Advanced Veterinary Nursing for Patients With Cleft Palate

Cleft palate (palatoschisis) is a congenital malformation affecting the face that may present as an isolated defect or in conjunction with a cleft lip (cheiloschisis). Affected neonates cannot generate the negative intraoral pressure required for effective suckling, which predisposes them to aspiration pneumonia, malnutrition, and developmental failure. Surgical correction is the gold standard of treatment; however, it is usually not performed until the patient is 4 to 6 months old. Therefore, meticulous supportive care, including alternative nutritional delivery methods such as orogastric tube feeding, is required until the patient is old enough for surgery. Veterinary nurses are integral to this process, providing crucial client education on proper feeding protocols, monitoring neonatal growth, and guiding postoperative care.

Cleft Palate Classifications

There are 3 types of cleft palate^1,2:

• Cleft of the primary palate: More commonly known as cleft lip, these clefts might involve only the soft tissues (lip and nose) anterior to the incisive foramen. They can also affect the maxilla and incisive bone (Figure 1).
• Cleft of the secondary palate: These clefts are located posterior to the incisive foramen and may involve the hard palate, the soft palate, or both (Figure 2).
• Cleft lip and palate: These clefts affect both the primary and secondary palates (Figure 3).

While clefts are typically on the midline, cases of left- or right-sided soft palate clefts have been documented. Clefts of the secondary palate occur more commonly than cleft lip or a cleft lip/palate combination, according to a recent canine survey-based study.¹

Figure 1. Cleft of the primary palate (cleft lip) in a puppy. Courtesy Save the Clefts Rescue

Figure 2. Cleft of the secondary palate (cleft palate) in a dog. Courtesy Dr. Villamizar-Martinez, NC State Veterinary Hospital

Figure 3. Combined cleft lip and palate in a dog. Note: Although the person handling the dog’s mouth in this photo is not wearing gloves, gloves should always be worn when interacting with the oral cavity. Courtesy Save the Clefts Rescue

Cleft Palate Etiology

Orofacial clefts in dogs and cats arise during embryonic development, typically between days 25 and 39 of gestation for dogs and between days 10 and 21 for cats. These clefts are complex and can be caused by genetic and/or environmental factors. Purebred cats, such as Siamese, are predisposed, although the specific genes responsible are not currently known.^1,3 Certain dog breeds have a documented autosomal recessive inheritance pattern, including boxers, Nova Scotia duck tolling retrievers, and Pyrenean shepherds.¹ Dogs from the mastiff/terrier genetic cluster also have a higher risk of cleft development than dolichocephalic (long-nosed) breeds.^1,2 Other dog breeds that have a higher prevalence of clefts include brachycephalic (short-nosed) breeds such as Boston terriers, French bulldogs, Cavalier King Charles spaniels, and English bulldogs. Orofacial clefts are uncommon in dolichocephalic breeds.⁴

Studies in dogs and cats have established a correlation between hypervitaminosis A caused by excessive maternal vitamin A intake and the development of cleft palate in offspring.⁴ Hypervitaminosis A can occur through oversupplementation of commercially available diets with sources of vitamin A such as liver or fish oil.⁴ Therefore, careful dietary management is crucial during gestation.^4-6 Viral infections during pregnancy, maternal drug exposure, and nutritional imbalances are also believed to be factors in cleft palate development.^1,4,5

Clinical Management of Cleft Palate in Neonates

The clinical signs of cleft palate are often evident in neonates shortly after birth. Initial observations commonly include nasal discharge of milk, which indicates a direct communication between the oral and nasal cavities. Affected animals typically exhibit dysphagia (difficulty swallowing), gagging, or coughing during attempts to feed.^1,3 Additional clinical findings may include sneezing and failure to thrive due to inadequate nutritional intake.^1,3

The clinical management of a neonatal patient with a cleft palate requires a comprehensive and systematic approach. Upon presentation, the veterinary team must conduct a thorough physical examination to assess the patient’s overall health status. This includes evaluation for signs of malnutrition, dehydration, and any other congenital anomalies. Key parameters to assess are body weight and body condition score, which provide direct metrics of caloric intake. Hydration status is assessed via skin turgor, mucous membranes, and capillary refill time. Additionally, auscultation of the heart and lungs is critical to identify potential murmurs or pulmonary complications. A definitive diagnosis of cleft palate is established through a careful visual inspection of the oral cavity, particularly the hard and soft palate.

Common complications associated with this congenital defect include rhinitis and, most critically, aspiration pneumonia.¹ These complications arise from aspiration of food and liquid into the nasal passages and lower respiratory tract. Obtaining thoracic radiographs is crucial if aspiration pneumonia is suspected, allowing for a definitive diagnosis and the initiation of appropriate therapeutic interventions.

The Veterinary Nurse’s Role

The veterinary nurse is indispensable in providing support throughout the patient’s care, beginning with the initial assessment and continuing through stabilizing the patient and administering prescribed supportive care. A primary responsibility is nutritional management, which involves calculating and preparing the appropriate formula or milk replacer and administering it via orogastric or esophagostomy tube feedings. This feeding method is essential as it bypasses the palatal defect, preventing the risk of aspiration.

The veterinary nurse is also responsible for continuous monitoring, including tracking the patient’s daily weight, evaluating for signs of regurgitation or other feeding complications, and maintaining detailed medical records to identify any complications early. Ultimately, diligent nursing care and monitoring are fundamental to ensuring the neonate’s survival and successful development until surgical correction can be performed at a more appropriate age.

Tube Feeding and Nutrition

A cleft palate prevents a neonate from creating the negative pressure necessary for suckling, which is essential for proper feeding. This limitation results in insufficient nutrition, which can lead to a failure to thrive and a lack of weight gain. Given the significant risk of aspiration, oral feeding is contraindicated; therefore, nutritional support in the form of tube feeding is an immediate intervention that is critical for the patient’s survival.^2,6,7 Tube-fed diets must be nutritionally balanced to support the animal’s development. It is highly recommended that a board-certified veterinary nutritionist be consulted for accurate, tailored nutritional calculations.

To ensure that these patients receive essential nutrients for growth and development, and to prevent the life-threatening complication of aspiration pneumonia caused by accidental introduction of food into the lungs, it is vital to be proficient in accurately placing orogastric or nasogastric tubes. The meticulous execution of tube feeding protocols is a cornerstone of care for these patients, and expertise in this area is indispensable for a positive outcome (Box 1).

Client Education

Beyond clinical management, owner education is paramount for a successful outcome. Veterinary nurses play a huge role in client communication, providing empathetic support and explaining the diagnostic process and immediate care plan to anxious owners, who are often overwhelmed by their pet’s condition. The veterinary team, particularly the veterinary nurse, must thoroughly train the owner on the proper technique for tube feeding, including the correct amount to be given at each feeding, proper preparation of the formula, frequency of feedings, sanitation protocols, and crucial safety measures to prevent aspiration (Box 2). The owner must also be educated on how to monitor the neonate’s weight gain and recognize signs of distress or complications. Comprehensive guidance empowers the owner to provide essential at-home care, which is critical for the patient’s long-term health and growth.

Long-Term Management of Cleft Palate

Historically, the clinical approach to a neonate with a cleft palate was limited to 2 options: definitive surgical repair or euthanasia. However, a recent study has introduced a third potential option of long-term conservative medical management.²

The gold standard for treating a persistent oronasal communication is surgical repair, which aims to create a permanent physical barrier between the oral and nasal cavities (Figure 4). It is essential that this procedure be performed by an experienced, board-certified veterinary surgeon to ensure optimal outcome and minimize the risk of complications.

Figure 4. Surgically repaired cleft palate in a dog 2 weeks after surgery.

Medical management is required for all patients to sustain them until they are old enough for definitive surgical correction, typically around 4 to 6 months of age.^1,7 This timing is crucial as it allows for the eruption of permanent teeth (Table 1) and the establishment of more complete maxillofacial growth, which increases the success rate of the procedure.^1,6,7

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For patients in which surgical intervention is not a viable option, due to either their overall health status or owner preference, medical management can be a long-term solution. One nonsurgical method involves the use of obturators, which are custom-fitted devices used to physically close the oronasal communication, thereby preventing the aspiration of food and liquid (Figure 5).^1-3

Figure 5A. Use of an obturator in a dog- Palatal defect. Courtesy Dr. Villamizar-Martinez, NC State Veterinary Hospital

Figure 5B. Use of an obturator in a dog- Customized obturator. Courtesy Dr. Villamizar-Martinez, NC State Veterinary Hospital

Figure 5C. Use of an obturator in a dog- Obturator in place. Courtesy Dr. Villamizar-Martinez, NC State Veterinary Hospital

Surgical Management of Cleft Palate Patients

The successful surgical management of cleft palate requires attention to both preoperative and postoperative considerations. A comprehensive preoperative assessment is crucial for surgical planning and ensuring patient safety. Computed tomography is recommended before surgical intervention to precisely define the extent of the defect and identify any concurrent maxillofacial abnormalities.¹ A CBC, serum chemistry panel, and thoracic radiography are essential to evaluate the patient’s overall health and assess for potential pulmonary complications, such as aspiration pneumonia, before general anesthesia.^1,3

Postoperative care is critical to prevent complications and promote healing. Nutritional support is a cornerstone of successful recovery. While not all patients require a feeding tube postsurgery, great care must be taken during feeding to prevent dehiscence, or breakdown, of the palatal repair site. A soft recovery diet, which can be prepared as a slurry or formed into small meatballs, is often recommended to minimize trauma to the surgical site.

Postoperative Feeding

Common feeding tubes used postoperatively are nasogastric, nasoesophageal, and esophagostomy tubes.^8,9 Esophagostomy tubes offer several key benefits for patient care. They are simple to place in animals of all sizes and cause minimal postoperative discomfort, which helps to shorten the length of a hospital stay. They are also easy for owners to maintain, provided the stoma is kept clean.

A major advantage of esophagostomy tubes is their suitability for long-term use, making them a good option for patients who require extended medication or nutritional support. When an esophagostomy tube is no longer needed, it can be easily removed by simply cutting the sutures. The stoma heals remarkably quickly, often within an hour.⁸

Given their narrow diameter, nasogastric and nasoesophageal tubes are best suited for administering liquid veterinary diets. In a hospital setting, postoperative trickle feeding via a constant-rate infusion is common, although these tubes can also be used for bolus feedings and for giving liquid oral medications.⁹ Nasogastric and nasoesophageal tubes need to be removed before sending a patient home.

Postoperative Instructions for Clients

To ensure a smooth recovery, clients must follow several restrictions and care protocols:

• Medication: Administer antibiotics as prescribed, especially if the pet has concurrent pneumonia or a nasal infection.
• Preventive measures: A soft E-collar (Elizabethan collar) should be worn for 1 to 2 weeks to prevent the pet from rubbing or scratching its face and surgical site and causing dehiscence.
• Dietary restrictions: For 2 to 4 weeks following the procedure, feed a soft, blenderized diet, either orally or via a feeding tube. To avoid damage to the surgical site, hard foods and toys should be completely restricted for at least 1 month.^3,8,9

Veterinary nurses are responsible for monitoring patients for a range of complications, including refeeding syndrome, food aversion, fluid overload, and electrolyte imbalances. They should also watch for feeding tube issues, such as tube malfunction and infections at the insertion site.⁹

Postoperative Complications

Due to patients’ young age and potential for being underweight or having preexisting respiratory issues, anesthesia and recovery for cleft palate repair can carry significant risks. Postsurgical swelling of the soft palate is common, which may cause breathing difficulties or snoring; however, this typically resolves on its own.³ Signs such as increased abdominal effort; open-mouthed breathing; neck extended and/or head held low with shallow, rapid breathing; or a pale to bluish-purple tongue and mucous membranes can indicate the patient is in distress and needs immediate attention.

Dehiscence of the palatal flaps—the breakdown of the surgical incision—presents a significant postoperative challenge. Dehiscence can have several causes, including suboptimal closure technique, patient self-trauma, chewing on inappropriate items, and infection.

Should the initial surgical repair fail, a second surgical attempt can be considered if the remaining tissues are deemed viable and sufficient for reclosure. Alternatively, an obturator can be placed. Obturators can be used as a temporary measure before a second surgery or as a long-term alternative to surgical repair, particularly when the patient is not a suitable candidate for additional anesthetic procedures.¹

Summary

Cleft palate is a serious congenital anomaly in pets that requires immediate and diligent medical intervention to ensure the neonate’s survival and growth. The most critical short-term concern is the risk of aspiration pneumonia due to the inability to feed properly. Therefore, the cornerstone of initial treatment is providing nutritional support via orogastric tube feeding while waiting for the patient to reach the appropriate age for surgical correction.

The veterinary nurse plays an indispensable role in this process, from providing hands-on care and monitoring to empowering owners with the knowledge and skills needed for home management. While surgical repair is the definitive long-term solution, a comprehensive approach involving immediate nutritional support, diligent monitoring, and thorough client education is essential for a successful outcome.