The effects of infant orthopedics in patients with cleft lip and palate
A scientific essay in Medical Sciences
DOCTORAL THESIS defended in public on 6th of June 2008
Unilateral cleft lip and palate (UCLP) is a complex congenital anomaly. The anomaly is associated with numerous problems and consequent treatments to solve them but often with remaining handicaps to live with. Through time researchers have elucidated many aspects of these associated problems and their optimal treatment, of the psycho-social wellbeing of the affected individuals and recently also some aspects of their quality of life. Research into the effectiveness of treatment in CLP is however limited by amongst others the low prevalence and the long follow up period. Current research is focused to enhance knowledge regarding the etiology of CLP, prevention of CLP, the effectiveness of CLP treatment and the quality of life. One of the treatment modalities that is performed during infancy is infant orthopedics (IO), a treatment performed with a passive acrylic plate during early infancy in order to narrow the cleft. This controversial treatment modality however appeared to be insufficiently evidence based which was one of the objectives to initiate this study. It was the aim of this clinical trial to evaluate the effectiveness of IO. Because of the low prevalence the cleft palate centers of Amsterdam, Nijmegen and Rotterdam participated. At the onset of this clinical trial IO was part of UCLP treatment protocol in all 3 centers. In this clinical trial 2 computer randomized treatment groups were evaluated comprehensively, one group was treated with IO during the first year of life the second group was not. In order to accomplish this, relevant domains were identified and included and relevant and representative variables were measured. Four domains were identified and evaluated i.e.: general aspects, surgical and orthodontic aspects, speech/language development and costs of treatment. The latter in order to perform a cost effectiveness analysis. This thesis presents the results of the first two domains. General aspects of IO included feeding, nutritional status, and a substitute for the patients quality of life, satisfaction in motherhood. The surgical and orthodontic aspects included maxillary morphology, growth and development, and facial appearance. Results from these parts of the study are presented and discussed in chapter 2 to 7. It was concluded from these chapters that IO had a small temporary effect on some of the maxillary dimensions. However no differences were found for the different feeding variables and the consequent nutritional status although the infants appeared to be shorter and lighter then their normal peers. The facial appearance did not differ between treated and non treated infants nor did the satisfaction in motherhood. All in all it could be concluded from this thesis that IO can be discarded from the UCLP treatment protocol. This conclusion was supported by the results from the other two domains and by recent follow-up studies. Regarding the implementation of the temporary guidelines, resulted from the findings of the present study, it should be mentioned that IO is no longer part of the normal treatment protocol in UCLP in the participating cleft palate centers of Amsterdam, Nijmegen and Rotterdam.