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This judgment may take place during a modification session or after
a few days of the patient's wearing the modified device. Thus, each
session should begin with another perceptual evaluation (although
this may be brief) to see whether a change in speech has occurred
since the last session.
Box 10-1
Role of the Patient and Family in Prosthetic
Management of Velopharyngeal Inadequacy
Prosthetic management will not work if the patient and the patient's
family do not understand what the prosthesis is intended to do and
what is involved in creating the device. The speech-language
pathologist and prosthodontist should provide the necessary
patient-family education and counseling, including the fact that
there may be some initial discomfort but there are ways to overcome
this. There is almost always an acclimation period that may last
several days during which the patient will need to wear the device
continuously, even though he or she may want to remove it because
of the discomfort. The family must be earnestly advised that
comfort, tolerance, and therefore the success of the device require
this continuous use, and they should agree to this requirement
before they invest the time and money in the treatment. It is the
speech-language pathologist who can emphasize that the payoff for
this investment is improved speech.
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References
Abyholm F, D'Antonio L, Davidson Ward SL, et al. Pharyngeal
flap and sphincterplasty for velopharyngeal insufficiency
have equal outcome at 1 year postoperatively: results of a
randomized trial. Cleft Palate Craniofac J. 2005;42:501–511.
Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of
secondary velopharyngeal insufficiency in cleft palate
patients with the Furlow palatoplasty. Plast Reconstr Surg.
1994;94:933–941.
Chim H, Eshraghi Y, Lamphongsai S, Gosain AK. Double-
opposing Z-palatoplasty for secondary surgical management
of velopharyngeal incompetence in the absence of a primary
Furlow palatoplasty. Cleft Palate Craniofac J. 2015;52:517–524.
Cho BC, Kim JY, Yang JD, et al. Influence of the Furlow
palatoplasty for patients with submucous cleft palate on
facial growth. J Craniofac Surg. 2004;15:547–554.
Collins J, Cheunga K, Farrokhyarb F, Strumas N. Pharyngeal
flap versus sphincter pharyngoplasty for the treatment of
velopharyngeal insufficiency: a meta-analysis. J Plast Reconstr
Aesthet Surg. 2012;65:864–868.
Dailey SA, Karnell MP, Karnell SH, Canady JW. Comparison of
resonance outcomes after pharyngeal flap and Furlow
double-opposing Z-plasty for surgical management of
velopharyngeal incompetence. Cleft Palate Craniofac J.
2006;43:38–43.
D'Antonio LL. Correction of velopharyngeal insufficiency
using the Furlow double opposing Z-plasty. West J Med.
1997;102:101–102.
D'Antonio LL, Eichenberg BJ, Zimmerman GJ, et al.
Radiographic and aerodynamic measures of velopharyngeal
anatomy and function following Furlow Z-plasty. Plast
Reconstr Surg. 2000;106:539–549.
Delgado AA, Schaaf NG, Emrich L. Trends in prosthodontic
treatment of cleft palate patients at one institution: a twentyone year review. Cleft Palate Craniofac J. 1992;29:425–428.
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Hudson DA, Grobbelaar AO, Fernandes DB, Lentin R.
Treatment of velopharyngeal incompetence by the Furlow Zplasty. Ann Plast Surg. 1995;34:23–26.
Kilpatrick LA, Kline RM, Hufnagle KE, et al. Postoperative
management following sphincter pharyngoplasty.
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Kriens OB. An anatomical approach to veloplasty. Plast
Reconstr Surg. 1969;43:29–41.
Kriens OB. Fundamental anatomic findings for an intravelar
veloplasty. Cleft Palate J. 1970;7:27–36.
Randall P, LaRossa D, Salomon M, Cohen M. Experience with
the Furlow double-reversing Z-plasty for cleft palate repair.
Plast Reconstr Surg. 1986;77:569–576.
Sie KC, Tampakopoulou DA, Sorom J, et al. Results with
Furlow palatoplasty in management of velopharyngeal
insufficiency. Plast Reconstr Surg. 2001;108:17–25.
Sloan GM. Posterior pharyngeal flap and sphincter
pharyngoplasty: the state of the art. Cleft Palate Craniofac J.
2000;37:112–122.
Sullivan SR, Vasudavan S, Marrinan EM, Mulliken JB.
Submucous cleft palate and velopharyngeal insufficiency:
comparison of speech outcomes using three operative
techniques by one surgeon. Cleft Palate Craniofac J.
2011;48:561–570.
Ysunza A, Pamplona MC, Molina F, et al. Surgery for speech in
cleft palate patients. Int J Pediatr Otorhinolaryngol.
2004;68:1499–1505.
Ysunza A, Pamplona C, Ramirez E, et al. Velopharyngeal
surgery: a prospective randomized study of pharyngeal flaps
and sphincter pharyngoplasties. Plast Reconstr Surg.
2002;110:1401–1407.
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Early Intervention for Infants
and Toddlers
Many children with cleft palate require the services of a speechlanguage pathologist (SLP) at some point during childhood. Some of
these children are followed by cleft palate teams and monitored
periodically through early intervention programs to ensure normal
development. In such cases, the SLP may not provide direct services
to the baby but will instead serve as a resource for parents who need
information about the effects of a cleft on speech and language
development. For other children, more focused intervention may be
needed during the toddler and preschool years.
In this chapter, we examine some of the problems presented by
babies and toddlers and the services needed to help minimize the
effects of the cleft on later development.
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Early Monitoring and Intervention
SLPs serve as an important resource for parents of babies with cleft
palate. Following the birth of their child, many parents are focused
on immediate concerns such as physical appearance and feeding.
Although they may be directed to pamphlets that describe the
impact of a cleft palate on speech and language development, they
may simply be too overwhelmed to appreciate fully the importance
of their role in fostering good communication skills. We certainly
support the dissemination of helpful information to parents and
families, but not leaving those families on their own to interpret the
material.
Well-meaning but poorly informed professionals (not SLPs) have
been known to tell parents not to worry about their baby's speech
until the palate is repaired. Such a message implies that parents can
do nothing to facilitate their baby's development until surgery has
been performed and only confirms some parents' belief that life
begins after the palate has been repaired. Messages of this type can
best be addressed by educating parents early about the impact of a
cleft on a baby's oral-pharyngeal anatomy, its likely influence on
feeding and early speech development, and what they can do to
help.
SLPs may meet with parents and their baby for the first time just
before or immediately after the palatal repair. This is unfortunate
because valuable time has been lost during a critical period in
communication development. Ideally, the SLP on a cleft palate team
or early intervention team should initially meet with parents when
the infant is no more than 3 months old to:
• Briefly discuss the expected impact of the cleft palate on speech
and language development.
• Provide suggestions for enhancing the baby's early communicative
development.
• Answer any questions the parents may have.
The SLP on a cleft palate team will intervene much sooner if he or
she is the primary team contact for feeding issues and may intervene
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before a child's birth if a cleft has been detected prenatally and the
parents-to-be seek information.
The next meeting should take place when the child is no more
than 6 months of age, before the onset of babbling. At this time, more
specific information should be provided about ways that parents can
assist their child's vocal development. It is not enough to simply
provide suggestions for enhancing their child's receptive and
expressive language; you must assist the parents in understanding
why they are doing it and what the anticipated outcome will be.
Subsequent routine visits by the SLP (at least every 6 months
throughout the preschool years) should be scheduled to:
• Ensure that the baby's receptive language and early
communicative behaviors are developing appropriately.
• Determine whether the parent-child dyad could benefit from more
frequent, direct intervention from the SLP.
This recommendation of reevaluation every 6 months is more
stringent than that recommended in the current revision of the
American Cleft Palate–Craniofacial Association (ACPA) Parameters
for Evaluation and Treatment of Patients with Cleft Lip/Palate or
Other Craniofacial Anomalies (ACPA, 2009). This consensus
document was derived from the opinions of many professionals,
across professions, and aempts to provide the least restrictive
guidelines. As SLPs ourselves, we believe that reevaluation every 6
months is most appropriate.
Appropriate goals for early intervention are shown in Table 11-1.
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TABLE 11-1
Goals of Early Intervention
PRELINGUISTIC LINGUISTIC
Education and training for
parents
Increase consonant and syllable shape inventory
Increase frequency of
vocalizations
Increase expressive language
Increase diversity of
vocalizations
Teach oral versus nasal airflow distinction (when indicated)
postpalatal surgery
Increase communicative
opportunities
—
From Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft palate speech
(4th ed). St. Louis: Mosby, 2010.
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Intervention With the Prelinguistic
Child
Most services for children at this stage are home based. Although
you may be called on to develop an early intervention program and
may make routine home visits to monitor the baby's progress,
parents should always be the primary agents of intervention when possible.
As indicated in Chapter 4, children with cleft palate frequently
produce fewer total consonants and fewer types of consonants than
do their noncleft peers. You will probably also notice that some
babies vocalize less frequently than expected. Given the nature of
their delays in vocal development, an initial goal for many of these
babies is simply to increase their rate of vocalization (Hardin-Jones
et al., 2006). To accomplish this goal, parents need to talk to (and
babble to) their baby throughout the day and be responsive to
vocalizations when they occur. Ask the parents to observe their child
and identify times or activities throughout the day when their child
is most vocal. Although we want parents to talk to their child
throughout the day, there will probably be times when their baby is
more responsive than others (e.g., during bathing, tummy tickling,
looking in a mirror). Each time their baby vocalizes, parents (and
other family members) should be encouraged to respond by
imitating the vocalization. Over time, the baby will respond by
vocalizing back, and the parent can use these simple turn-taking
activities to expand their child's consonant inventory (as described
later).
It is very important to convey to parents that although we may
expect older children to respond quickly to directives and requests,
babies are not developmentally ready to do that. A parent must
produce a sound (or word) many, many times before the baby
begins producing it. Although many parents understand this
intellectually, they often expect an immediate response from their
baby when they (or we) are aempting to elicit a behavior and may
comment that a strategy is “not working.”
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• Encourage parents to use different types of sounds (e.g., animal
noises, raspberries) to engage their child's aention. One of the
noises that babies most enjoy is the “raspberry.” Even before he or
she starts to truly imitate a parent producing this sound, a baby
shows alert aention to the parent's face when he or she hears it.
Once the palate is repaired, the baby should be able to make the
sound appropriately (a fully oral raspberry requires an intact palate
and velopharyngeal mechanism).
• Help the parents identify sounds that their baby rarely, if ever,
produces that are within the stage of vocal development that is
emerging (Paul and Norbury, 2012). For example, if the baby has
been vocalizing /u/ for some time but has not begun to produce
high, front vowels, encourage the parents to say (or sing) /i/ as they
play with the baby.
• Greetings are a simple way for parents to encourage their baby to
vocalize. Each time parents enter a room where the baby is siing,
they should greet their child by saying “hi” using exaggerated
intonation. They should also be encouraged to say “bye-bye” each
time they leave a room or put a toy away.
• Encourage parents to use infant-directed speech. Although many
parents naturally change the way they talk to their baby to hold his
or her aention, some adults find it difficult to engage in “baby
talk” and need you to model this interaction for them repeatedly
before they become comfortable with it. We do not want the parents
to change the way they articulate words; we do want them to use
exaggerated intonation to elicit their baby's aention more fully. To
be on the safe side, we also want them to use a somewhat elevated
loudness level (not yelling) because babies with clefts are so prone
to ear disease and fluctuating hearing levels (Box 11-1).
Box 11-1
Those Cute Growls
The vocal play that is expected of any baby typically includes some
growls. This type of vocal gesture is commonly produced by babies
who do not have cleft palate and is gradually eliminated as the baby
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