Research synthesis based on guidance and clinical information from the CDC, NIH/NIDCR, MedlinePlus, American Academy of Pediatrics, ASHA, ACPA, Children’s Hospital of Philadelphia, Boston Children’s Hospital, Cleveland Clinic, Johns Hopkins Medicine, Stanford Medicine Children’s Health, and Mayo Clinic.
A cleft lip or cleft palate can make a baby’s first days feel unexpectedly complicated. Parents may suddenly hear unfamiliar terms, meet a small army of specialists, and discover that feeding a newborn sometimes requires equipment that looks as though it came from a tiny medical supply convention.
Fortunately, cleft lip and cleft palate are well-studied, treatable congenital conditions. Modern care is about much more than closing an opening. A coordinated cleft and craniofacial team supports feeding, growth, hearing, dental development, facial growth, emotional well-being, and speech from infancy into young adulthood.
This guide explains how clefts form, which factors may influence risk, how treatment is planned, and why speech problems sometimes continue even after a successful palate repair.
What Are Cleft Lip and Cleft Palate?
A cleft lip is an opening in the upper lip that develops when facial tissues do not join completely during early pregnancy. The opening may be a small notch or extend through the lip and into the nostril. It may affect one side of the lip, called a unilateral cleft, or both sides, called a bilateral cleft.
A cleft palate is an opening in the roof of the mouth. It may involve the hard palate at the front of the mouth, the soft palate toward the throat, or both. A child can have a cleft lip without a cleft palate, a cleft palate without a cleft lip, or both conditions together.
What Is a Submucous Cleft Palate?
Not every cleft palate is immediately visible. In a submucous cleft, the lining of the mouth may appear intact while the muscles or bone underneath have not formed normally. Possible signs include a split uvula, nasal-sounding speech, liquid coming through the nose, frequent middle-ear problems, or difficulty producing certain consonants.
Because the surface can look nearly normal, a submucous cleft may not be identified until speech develops. This is one reason persistent hypernasality deserves a specialized evaluation rather than a cheerful but unhelpful instruction to “talk more clearly.”
Formation, prevalence, definitions, and delayed diagnosis of some cleft types:
How Common Are Orofacial Clefts?
Orofacial clefts are among the more common congenital differences involving the face. Updated CDC estimates indicate that approximately 1 in 1,031 babies born in the United States has a cleft lip with or without a cleft palate, while roughly 1 in 1,563 has a cleft palate alone.
Those numbers describe large populations, not an individual child’s future. The type and extent of the cleft, associated health conditions, access to specialty care, and response to treatment all influence the care journey.
Current U.S. prevalence estimates:
What Causes Cleft Lip and Cleft Palate?
The lip normally forms early in pregnancy, generally between the fourth and seventh weeks. The palate develops slightly later, approximately between the sixth and ninth weeks. A cleft occurs when the developing tissues do not fully join.
In most cases, doctors cannot identify one single cause. Researchers generally describe cleft lip and cleft palate as multifactorial conditions, meaning they may result from a combination of genetic susceptibility and environmental influences.
This point matters: a cleft is usually not the result of something a parent deliberately did or failed to do. Families often search their memories for one meal, one stressful week, or one missed prenatal vitamin. Human development is considerably more complicated than thatand considerably less interested in assigning blame.
Genetic Influences
Some clefts occur as isolated conditions, while others are associated with a genetic syndrome or chromosome difference. A family history of cleft lip or palate can increase risk, but many babies with clefts have no close relative with the condition.
Genetic counseling may be recommended when a cleft occurs with other physical findings, developmental concerns, heart problems, airway differences, or a family history of similar conditions. A genetic counselor can explain testing options and discuss the estimated chance of recurrence in a future pregnancy.
Environmental and Pregnancy-Related Risk Factors
Research has identified several factors associated with a higher likelihood of orofacial clefts. These include smoking during pregnancy, diabetes that existed before pregnancy, and exposure to certain medications, including some antiseizure medicines.
An association does not mean every exposure causes a cleft or that every cleft could have been prevented. Pregnant patients should never stop a prescription medication without medical guidance. Abruptly stopping treatment for epilepsy, diabetes, or another serious condition may create substantial risks for both parent and fetus.
People who are pregnant or planning pregnancy should review medications with a qualified healthcare professional, avoid tobacco, manage chronic health conditions, and follow recommendations for prenatal vitamins and folic acid.
Developmental timing, multifactorial causes, risk factors, and genetic consultation:
How Is a Cleft Diagnosed?
Many cleft lips are detected during a prenatal ultrasound, often around the mid-pregnancy anatomy scan. When a cleft lip is identified before birth, families may be referred to a cleft and craniofacial team for prenatal counseling.
Isolated cleft palate is much harder to see on a routine ultrasound because it is located inside the mouth. It may be diagnosed during a newborn examination. Submucous clefts and other subtle palatal differences may not become apparent until feeding, hearing, or speech concerns develop.
A prenatal diagnosis can feel alarming, but it also gives families time to meet specialists, learn feeding techniques, discuss delivery planning, and replace frantic late-night searching with an actual care plan.
Prenatal and postnatal diagnosis:
Feeding a Baby With a Cleft
Feeding difficulty is especially common when the palate is involved. To create suction, a baby normally presses the nipple against the palate while sealing the mouth and separating it from the nasal cavity. An opening in the palate can make that suction weak or ineffective.
Many babies with an isolated cleft lip can breastfeed or use a standard bottle, although positioning support may help. Babies with a cleft palate often require a specialized bottle with a one-way valve, squeezable reservoir, or other system that allows milk to flow with compression rather than suction alone.
Practical Feeding Strategies
- Hold the baby in a more upright position to reduce nasal regurgitation.
- Use the bottle and nipple recommended by the cleft feeding specialist.
- Follow the baby’s breathing and swallowing cues instead of forcing a fixed pace.
- Burp frequently because babies may swallow extra air.
- Monitor feeding duration, hydration, and weight gain.
- Contact the care team if feeding regularly takes longer than about 30 minutes or the baby tires, coughs, chokes, or gains weight slowly.
Milk coming through the nose can look dramatic, but occasional nasal regurgitation is not unusual with a cleft palate. Repeated choking, breathing difficulty, bluish coloring, marked fatigue, or poor growth requires prompt medical evaluation.
Families interested in providing breast milk may be able to pump and offer expressed milk through a specialty feeder. A feeding therapist, cleft nurse, pediatrician, or lactation consultant familiar with clefts can help create a safe plan.
Feeding challenges, specialty bottles, positioning, pacing, and monitoring:
Cleft Lip and Palate Treatment
Treatment is individualized. Two children with similar-looking clefts may follow different timelines because of their airway, growth, medical history, facial development, dental needs, or surgical plan.
High-quality care is usually coordinated by an interdisciplinary cleft or craniofacial team. Depending on the child’s needs, the team may include a plastic surgeon, oral and maxillofacial surgeon, pediatrician, ear-nose-and-throat specialist, audiologist, speech-language pathologist, orthodontist, pediatric dentist, feeding specialist, genetic counselor, psychologist, social worker, and specialized nurse.
Presurgical Treatment
Some babies receive presurgical orthopedics such as lip taping or nasoalveolar molding, commonly called NAM. NAM uses a custom appliance to gradually guide the gums, lip, and nose into a more favorable position before surgery. It is not necessary for every child, and its use depends on the cleft team’s approach and the baby’s anatomy.
Cleft Lip Repair
Cleft lip repair is commonly performed during the first several months of life and is generally recommended within the first year. The surgeon reconnects the lip muscle, closes the opening, and shapes the upper lip and nose.
The goal is functional as well as cosmetic. Lip muscles influence feeding, facial expression, and growth. Scars usually soften and fade with time, although revision surgery may be considered later for selected patients.
Cleft Palate Repair
Palate repair is often completed around the first birthday and is generally recommended before 18 months, although exact timing varies. The surgeon closes the communication between the mouth and nose and repositions the soft-palate muscles to support swallowing and speech.
The palate must do more than look closed. During speech, it needs to lift and contact the back and sides of the throat, briefly separating the mouth from the nose. Restoring this function is one of the central goals of palatal surgery.
Dental, Orthodontic, and Jaw Treatment
A cleft involving the gum ridge can affect the position, shape, or number of teeth. Children may need preventive dental care, expansion of the upper arch, braces, or an alveolar bone graft during the mixed-dentition years.
An alveolar bone graft places bone into the cleft in the upper gum, helping support permanent teeth and stabilize the dental arch. Some teenagers or young adults later need jaw surgery if the upper and lower jaws do not align after facial growth is complete.
Why Treatment May Continue Into Adulthood
A successful infant repair is a major milestone, not necessarily the final chapter. Additional treatment may address a palatal fistula, nasal shape, breathing, dental alignment, jaw position, scarring, or persistent speech concerns. The timeline is often measured in developmental stages rather than one dramatic “before and after” moment.
Team care, surgery timing, NAM, dental treatment, bone grafting, and longitudinal care:
Why Cleft Palate Can Affect Hearing
The muscles of the soft palate help open the eustachian tubes, which ventilate the middle ears. When those muscles do not work normally, fluid can collect behind the eardrums. This may lead to recurrent ear infections or temporary conductive hearing loss.
Even mild hearing loss can make speech and language learning harder. A child who hears muffled consonants may naturally produce muffled consonants. That is not stubbornness; it is acoustics doing an unhelpful little magic trick.
Children with cleft palate commonly receive regular hearing evaluations and examinations by an ear-nose-and-throat specialist. Tympanostomy tubes may be recommended to ventilate the middle ear, but practices vary according to the child’s history and the team’s clinical findings.
Middle-ear dysfunction, hearing surveillance, and its relationship to communication:
How Cleft Palate Affects Speech
A cleft lip by itself usually does not cause a major speech disorder. A cleft palate can affect speech because it changes how air pressure and sound move through the mouth and nose.
Most English consonants require air to be directed through the mouth. Sounds such as p, b, t, d, k, g, s, and z depend on controlled oral airflow or pressure. During normal speech, the soft palate lifts to close the space between the throat and nose. This is called velopharyngeal closure.
If the palate is too short, does not move effectively, or cannot reach the throat, air may escape through the nose. This condition is called velopharyngeal dysfunction or velopharyngeal insufficiency.
Common Speech Characteristics
- Hypernasality: Too much sound resonates in the nasal cavity, especially during vowels.
- Nasal air emission: Air can be heard or seen escaping through the nose during pressure consonants.
- Weak consonants: The child may have difficulty building enough oral pressure for crisp sounds.
- Compensatory articulation: The child learns to make sounds farther back in the throat to work around the structural problem.
- Reduced intelligibility: Listeners may have difficulty understanding the child, particularly in longer sentences.
Compensatory errors may include glottal stops, pharyngeal fricatives, or unusual backing of sounds. These patterns can become learned habits, even after the palate has been repaired.
Speech mechanism, resonance, nasal emission, compensatory errors, and VPI:
When Does Speech Therapy Help?
Speech therapy is valuable for learned articulation errors. A speech-language pathologist can teach the child where to place the lips and tongue, how to direct air through the mouth, and how to replace a throat-based sound with the intended consonant.
However, therapy cannot physically lengthen a short palate, close a fistula, correct major dental misalignment, or force an inadequate velopharyngeal valve to seal. Structural problems generally require surgical, dental, orthodontic, or prosthetic management.
This distinction prevents children from spending years practicing sounds their anatomy cannot yet produce correctly. Speech therapy is powerful, but it is not wizardry wearing a name badge.
How Speech Is Evaluated
A cleft-trained speech-language pathologist listens to resonance, nasal airflow, consonant production, voice, language, and overall intelligibility. Hearing should also be evaluated because unnoticed hearing loss can affect speech development.
When velopharyngeal dysfunction is suspected, the team may recommend nasoendoscopy. A small flexible camera is passed through the nose so specialists can observe the palate and throat during speech. Videofluoroscopy, pressure-flow testing, or computerized measurement of nasal resonance may also be used in selected cases.
Treatment for Persistent Velopharyngeal Dysfunction
When the palate cannot close adequately despite appropriate articulation, treatment may include revision palatoplasty, a pharyngeal flap, sphincter pharyngoplasty, palate-lengthening procedures, or another operation selected according to the closure pattern.
For some patients, a prosthetic device such as a palatal lift or speech bulb may help. Speech therapy is often provided before or after physical management to correct articulation patterns and improve intelligibility.
Appropriate limits of speech therapy, assessment, imaging, prosthetics, and secondary surgery:
Emotional and Social Support Matters
Children may receive questions about scars, speech, dental appliances, or facial appearance. Parents cannot control every comment, but they can help a child develop confident, age-appropriate responses.
Useful support may include counseling, school communication plans, peer groups, and opportunities to meet other children or adults with craniofacial differences. Adults should also watch for teasing, avoidance of speaking in class, anxiety about photographs, or reluctance to attend medical appointments.
The preferred language varies. Some people describe themselves as having been “born with a cleft,” while others identify more strongly with the cleft and craniofacial community. Following the individual’s preference is more respectful than assuming everyone wants the same terminology.
Psychosocial care, participation, communication impact, and long-term support:
A Realistic Cleft Care Journey: Experiences Families Often Describe
The following examples are composites based on common care experiences rather than the story of one specific patient.
The First Feeding Can Feel Like the First Big Test
Many parents describe feeding as their earliest challenge. They may leave the hospital carrying a specialty bottle, several instruction sheets, and the unsettling realization that their newborn did not read any of them.
The first attempts can be messy. Milk may appear at the nose. The baby may swallow air and need frequent burping. Parents may worry that every sound means choking. With guidance, they usually become skilled at watching breathing cues, controlling milk flow, adjusting the bottle angle, and recognizing when the baby needs a pause.
Keeping a feeding log can make progress easier to see. Recording the amount taken, feeding duration, wet diapers, and weight checks also gives the medical team useful information. What initially feels like a complicated procedure often becomes an ordinary family routine surprisingly quickly.
Surgery Day Brings Relief and Anxiety at the Same Time
Parents commonly describe mixed emotions before lip or palate surgery. They want the repair, yet handing a baby to an operating-room team can feel deeply unnatural. The waiting period may seem longer than the entire first year of parenthood, even when the clock insists otherwise.
After lip repair, swelling and stitches may make the result difficult to appreciate immediately. After palate surgery, a child may be uncomfortable, congested, irritable, or temporarily less interested in eating. Families often find that recovery improves in small steps: a better night of sleep, more interest in fluids, a return to smiling, and finally the unmistakable demand for a favorite toy.
Speech Progress Is Rarely a Straight Line
Some children develop clear speech after palate repair with little or no therapy. Others need targeted help. A child might master p in a therapy session but return to an old throat-based production while excitedly explaining a playground emergency involving a ball, a puddle, and somebody’s missing shoe.
That inconsistency is common during learning. Short, frequent practice often works better than turning the kitchen table into a nightly speech examination. Families can practice target words during play, reading, or daily routines while avoiding constant correction that makes a child reluctant to talk.
When progress remains limited, families sometimes assume the child is not trying hard enough. A structural reassessment may reveal that air is still escaping through the nose. Identifying the difference between a learned error and a physical limitation can save time, frustration, and many unnecessary repetitions of “Say it again.”
Team Visits Become Developmental Checkpoints
As children grow, the focus of appointments changes. Infancy may center on feeding and surgery. Preschool visits emphasize hearing, speech, and early dental care. School-age treatment may involve braces, expansion, bone grafting, or classroom communication. Teenagers may participate more directly in decisions about jaw alignment, nasal breathing, scar revision, or appearance.
Families often benefit from keeping a single medical folder containing operative reports, hearing results, dental images, speech evaluations, medication lists, and questions for the next visit. Cleft care involves many specialists, and even excellent professionals appreciate organized information.
The Child Is Always More Than the Treatment Plan
Appointments and procedures can occupy a large part of family life, but they should not become the child’s entire identity. Children with cleft lip and palate have the same need for independence, friendships, humor, privacy, and ordinary mischief as their peers.
The long-term goal is not perfection. It is comfortable eating, reliable hearing, understandable speech, healthy teeth, confident social participation, and the freedom to spend less time thinking about medical care. With coordinated treatment and appropriate support, most children with clefts grow into healthy, active adults whose lives are far larger than a diagnosis made at birth.
The composite experiences above reflect common clinical themes involving feeding education, surgical recovery, speech monitoring, longitudinal team care, and family support:
Conclusion
Cleft lip and cleft palate develop early in pregnancy when parts of the lip or roof of the mouth do not join completely. Their causes are usually complex, involving a combination of genetic and environmental factors rather than a single preventable event.
Treatment may include specialty feeding support, lip repair, palate repair, hearing care, speech-language services, dentistry, orthodontics, bone grafting, and additional surgery as the child grows. The most effective care is coordinated by an experienced cleft and craniofacial team that evaluates the whole childnot merely the visible opening.
Speech deserves particular attention because therapy and surgery solve different problems. Learned articulation patterns may improve with targeted speech therapy, while persistent hypernasality or widespread nasal air escape may signal a structural problem requiring further evaluation.
With timely treatment, careful hearing and speech monitoring, and strong family support, most children born with cleft lip or cleft palate can eat, communicate, learn, build relationships, and lead healthy lives.
