More South Africans with cleft palates could be spared physical and emotional pain if there were a larger number of specialised surgeons to operate on them, medical experts say. The country has only 10 maxillofacial surgeons and 20 plastic surgeons doing this surgery and only 10 treatment clinics where this common birth condition can be dealt with.
The resources crisis in health care, affecting especially anaesthetists and theatre nurses, reduces theatre availability and the time for hands-on collegial teaching.
A cleft palate is an opening or split in the roof of the mouth that occurs when the tissue doesn’t fuse during development in the womb. A cleft palate often includes a split in the upper lip (a cleft lip) but can occur without affecting the lip.
Surgeons tell the FM of weekly appointments with patients for whom treatment at an earlier age would have avoided the pain and stigma they experienced.
Late case presentation and low awareness are major treatment barriers for the disfiguring condition, say Prof Anil Madaree, medical director of Operation Smile South Africa, who is also head of the department of plastic and reconstructive surgery at Durban’s Albert Luthuli Tertiary Hospital, and Prof Risimati Rikhotso, head of the department of maxillofacial surgery in health sciences at Wits University.
The professors are among the few physicians who treat the condition, which also causes speech impediments, educational handicaps and major discomfort. Most operations take just under an hour, and transform lives, they say.
Last month such transformations were achieved at no cost to 42 young patients. The global Operation Smile, just 16 years old in South Africa, turned its surgical knowledge into a skills transfer programme that began at the Nelson Mandela Children’s Hospital in Joburg.
Twenty-four newly qualified maxillofacial surgery specialists and younger registrars, plus an equal number of colleagues online, attended a day-long clinical teaching session at the hospital. During another two days some of them observed five top surgeons operate on children with cleft lips and palates. The children were aged between 12 months and 12 years.
Operation Smile CEO Sarah Scarth reassured parents that children who had not been chosen for the operation (for a variety of risk-associated reasons, including body weight and co-morbid conditions), would continue to be cared for, with regular reassessments for when surgery would become appropriate.
The closer the patient is to the ages of one and four years the better the outcome
— Anil Madaree
Also present for the five-day programme were psychologists, social workers, orthodontists, dentists, paediatricians, intensivists, biomedical technicians, speech therapists and theatre nurses. All took part in the preoperative screening of 60 surgery candidates, and helped with post-operative care.
Saleigh Adams, a professor of plastic surgery at the University of Cape Town, says the cleft palate condition occurs across the country and affects one in 500 Asian, one in 1,000 white and one in 2,000 black people. Madaree says a combination of cleft lip and cleft palate occurs in more than 20% of patients.
Those attending the Operation Smile event in Joburg were told that surgery is best done when patients are three to four months of age, as this enables better post-operative physical development and adaptation. Madaree says surgery helps most before a child has learnt to talk and make sounds. “Otherwise their sounds and language get ingrained, and they learn bad speech habits,” he says.
Madaree says that when palate repair is done late, the effect on speech is not as beneficial, but that it nevertheless improves by 60% or more. The services of a speech therapist are indispensable, he says.
“The closer the patient is to the ages of one and four years, the better the outcome,” Madaree says. But he adds that he has operated on a 75-year-old with excellent results.
The medical experts at the event said the causes of cleft lips and palates were genetic and dietary. Adams says the causes are 50% genetic or hereditary and 50% environmental, and says the University of the Western Cape is conducting advanced gene studies on the subject.
Scarth says that globally, one in 10 people with cleft lips and/or palates die of malnutrition because they are unable to eat or consume enough food to avoid starvation.
Operation Smile’s world care programme flies the more severe cases from distant areas to places where there are people with skills and services to deal with the condition. Recently children and their treating physicians were flown to South Africa from the Democratic Republic of Congo and Mozambique.
Researchers at the Red Cross War Memorial Children’s Hospital in Cape Town who studied maternal behaviour found that among mothers with cleft-palate babies 65% had a high school education and 51% were unemployed. Altogether 31% were smokers (the Cape Flats being notorious for smoking among women); of these, 16% continued to smoke during pregnancy.
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