Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic.

OBJECTIVE: To quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31 March 2021; 2020/2021) compared with the preceding year (1 April 2019 to 31 March 2020; 2019/2021). DESIGN: National observational study of administrative hospital data. SETTING: National Health Service hospitals in England. STUDY POPULATION: Children <5 years undergoing primary repair for an orofacial cleft Population Consensus and Surveys Classification of Interventions and Procedures-fourth revisions (OPCS-4) codes F031, F291). MAIN EXPOSURE: Procedure date (2020/2021 vs 2019/2020). MAIN OUTCOMES: Numbers and timing (age in months) of first primary CLP procedures. RESULTS: 1716 CLP primary repair procedures were included in the analysis. In 2020/2021, 774 CLP procedures were carried out compared with 942 in 2019/2020, a reduction of 17.8% (95% CI 9.5% to 25.4%). The reduction varied over time in 2020/2021, with no surgeries at all during the first 2 months (April and May 2020). Compared with 2019/2020, first primary lip repair procedures performed in 2020/2021 were delayed by 1.6 months on average (95% CI 0.9 to 2.2 months). Delays in primary palate repairs were smaller on average but varied across the nine geographical regions. CONCLUSION: There were significant reductions in the number and delays in timing of first primary CLP repair procedures in England during the first year of the pandemic, which may affect long-term outcomes.

Online Speech Therapy for Cleft Palate Patients in Rural Nepal: Innovations in Providing Essential Care during COVID-19 Pandemic.

BACKGROUND: Speech therapy is important for ideal functional outcome after cleft palate surgery. Nationwide lockdown due to outbreak of COVID-19 in Nepal restricted the ability of patients to travel to nearby outreach centers for regular speech therapy. The objectives were to assess the feasibility and challenges of conducting online speech therapy with postpalatoplasty children during COVID-19 pandemic; and evaluate the ways to overcome them. METHODS: Patients with cleft palate surgery done at least 3 months prior were given online speech therapy. Feasibility, advantages and challenges of online speech therapy were evaluated through interviewing the guardians and speech therapy providers. RESULTS: A total of 89 patients were included in the study. Only 11.2% had secondary palatine procedures. Almost all the children (97.8%) had face to face speech therapy prior to study period. Best use of time, use of audiovisual aid, no need to travel and rapid progress were the most commonly perceived strengths of online speech therapy. The most frequent challenges were internet connectivity, unclear voice, lack of direct interaction and unstable power supply. Recommended ways to improve online speech therapy were cited as better internet connectivity, having a fixed schedule and availing free or affordable Wifi. CONCLUSIONS: Despite the challenges, online speech therapy provided us with a way to reach out to the cleft palate children when face-to-face therapy was not possible due to COVID-19 pandemic. We see its role even during non-pandemic situations for the children who are unable to visit the speech therapy centers.

Smile Train: A Sustainable Approach to Global Cleft Care.

ABSTRACT: Smile Train, the largest global cleft nonprofit organization, employs a model of establishing partnerships with treatment centers and medical professionals in low- and middle-income countries (LMICs). Having a presence in over 90 countries throughout its history, the organization provides support for cleft lip and palate repair as well as comprehensive cleft care (CCC) for patients with clefts. With the goal of reducing disparities in access to quality surgical, anesthesia, and medical care, Smile Train strengthens partners with training, education, equipment, and patient support grants. Furthermore, safety and quality protocols have been put in place as guidelines for each partner center, and partnerships with other nongovernmental agencies were created to increase safety in the operating rooms. The founder of Smile Train desired to apply technology wherever possible to build sustainability within the treatment centers and surgeons supporting their own community. Smile Train's model, aimed at increased sustainability, is supplemented by technological advancements to assist in the safety and quality of cleft care services provided in LMIC treatment centers. Examples include centralized online data record keeping for every patient, virtual simulations and training, and mobile applications to enhance care. Recently, Smile Train's focus is expanding CCC with nutrition, oral health, speech, and nursing care programs to improve functional and psychosocial outcomes for patients following their procedure. Despite the challenges imposed by the COVID-19 pandemic, Smile Train continues to provide safe, efficacious, and CCC alongside their partners in LMICs further investing tremendous efforts towards the livelihood of children with clefts globally.

Impending Backlog of Cleft Palate Patients Due to COVID-19.

Coronavirus disease 2019 (COVID-19) has placed an unprecedented strain on healthcare systems worldwide, but while high-income countries (HICs) have been able to adapt, low- and middle-income countries (LMICs) have been much slower to do so due to a lack of funding, skilled healthcare providers, equipment, and facilities. The redistribution of resources to combat the pandemic in LMICs has resulted in decreased surgical volumes at local surgical centers as well as a dramatic reduction in the number of humanitarian aid missions. Despite recent global investment in improving the surgical capacities of LMICs, even in the pre-COVID-19 era there was a vast unmet surgical need. This deficit in surgical capacity has grown during the pandemic and it will be a significant struggle to overcome the resulting backlog of patients. A topic of particular concern to the authors is the effect that the pandemic will have on the delivery of time-sensitive surgical care to patients with cleft palate deformities as delay in providing care can have enormous physical and psychosocial consequences. This paper draws increased attention to the lasting impact that the COVID-19 pandemic may have on cleft palate patients in LMICs. SSRN Pre-print server link: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3898055.

The limits of pandemic precautions: Tympanostomy tube placement in children with cleft palate during COVID-19.

PURPOSE: Coronavirus Disease-2019 (COVID-19) mitigation measures have led to a sustained reduction in tympanostomy tube (TT) placement in the general population. The present aim was to determine if TT placement has also decreased in children at risk for chronic otitis media with effusion (COME), such as those with cleft palate (CP). MATERIALS AND METHODS: A cohort study with medical record review was performed including consecutive children, ages 0-17 years, undergoing primary palatoplasty at a tertiary children's hospital February 2019-January 2020 (pre-COVID) or May 2020-April 2021 (COVID). Revision palatoplasty (n = 29) was excluded. Patient characteristics and middle ear status pre-operatively and at palatoplasty were compared between groups using logistic regression or Wilcoxon rank-sum. RESULTS: The pre-COVID and COVID cohorts included 73 and 87 patients, respectively. Seventy (44%) were female and median age at palatoplasty was 13.5 months for CP ± cleft lip (CP ± L) and 5.5 years for submucous cleft palate (SMCP). In patients with CP ± L, TT were placed or in place and patent at palatoplasty in 28/38 (74%) pre-COVID and 37/50 (74%) during COVID (P = 0.97). In patients with SMCP, these proportions were 5/35 (14%) and 6/37 (16%), respectively (P = 0.82). Examining only patients <2 years of age also revealed no difference in TT placement pre-COVID versus COVID (P = 0.99). Finally, the prevalence and type of effusion during COVID was similar to pre-COVID. CONCLUSIONS: Reduced infectious exposure has not decreased TT placement or effusion at palatoplasty. Future work could focus on non-infectious immunologic factors underlying the maintenance of COME in these children.

Isolation, Uncertainty and Treatment Delays: Parents' Experiences of Having a Baby with Cleft Lip/Palate During the Covid-19 Pandemic.

OBJECTIVES: Previous literature finds that having a child with a cleft lip and/or palate (CL/P) may pose social and emotional challenges for parents. For parents of children born during the Covid-19 pandemic, such challenges may be heightened. Further, novel demands brought about by the pandemic could have caused additional hardships. The aim of this study was to describe the impact of the pandemic on new parents through qualitative exploration of their experiences. DESIGN: Semi-structured interviews were conducted with 14 parents of children born in the United Kingdom with CL/P between January and June 2020, around the start of the pandemic. Data were analysed using inductive thematic analysis. RESULTS: Three themes, with sub-themes, were identified. The first theme, "Changes to Healthcare: The Impact of Restrictions and Reduced Contact", discussed the impact of the pandemic on perinatal care, the care received from the specialist CL/P teams, and parents' experiences of virtual consultations. The second theme, "Family Functioning During the Pandemic", covered parental anxiety, fathers' experiences, and social support. The third theme, "Surgical Prioritisation: Delays and Uncertainty", addressed changes to surgical protocols, coping with uncertainty, complications associated with delayed surgery, and how parents created positive meaning from this period. CONCLUSIONS: A range of increased and additional psychosocial impacts for parents were identified, along with several coping strategies, utilization of social support, and the positive aspects of their experiences. As the pandemic continues, close monitoring of families affected by CL/P remains imperative, particularly for those at risk of emotional distress.

The impact of COVID-19 on cleft services in Great Britain & Northern Ireland.

INTRODUCTION: Cleft lip and/or palate is the most common craniofacial anomaly and occurs in 1 in 650 to 700 live births in the United Kingdom (UK). The majority of cleft surgery is elective, and as a result, almost all cleft surgery was suspended across the UK in March 2020 during the first national lockdown. The UK has centralised regional Cleft Services which all use the same agreed target-age standards for primary surgery including lip and palate repairs. The coronavirus disease-2019 (COVID-19) response has caused a delay in carrying out procedures. The severity of this delay depends on the impact of COVID-19 on local trusts and R-value within that region. As the country goes through the second and third wave, the impact could be long lasting, and we aimed to quantify it so that the data could be used to guide service prioritisation in the NHS and help future workforce planning. METHODS: An online survey was designed based on the cleft quality dashboard indicators and circulated nationally to all nine cleft regions in the UK. The survey was divided into three main headings: • Duration of suspended cleft services • Quantification of the impact on delayed in surgery/services • Changes needed to restart surgery/services RESULTS: We obtained a 60% response rate with five completed surveys from five out of nine regions. All regions reported that they suspended their cleft services in March 2020 around the time of the first wave and the first national lockdown. There has been an impact on delayed surgical and clinical interventions for cleft patients. Regions were affected differently with some on an exponential waiting list growth projection, whereas other teams are on track to recover from the backlog within 7-22 weeks. There has been an impact on the allied health professionals' services within the cleft multidisciplinary team. The cleft nurses' 24-h reviews, Speech And Language Therapy (SALT), and psychology maintained service delivery in some format. Patient-facing services such as audiology and dentistry were significantly disrupted and continue to experience delays due to reduced capacity. CONCLUSIONS: Various regions have seen a varied impact from COVID-19 on their services, from all cleft regions there seems to be an impact on achieving surgery within the national target age. The adverse effect of the COVID-19 impact is unlikely to be known for a few years to come; however, the data are a useful guide when supporting the allocation of resources within the healthcare setting. A prospective long-term study is required to assess the impact of COVID-19 on cleft surgery, follow-up, assess access to allied health professional MDT clinics, and long-term complications.

Evaluating Psychosocial Problems in School-Age Children with Cleft Lip and Palate in Bandung, Indonesia Using CBCL/6-18.

BACKGROUND: Cleft lip with or without palate (CL ± P) may impact children's eating, drinking, speaking, breathing, and hearing. We aim to evaluate psychosocial problems in Indonesian cleft center school-age patients identified after one or more surgical interventions. METHODS: This is a cross-sectional study of parent report of patients with unilateral CL ± P who had cleft surgery from 2011 to 2016 in the Bandung Cleft Center using the Bahasa Indonesia version of CBCL/6-18 questionnaire. Descriptive statistics were completed based on measure norms and score ranges. RESULTS: There were 104 participants (56.7% male) with a median age of 8 years old and 73.0% had unilateral cleft of lip, gum, and palate. We found that speech and appearance problems were not perceived by parents for 34.6% of participants after undergoing surgery. The majority of parents reported normal range scores for the Social scale (93.3%) and the School scale (92.3%). In contrast, largely due to the restrictions in the covid-19 pandemic, 78.8% of the patients had below normal range scores for the Activities scale. Borderline or Clinical range scores were reported for 6.7% of children on the Problem Items section and 15.4% of parents endorsed one or more Critical Items about their children, which indicate significant behavioral concerns. CONCLUSION: In this study, we found 6.7% of the school-age children population with CL/P had psychosocial problems. The result of this study hopefully can shed some light in the long-term psychosocial conditions of the CL/P children post-operatively.

Running a safe and effective Cleft Network Service in response to the COVID-19 pandemic.

Maintaining an excellent level of service in a network Cleft Lip and Palate service in the UK has been an added challenge for both clinicians and patients throughout the COVID-19 pandemic. We describe the changes to our service, and report a high level of patient satisfaction with the changes. Some of the enforced changes may last beyond the duration of this pandemic.

The Preventive and Control Recommendations on Patient With Cleft Lip and Palate During COVID-19 Pandemic in Shanghai.

ABSTRACT: As Corona Virus Disease 2019 (COVID-19) has been gradually controlled domestically, various industries began to resume production in an orderly way. Attention should be paid to the disease and population characteristics of patients with cleft lip with/without palate during diagnosis and treatment. This article summarized and provided prevention and control recommendations on management strategies during hospitalization and protective measures of patients and healthcare workers, hoping to minimize the spread of disease and create a relatively safe environment for medical work.

Interdisciplinary Considerations for Nasolabial Repair During a Global Pandemic.

BACKGROUND: At the declaration of the global pandemic on March 11, 2020, many hospitals and institutions developed a tiered framework for the stratification and prioritization of elective surgery. Cleft lip and palate repair was classified as low acuity, and nasoalveolar molding (NAM) clinics were closed. Anticipating the consequences of delayed cleft care and the additional burden this would cause families, we reassessed our risk-stratification and perioperative algorithms. We hypothesized we could safely optimize nasolabial repair without burdening our care systems and without increasing COVID-19-related morbidity/mortality. METHODS: Our multidisciplinary cleft team reevaluated patient selection to maximize surgical impact. Perioperative protocols were adjusted, and COVID-19 preoperative testing was utilized before nasolabial repair and prior to suture removal under anesthesia. RESULTS: Early in the pandemic, unilateral cleft repair was prioritized and successfully completed on 9 patients. There were no complications related to COVID-19. Nasoalveolar molding clinic was reopened after total patient volume was significantly decreased. CONCLUSIONS: We offer an approach for surgical management of nasolabial clefts during a global pandemic. Although guidelines have suggested postponing all cleft care, we found that at our dedicated pediatric hospital with low burden of COVID-19 and adequate resources, we could follow a strategy to safely resume cleft care while decreasing burden on our patients' families and care delivery systems.