With the exception of the low-tech/no-tech tools listed below, some instrumentation for feedback may not be available to SLPs in early intervention, early childhood, school-based, or hospital-based programs.

Technologies for real-time feedback include the following:

• Low-tech or no-tech tools for targeting phoneme-specific nasal emission, such as
  • a dental mirror placed under the nose,
  • a stethoscope (placed against the side of the nose), and
  • plastic tubing or drinking straw for self-monitoring one’s own productions (one end is placed at the patient’s/client’s nostril entrance, and the other end is placed by the ear).
• Nasometer to monitor oral versus nasal speech and provide real-time visual feedback. A nasometer is used in cases of phoneme-specific disorders or nasalization errors (not to treat consistent hypernasality).
• Nasopharyngoscopy to provide visual feedback about the actions of the VP mechanism during speech (Brunner et al., 2005), which may help individuals improve VP movements when they have the physical ability to achieve VP closure but do not do so because of faulty articulation (e.g., phoneme-specific nasal emission; Brunner et al., 2005; Witzel et al., 1988).
• Electropalatography—a computer-based technique for training correct oral articulation placements. Electropalatography provides a visual feedback display of the tongue’s contact with the hard palate during speech (Lee et al., 2009).

See Kummer (2020b) for a description of some of the technologies used in speech therapy for cleft-type speech errors.

Early Speech and Language Intervention

Delays in the onset of babbling and the lack of diversity in consonant production during the prelinguistic period have been linked to delays in speech and language development (Stoel-Gammon, 1994). Early speech and language intervention can lessen the impact of these factors on the development of communication skills in infants and toddlers (see, e.g., Scherer, 1999; Scherer & Kaiser, 2007).

Early intervention for babies and toddlers with clefts involves helping them to develop the use of oral speech sounds after palate repair by increasing consonant inventory, increasing expressive vocabulary, and teaching oral airflow for early emerging fricatives (e.g., /h/; Hardin-Jones et al., 2006; Trost-Cardamone, 2013).

Parent education and training are essential in early intervention. SLPs counsel parents about the expected impact of clefts on speech and encourage parents to foster communication skills in their babies (Peterson-Falzone et al., 2010). Parent-implemented early intervention programs have been shown to facilitate speech and language development in young children with cleft palate (e.g., Scherer, 2003; Scherer et al., 2008).

SLPs play a role by teaching parents

• how to engage in vocal play with their children before surgery;
• how not to reinforce compensatory productions (e.g., laryngeal growls and nasal fricatives); and
• how to provide intensive language stimulation (Golding-Kushner, 2001; Hardin-Jones et al., 2015; Scherer, 2017; Trost-Cardamone, 2013).

Before Palatal Repair

Prior to palatal repair, goals include the following:

• Using vocal play activities to stimulate production of speech sounds least affected by the cleft (e.g., nasals, glides, glottal fricative /h/, and vowels) by
  • modeling varied sounds and encouraging imitation of sounds and
  • reinforcing attempts to produce oral stop consonants and ignoring any obligatory nasal emissions.
• Modeling alternatives for compensatory productions (e.g., “no no” instead of “uh uh”).

After Palatal Repair

After palatal repair, goals include the following:

• Using sound play and early word productions to increase variety of vocalizations.
• Increasing consonant inventories, especially oral pressure consonants.
• Increasing vocabulary, with a focus on functional and high-frequency words.
• Increasing awareness of oral airflow for speech.
• Monitoring persistent nasal substitutions and glottal stops.
  • If present after surgery, this might indicate learned behaviors (emerging compensatory misarticulations) despite a potentially adequate VP mechanism.

(Hardin-Jones et al., 2006, 2015; Peterson-Falzone et al., 2016; Scherer, 2017.)

Audiologic Care

Given the potential impact of hearing loss on speech and language development (Holm & Kunze, 1969; Yoshinaga-Itano et al., 2000), early assessment and ongoing monitoring of ear and hearing status by an audiologist are essential for individuals with cleft lip and palate, especially because of the potential impact of hearing loss on speech and language development (Holm & Kunze, 1969; Yoshinaga-Itano et al., 2000).

Audiologic assessment and management depend on the type and degree of hearing loss and include the following:

• Diagnostic auditory brainstem response testing shortly after birth if the child failed the newborn hearing screening.
• Frequent monitoring of hearing sensitivity, middle ear function, and the status of pressure equalization tubes. This monitoring is especially important from birth to the age of 6 years (Dochy et al., 2019).
• Making appropriate referrals to the otolaryngologist.
• Educating parents regarding the importance of monitoring hearing and middle ear status and the correlation of consistent, normal hearing levels with optimal speech/language outcomes.
• Making appropriate recommendations for amplification and other appropriate hearing technologies, such as a personal FM system for educational settings when a persistent or permanent hearing loss is identified.

Teachers and other school personnel should be informed of any necessary services and accommodations for school-age children with fluctuating or permanent hearing loss (ACPA, 2018).

See ASHA’s Practice Portal pages on Hearing Loss in Adults, Hearing Loss in Children, and Language and Communication of Deaf and Hard of Hearing Children for information related to audiologic management.

Role of the Community-Based SLP in Treatment

Collaboration

Successful speech therapy involves a partnership between the community-based SLP (e.g., school, private clinic), the cleft palate team, and the child’s parents and caregivers.

Collaboration between the community-based SLP and the SLP on the cleft palate team is essential to develop a treatment program and ongoing monitoring to ensure optimal speech outcomes (Bedwinek, 2010; Golding-Kushner, 2001; Peterson-Falzone et al., 2016).

Models of collaboration vary and may change over the course of treatment, based on the needs of the individual and the availability of resources (Dailey & Wilson, 2015; Grames, 2004). Models include informal consultation, formal consultation, parallel service delivery, and co-provision of care (Lorenz et al., 1999).

See Ruscello (2017) for a discussion of how the school SLP can use various models of collaboration in treatment. See also ASHA’s resource on collaboration and teaming.

Persistent Speech Difficulties

Speech difficulties associated with cleft lip and palate can persist into adolescence and adulthood and can impact self-esteem, quality of life, and ease of communication in educational, social, and vocational settings.

Speech difficulties can persist for a number of reasons, including

• lack of access to adequate speech services when the child was younger, resulting in habituated speech patterns (compensatory articulations) that may be more difficult to change;
• lack of or delayed access to surgical intervention of the cleft palate and/or VPD;
• persistent anatomic obstacles to normal speech, such as severe malocclusion or untreated VPI;
• poorly developed self-monitoring skills; and
• lack of motivation.

Some of the speech errors that persist into adolescence are related to past or ongoing dental anomalies, malocclusion, or untreated VPI. Malocclusion is corrected through maxillary advancement (orthognathic) surgery, but this cannot be done until facial growth has been completed in adolescence. Therefore, treatment of related obligatory distortions or compensatory productions is deferred until the structure is surgically corrected. Speech is reevaluated after maxillary advancement to determine if speech therapy is indicated for the remaining compensatory productions or to rule out VPI that can develop as a result of surgery.

Special Considerations: Adults

Although cleft lip and palate is present from birth, many adults deal with the implications of these conditions. Treatment may be complete by adulthood for some adults, but for others, dental, appearance, and speech problems may persist and can impact their quality of life. SLPs may be key in assessment, treatment, and provision of appropriate referrals for adults who have these concerns. This role involves going beyond articulation testing to include self-reports about speech and assessment of the social impact of the cleft. The International Classification of Functioning, Disability and Health (World Health Organization, 2001) can serve as a guide for these questions.

For the person with cleft lip and palate, adulthood marks the transition from child-centered team care to adult-centered care. For many, team care for adults after age 21 years may not be accessible, and care is undertaken by community-based providers who may have limited knowledge about or experience with cleft lip/palate. Individuals transitioning from child-centered multidisciplinary care to adult-centered care may face a number of challenges, including difficulties locating appropriate services on their own. Barriers associated with the transition may have a negative impact on quality of care and on the individual’s quality of life. A model of adult care that incorporates a team approach would likely facilitate this transition (Zajac & Vallino, 2017a).

SLPs advocate for adults with cleft lip and palate, particularly by providing education on the rights of these individuals. It is important to provide education and resources to help raise individuals’ awareness of their rights within the Americans with Disabilities Act.

See ASHA’s resources on Postsecondary Transition Planning and advocacy for further information.

Counseling and Education Regarding Cleft Lip and Palate

Counseling and education are important in treating cleft lip and palate, particularly because of beliefs, perceptions, and views on society’s acceptance of individuals with cleft lip and palate.

Cultural sensitivity is essential when providing counseling and education and when designing treatment goals. The clinician must consider the individual’s linguistic environment to ensure that goals meet the linguistic demands of daily life for the individual and their family. For additional information, see ASHA’s Practice Portal page on Cultural Responsiveness.

Researchers have theorized that craniofacial conditions may negatively impact mother–infant interaction and attachment (Clifford, 1969; Endriga et al., 1992; Field & Vega-Lahr, 1984; Waechter, 1977); however, there is currently mixed information on the extent and/or presence of such an impact (Maris et al., 2000). Regardless, SLPs should be aware of the potential impact of facial differences on parents’ and caregivers’ perceptions of individuals’ abilities and capacities when providing counseling and education. Cleft lip and palate can have an impact on the individual’s psychological and social well-being; this impact can vary on the basis of cultural belief. Clinicians provide counseling related to psychosocial impact when it is within the SLP scope of practice and refer to additional services (e.g., psychotherapy) when appropriate.

Considerations for counseling include the following:

• The possible psychosocial impact stemming from personal recognition of one’s facial differences and the reactions/judgments of others, including
  • poor self-concept;
  • low self-confidence;
  • feelings of depression and anxiety; and
  • difficulties initiating and maintaining friendships (see, e.g., Broder & Strauss, 1989; Noar, 1991; Ramstad et al., 1995; Turner et al., 1997).
• Impact of hearing loss on socialization—even mild hearing loss can result in missed portions of fast-paced conversations and can have a negative impact on social interactions (Anderson & Matkin, 1991).
• Misconceptions and misunderstanding of cleft lip and palate that may lead teachers to misunderstand and/or underestimate an individual’s academic ability (Richman, 1978a, 1978b; Stock et al., 2019).
• Vulnerability to teasing/bullying and discrimination on the basis of appearance (e.g., Lorot-Marchand et al., 2015; Turner et al., 1997).

See Hunt et al. (2005) and Peterson-Falzone et al. (2010) for more detailed discussions of the psychosocial impact of cleft lip and palate. Please also see ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology.

Service Delivery

In addition to determining the type of speech and language treatment that is optimal for individuals with cleft lip and palate, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

• Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group. The format of service delivery for this population can include in-office and telepractice models (Golding-Kushner, 2015).
• Provider—the person providing treatment (e.g., SLP, trained volunteer, caregiver).
• Dosage—the frequency, intensity, and duration of service.
• Timing—the timing of intervention relative to the diagnosis. This includes timing of behavioral intervention in relation to surgical/physical management.
• Setting—the location of treatment (e.g., home, community-based, school).

ASHA Resources

• A Guide For Cleft Palate Speech Sampling [PDF]
• Aerosol Generating Procedures 
• ASHA Guidance to SLPs Regarding Aerosol Generating Procedures
• ASHA State-by-State
• Assessment Tools, Techniques, and Data Sources
• Cleft Lip and Palate Evidence Map 
• Collaboration and Teaming
• Common Types of Palatal Clefts
• Comprehensive Assessment for Cleft Lip and Palate and Resonance
• Cultural Competence Check-Ins
• Evidence Indicates Nonspeech Oral Motor Exercises for Children With Cleft Palate Are Not Effective
• Interprofessional Education / Interprofessional Practice (IPE/IPP)
• Person-Centered Focus on Function: Cleft Lip and Cleft Palate [PDF]
• Possible Causes of Hypernasality and/or Nasal Emission
• Postsecondary Transition Planning
• Process Model for Assessing Speech, Resonance, and Language in Patients With Cleft and Craniofacial Anomalies [PDF]
• Public Page: Cleft Lip and Cleft Palate
• Scope of Practice in Speech-Language Pathology
• Special Interest Group 5, Craniofacial and Velopharyngeal Disorders
• Treatment Decision Tree for Managing Speech Problems Associated With Cleft Palate and VPD 

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• ACPA: American Cleft Palate Craniofacial Association
  • Feeding Your Baby
  • Parameters For Evaluation and Treatment of Patients With Cleft Lip/Palate or Other Craniofacial Differences
  • Standards for Approval of Cleft Palate and Craniofacial Teams [PDF]
• Alimentación Para Bebes con Paladar Hendido [YouTube]
• Americans with Disabilities Act
• Cincinnati Children’s Division of Speech-Language Pathology
  • Cleft Lip and Palate: The Effects on Speech and Resonance [PDF]
  • Resonance Disorders and Velopharyngeal Dysfunction
  • Speech Therapy Techniques: For Errors due to Clefts or Velopharyngeal Dysfunction [PDF]
  • Treatment of Velopharyngeal Dysfunction
• Cleft Lip and Palate, Resonance, and Velopharyngeal Dysfunction: Handouts for Parents
• Introduction to the Video Tutorials To Improve Speech of Children With Cleft Palate [Video; in Spanish]
• Las Estrategias Para Producir la “D” [YouTube]
• Las Estrategias Para Producir la “K” [YouTube]
• Las Estrategias Para Producir la “S” [YouTube]
• LEADERSproject
  • Cleft Palate Treatment Resources 
• National Organization for Rare Disorders
• Rare Diseases
• RCSLT: New Long COVID Guidance and Patient Handbook
• The Virtual Center for Velo-Cardio-Facial Syndrome

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Cleft Lip and Palate page.

• Adriane L. Baylis, PhD, CCC-SLP
• Anne P. Bedwinek, PhD, CCC-SLP
• Kathy L. Chapman, PhD, CCC-SLP
• Scott Dailey, PhD, CCC-SLP
• Karen J. Golding-Kushner, PhD, CCC-SLP
• Mary Hardin-Jones, PhD, CCC-SLP
• Pamela A. Koprowski, AuD, CCC-A
• Ann Kummer, PhD, CCC-SLP
• Brenda Loxton Louw, PhD
• Amy Rose Morgan, MA, CCC-SLP
• Kelly Nett-Cordero, PhD, CCC-SLP
• Mary M. O’Gara, MA, CCC-SLP
• Jamie L. Perry, PhD, CCC-SLP
• Alice E. Smith, PhD, CCC-SLP
• Jessica Stich-Hennen, AuD
• Judith E. Trost-Cardamone, PhD, CCC-SLP
• Linda Vallino-Napoli, PhD, CCC-SLP/A
• Michelle Wagner-Escobar, MA, CCC-A
• Kristina Wilson, PhD, CCC-SLP

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Cleft lip and palate [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Cleft-Lip-and-Palate/