THE IMPORTANCE OF A MULTI-DISCIPLINARY APPROACH
by Joanne Green

Cleft lip and palate is the most frequently occurring craniofacial deformity. Problems associated with cleft lip and palate can be adequately addressed in today's medical environment. However, because a child with a cleft represents a complex mix of problems associated with the deformity, the reconstruction process is most effectively approached by a team of professionals.

Treatment of a cleft begins at birth and continues throughout the child's growing years. While different needs are more pressing at different growth phases, all the members of the team contribute important input at every stage. Regular comprehensive evaluations and subsequent treatment by experts ensures the best possible outcome for every facet of the cleft condition.

Such teams can be found in almost every metropolitan area, as well as in many areas that may be considered less metropolitan. How does one go about finding such a team, and who are the specialists that may be working with the cleft child? Can you hope for good treatment and repair without a team?

These are good questions. First, good treatment CAN be accomplished without the services of a team per se, but the chances are great that BETTER treatment can be assured in a team setting. Many people live long distances from the nearest craniofacial team center and it is not practical to travel the distance for treatment. However, annual or semi-annual evaluations by a team may provide valuable suggestions to the physician who is actually working with the child.

Also, whether or not the child has work that is done by an actual recognized team, there remains a team of professionals working with the child (you may have a pediatrician, a plastic surgeon, an orthodontist, and ENT, etc.,) In such a case it is important that those professionals work well together and regularly consult concerning the child whose treatment they share. While there may be, and always are exceptions, the basic rule is that the care of a child with a cleft will be most comprehensive if provided by a craniofacial or cleft palate team.

Most families find the team in their area through a referral by their obstetrician or pediatrician. Some insurance carriers actually require that you obtain the services of an area team before they will provide coverage, and therefore make a referral. If you are not aware of any cleft palate team in your area you can call the Cleft Palate Foundation at 1-800- 24-CLEFT. They will let you know of any teams practicing near you.

Who makes up their craniofacial team? They are not all doctors. They are a collection of medical and social service providers who speak to the needs of the child born with a cleft and that child's family. The following persons may or may not be on the team treating your child. If one discipline is missing from your team and you feel your child is in need of services provided by that field, your team could refer you to someone in your area.

SURGEON
The Surgeon is often considered the "Captain" of the team. This person provides the plastic, reconstructive surgery on the cleft. This person will close the lip and the palate and provide for any scar revision and rhinoplasty. The plastic surgery to repair and reconstruct the cleft is often done by a Plastic Surgeon. Other persons who may do the plastic surgery include Oral Maxillofacial surgeons, Otolaryngologists, etc. What is important is that the surgeon you choose have experience with and a commitment to cleft repair.

PEDIATRICIAN
The pediatrician looks at the overall well-being of the child. The pediatrician checks the normal growth and development of the child and makes certain that the child is physically fit for upcoming surgical procedures.

PEDIATRIC DENTIST
The role of the pediatric dentist is to ensure that the child's teeth are healthy and strong. Many times children with clefts have teeth in unlikely positions in the mouth. It is sometimes very difficult to keep those teeth clean and therefore healthy. The pediatric dentist helps to maintain a healthy and cavity-free mouth.

ORTHODONTIST
The orthodontist, on the other hand, helps to establish a good shape to the dental arches. A child with cleft may need the services of an orthodontist even before she has teeth! The orthodontist will work to achieve a normal dental arch prior to bone graft surgery, and then follow-up to maintain the integrity of that arch once achieved. The orthodontist will be an active participant in much of the cleft-affected child's care.

PROSTHODONTIST
There are times when a child with a cleft needs a prosthetic device to meet her specific needs. Such prosthetic devices may be an obturator, a bridge, a retainer, an implant, or any one of a number of other devices. The prosthodontist works very closely with the orthodontist and the surgeon to provide the cleft-affected child with necessary appliances.

OTOLARYNGOLOGIST
Sometimes called an ENT (Ear Nose & Throat Doctor), the otolaryngologist helps to keep the ears functioning and clear. Children with clefts typically suffer from poorly functioning Eustachian Tubes and therefore experience a larger than normal number of ear infections. The Otolaryngologist serves to keep those infections at a minimum, and to minimize any damage done subsequent to such infections.

AUDIOLOGIST
The audiologist checks the child's hearing regularly. Recurring ear infections, waxy build-up and fluid behind the ear drum (all common among children with clefts) can rob a child of the ability to hear effectively. The Audiologist measures how well a child is hearing and makes recommendations if a child's hearing is compromised.

SPEECH AND LANGUAGE PATHOLOGIST
The Speech and Language Pathologist assists the child in producing intelligible language. The Speech and Language Pathologist will provide therapy in areas of articulation and language development, depending upon the child's unique need. It may be likely, due to the nature of speech therapy, that your child may see more of the Speech and Language Pathologist, and on a more regular basis,than any other member of the team.

COMMUNITY HEALTH NURSE
The Community Health Nurse assesses the health needs of the entire family and makes recommendations concerning resources that might aid in maintaining the overall health of the household. The Community Health Nurse may also help by instructing the parents on how to feed and otherwise care for the child.

GENETICIST
The Geneticist studies various aspects of the family, the family history, etc. and assists the family in determining a recurrence risk when choosing whether or not to have more children. The Geneticist helps the family gain an understanding concerning the factors that contribute to clefting conditions. The geneticist will also help persons of child-bearing age who were born with clefts to determine the probability of producing a cleft child themselves.

CLINICAL SOCIAL WORKER
The Clinical Social Worker helps the family to deal with all the issues that touch them concerning the cleft. Issues of grief, finance, emotional and moral support, feelings of anger and guilt, and so forth, are non-medical topics that affect the over-all treatment of the child and the family. The Clinical Social Worker will help the family to access appropriate resources and to network for support.

PSYCHOLOGIST
The Psychologist works with the child alone, the parents alone, or the family as a group to ensure normal functioning. Many times parents find a child's disability or deformity difficult to adjust to. Oftentimes a child with a cleft has self-esteem issues that limit his potential. The Psychologist will provide intervention that speaks directly to those needs.

The child born with a cleft presents a large package of treatment concerns. The particulars of that package are diverse. The craniofacial team is by definition a group of experts capable of speaking to each of the issues that child might present. How often a child visits the team depends on many factors. Those factors include the child's age and stage of reconstruction; distance between the clinic and the child's home; the specific needs presented by the child at that point in time; the requirements of the insurance carrier; and many more. But because the craniofacial team provides experts in all the disciplines that affect a child with a cleft lip and palate, team treatment and evaluation is most highly recommended.

------------------------------------

Joanne Green is the mother of three children born with cleft lip and palate. She is also the editor of WIDE SMILES Magazine.