Speech and Language development can be affected in Cleft Lip and/or Palate. It can be worrisome to witness improper speech, in your child, along with other challenges. Moreover, there can be confusion due to lack of knowledge in this area. Which is why we want to answer all the questions you might have! A Speech Therapist plays a vital role in the Craniofacial Team of Cleft Lip and Palate patients. As Speech Therapists, we want to make sure that you are aware and get all the information that you require.
1. Do children with cleft lip/palate have speech problems?
Yes, they do. A cleft lip alone does not cause speech problems. However, it is common for a child born with a cleft palate to have speech problems.
They may be unable to make a few speech sounds until the cleft is repaired.
Some children with a cleft palate experience both speech and language delays.
Some children with a cleft are at risk of ear infections, they are not able to hear language normally when fluid collects in the middle ear and thus show a delay in speech and language development.
Some children also have nasal sounding speech as the palate is not effectively closing off the nose from the mouth while they are speaking.
Over half of them will require speech therapy at some point during childhood. Regular evaluations by the speech-language pathologist who will assess your child’s speech production and language development and make appropriate therapy recommendations.
The good news is that most children will acquire speech and language skills at a normal pace after their cleft palates are repaired, and once middle ear tubes are placed for drainage.
2. How do these speech problems occur in children with a cleft?
Due to a cleft in the palate, there is no separation between the nasal cavity and the mouth. This means that
a) The child cannot build up air pressure in the mouth because air escapes out of the nose, and
b) There is less tissue on the roof of the mouth for the tongue to touch.
Both of these problems can make it difficult for the child to learn how to make some sounds adequately. A child with a cleft palate may show a delay in both the onset of speech and the development of speech sounds during the first 2 years of life.
Therefore, it is important to talk to your child and to encourage your child to talk to you.
c) Once the palate has been repaired, your child may be able to learn more speech sounds and say more words, but speech may still be delayed during the early years. The child may still have difficulties in making certain sounds throughout early childhood. This can be for a variety of reasons. If your child’s teeth are misaligned or missing, speech may be understandable, but some sounds (like “s” or “sh”) may sound distorted or “mushy.”
d) The inability to close off the nasal cavity from the mouth is called velopharyngeal inadequacy. Children who have velopharyngeal inadequacy may sound like they are “talking through their noses.” This problem occurs because when the soft palate cannot close off the nose from the mouth, air and sound can escape through the nose during speech, possibly resulting in hypernasality and nasal emission of air. Some children with repaired cleft palates still show signs of velopharyngeal inadequacy.
Please do not encourage your child to make grunting or growling sounds, because it can be difficult for him or her to “unlearn” this habit. These sounds represent behaviour that some children learn in an attempt to compensate for velopharyngeal inadequacy.
e) Children with velopharyngeal inadequacy may also have a voice disorder and your child’s voice may sound hoarse or “breathy” and may fatigue easily. This problem is usually caused by the strain that he or she puts on the vocal cords while trying to build the pressure necessary for normal speech.
3. What is the role of a Speech Therapist in Cleft treatment?
Speech and language therapist forms an important member of your baby's cleft team. Your Speech Therapist will:
Assess the child for his speech and language development. It is important to get the assessment 6 monthly or yearly to make sure that the child's speech sounds and language are age-appropriate.
After the assessment, the speech therapist will advise treatment or therapy plan based on the results. The speech therapist also guides the surgeon after assessing the child's speech sound errors or articulatory errors if further surgery is required to improve his speech.
The speech therapist also helps a mother with the right feeding techniques and helping her chose the appropriate modification required for the child's feeding.
4. How will speech therapy help my child?
Speech therapy teaches children to make and express sounds in a normal manner. The speech therapist on your child's cleft team will determine whether she needs this type of therapy. If so, the therapist will usually recommend a treatment plan with speech, language and articulation goals for the child.
The speech-language pathologist on the cleft palate team has many responsibilities and should see your child regularly. The speech-language pathologist should consistently assess your child’s speech and language development, as well as screen for hearing problems (with the help of an audiologist). In addition to evaluating speech, the speech therapist along with the help of nurse can help you and your child minimize feeding difficulties, possibly offering guidance on adapted feeding techniques.
Speech therapy can be extremely effective for children with mild hypernasality, an articulation disorder, or speech delay. The goal of speech therapy will be to develop good speech habits as well as to learn how to produce sounds correctly. To correct hypernasality that is caused by moderate to severe velopharyngeal inadequacy speech therapy alone would not help. It will need further surgical corrections or a prosthetic device. The type of therapy your child receives will be determined by the type of problem your child has. Furthermore, the amount of therapy your child needs will depend on the severity of the speech problem.
5. Will my child have difficulty in coping with his speech if his hearing loss persists?
Children with cleft lip/palate usually are at risk of developing hearing loss due to ear infections. As these infections happen in the early years of life when the child is developing speech and language they may not hear spoken language and miss out on some speech and language cues which will cause problems in learning speech and language skills. They may not be able to say some consonant sounds or have delayed language development. A Speech Therapist along with an Audiologist can routinely monitor the child's hearing and help with a proper intervention program.
6. Are there any Surgeries needed for my child to improve their speech?
Surgeries for cleft vary from child to child. However, for Speech, correcting a soft palate problem often involves combined skills of the craniofacial surgeon, orthodontist, and Speech-Language therapist. The structure and function of Soft Palate can be assessed and then if required, surgery is performed. Most children only need one surgery, but some need follow up surgery, as well.
After surgery, your Speech Therapist will give your child a set of sounds to practise. These speech exercises will become a lot easier once your child starts healing.
If your cleft palate team decides that speech therapy alone will not correct your child’s speech problem, there are some other options. Your child may require another palate surgery to help with speech. The two most common speech surgeries are
1) Pharyngeal flap
Children who undergo cleft palate repair remain unable to sufficiently seal off the nose during speech. As a result, their speech sounds overly nasal — this is also known as velopharyngeal insufficiency (VPI).
A child with this condition can benefit from another operation, called a pharyngeal flap, which repositions some tissue from the soft palate at the back of the throat in order to stop some of the escaping air. This surgery is performed after a thorough evaluation by a speech pathologist, otolaryngologist, and plastic surgeon.
2) Sphincter pharyngoplasty
(The surgeon may also choose to redo the original repair.)
Your child’s speech-language pathologist and the surgeon will work together to determine the most appropriate type of surgery for your child. Talk to your surgeon about which procedure he or she intends to perform. It is important to remember that surgery is not a “quick fix.” It is almost always necessary for a child to participate in speech therapy after surgery to practice correct articulation and good speech habits. Although surgery is the most frequently-chosen approach for improving velopharyngeal function, a prosthetic device may be an option for some patients.
If your child’s articulation difficulties are related to a dental abnormality, the combination of articulation therapy and dental treatment can help to minimize the problem.
7. What prosthetic devices are available to improve the speech?
The two most common speech aids are placed in the mouth are
1) the speech bulb
The speech bulb is designed to partially close off the space between the soft palate and the throat.
2) the palatal lift.
The palatal lift appliance serves to lift the soft palate to a position that makes closure possible. Many professionals feel that prosthetic appliances work best in children who are at least five years of age. However, each patient should be evaluated on an individual basis to determine if one of these devices is appropriate for him or her.
8. Will Cleft in Lip and/or Palate also affect my child’s intelligence?
Not all children with speech and language problem have cognitive problems such as learning and thinking. Some children with Clefts may have delays with thinking, learning and development. A Speech therapist and a Neuropsychologist can help you check on that.
9. What can parents do to help?
Parents and caregivers play a vital role in a child’s speech and language development. It is important that you talk to your child and encourage him or her to practice appropriate speech behaviours. If possible, work closely with your speech-language pathologist to develop a home carryover program. He or she can tell you about certain activities that are specific to your child’s speech disorder. It is important that your child feels successful about his or her speech, so always be encouraging and make it fun!
Your child's speech should be evaluated every 6 months until the age of 3, and on a yearly basis thereafter. You are encouraged to contact your team's speech pathologist at any time if you have questions or concerns.
There can be many challenges with Cleft Lip and/or Palate, however, with the right guidance and a team of Healthcare Professionals, you will overcome them. With advancement in technology and the healthcare system, there is always a way to surpass all obstacles. Speech is an integral part of Communication. Therefore, it is important to understand how improper speech affects quality of life. Nevertheless, speech and Language development will improve over time with speech therapy. Which is why it is essential to find a Speech Therapist who understands your child’s needs and follows through with the same.
Please check out our previous blog on all things cleft lip and palate here. To know more about Feeding difficulties in children with cleft lip and palate, check out our blog here.
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