Does Early Referral Lead to Early Repair? Quality Improvement in Cleft Care

Abstract

BACKGROUND/PURPOSE: Cleft lip and palate (CLP) is the most common congenital birth defect of the head and neck, occurring in approximately 1 in 700 live births. This diagnosis can often be made prenatally by conventional or 3-dimensional ultrasound. Early cleft lip repair (ECLR) (<3 months of age) for unilateral cleft lip, regardless of cleft width, has been the mainstay of cleft lip reconstruction at our institution for the past 6 years. Prior to this novel protocol, traditional lip repair (TLR) was performed at 3-6 months of age ± preoperative nasoalveolar molding (NAM). Previous publications from this institution report on the benefits of ECLR, such as enhanced aesthetic outcomes, decreased revision rate, better weight gain, increased alveolar cleft approximation, cost savings of NAM, and improved parent satisfaction. Occasionally, parents are referred to our institution for prenatal consultations to discuss ECLR. The purpose of this study was to evaluate the timing of both prenatal cleft diagnosis and preoperative surgical consultation as well as referral patterns to validate whether prenatal diagnosis and prenatal consultation lead to ECLR. METHODS: A retrospective chart review evaluated patients who underwent ECLR or TLR±NAM from November 2009-January 2020. Timing of repair, cleft diagnosis, and surgical consultation, as well as referral pattern, were abstracted upon review. Inclusion criteria dictated: age <3 months (ECLR group) or 3-6 months (TLR); no major comorbidities (ASA class I/II); and diagnosis of non-syndromic unilateral cleft lip without palatal involvement. Patients >6 months, or with bilateral cleft lip, cleft palate, clefts associated with craniofacial syndromes, or significant systemic comorbidities were excluded. RESULTS: Upon review, 51 patients (47.7%) received ECLR while 56 patients received TLR (52.3%). The average age at surgery was 31.8 days for the ECLR cohort and 112 days for the TLR cohort. Of these 107 patients, 75 patients (70.1%) were diagnosed prenatally with unilateral cleft lip while only 5.6% of families (6/107) had a prenatal consult for cleft lip repair, all of which underwent ECLR (11.8% of ECLR cohort). The majority of patients who received ECLR were referred by a pediatrician (n=39, 76.5%). A statistically significant association was found between the incidence of prenatal consults and ECLR (p=0.008). Additionally, prenatal diagnosis of unilateral cleft lip was significantly correlated with the incidence of ECLR (p=0.027). CONCLUSION: Our data demonstrates significance between prenatal diagnosis of cleft lip and prenatal surgical consultation with the incidence of ECLR; accordingly, we advocate for education to the referring providers as well as those in the surrounding community about the benefits of ECLR and the potential for prenatal surgical consultation. Efforts will be expanded to Obstetrician/ Gynecologists and Maternal-Fetal Medicine providers in the hopes that patients and families alike may enjoy the myriad benefits of ECLR. Further research should investigate the correlation of socioeconomic status with prenatal consultation for ECLR.