Cleft palate is one of the most common birth defects worldwide, occurring when the roof of the mouth does not fully close during fetal development. While the diagnosis can feel overwhelming, advances in surgical technique, multidisciplinary care, and speech therapy mean that children born with cleft palate can go on to live full, confident lives. This guide brings together everything you need to know — from the earliest causes and types, through feeding strategies and associated health conditions, to surgical aftercare and the transformative power of speech therapy.
What Causes Cleft Palate?
The exact cause of cleft palate is not always identifiable, but research consistently points to a combination of genetic predisposition and environmental influences during pregnancy. Understanding these risk factors is the first step toward prevention, early detection, and effective management.
Genetic Factors
Cleft palate has a well-documented hereditary component. If a parent or sibling has a cleft palate, the likelihood of a child being born with the same condition increases significantly. Specific genetic mutations have also been linked to its development, and families with a history of cleft palate are encouraged to seek genetic counselling before and during pregnancy.
Environmental Exposures
Maternal exposure to environmental tobacco smoke, pollution, pesticides, and certain industrial chemicals during early pregnancy has been associated with a higher risk of cleft palate. The first trimester — when palatal fusion occurs — is the most critical window of vulnerability.
Maternal Health and Lifestyle
Several maternal health factors directly influence the risk of cleft palate:
- Smoking during pregnancy is one of the most consistently identified risk factors.
- Alcohol consumption — particularly heavy or binge drinking — elevates risk considerably.
- Certain prescription medications, including some anti-depressants and anti-seizure drugs, have been associated with increased incidence.
- Poor nutritional status, including folate deficiency, can impair normal fetal palate formation.
- Untreated medical conditions, particularly poorly managed diabetes or thyroid disorders, may also contribute.
Infections During Pregnancy
Viral infections such as rubella (German measles) and cytomegalovirus (CMV) contracted during pregnancy can interfere with normal fetal development. Ensuring vaccination status is up to date prior to conception is an important preventive measure.
Prenatal care is one of the most effective tools for identifying and managing these risk factors early. Regular antenatal appointments, combined with genetic counselling where appropriate, give families the best opportunity for early detection and preparation.
Types of Cleft Palate
Cleft palate is not a single, uniform condition. It exists on a spectrum of severity and presentation, and understanding the different types is essential for accurate diagnosis and effective surgical planning.
Complete vs. Incomplete Cleft Palate
A complete cleft palate involves a total gap running from the front to the back of the palate, affecting both the hard palate (the bony anterior portion) and the soft palate (the muscular posterior portion). This form has the most significant impact on feeding, speech, and overall oral function. An incomplete cleft palate, by contrast, involves only partial separation — the gap may affect just the soft palate or a portion of the hard palate, resulting in a comparatively less severe clinical picture.
Unilateral vs. Bilateral Cleft
Cleft palate may occur on one side of the midline (unilateral) or both sides (bilateral). Bilateral clefts tend to be more complex structurally and typically require more involved surgical approaches. The distinction is clinically important when planning repair, as each requires a tailored surgical strategy.
Submucous Cleft Palate
A submucous cleft palate is a hidden form of the condition in which the tissue covering the roof of the mouth appears intact, but the underlying muscles and bony structures are not properly connected. Because there is no visible gap, it frequently goes undiagnosed until speech difficulties — particularly hypernasality or nasal air escape — arise in early childhood. Clinicians should maintain a high index of suspicion when a child presents with unexplained nasal speech in the absence of an obvious structural anomaly.
Midline Cleft Palate
Midline cleft palate is a rare variant that occurs along the central axis of the palate. It requires specialised evaluation and management given its atypical presentation and the potential for associated midline anomalies elsewhere in the body.
Nutrition and Feeding Challenges in Cleft Palate Infants and Children
Feeding is the most immediate and practical challenge facing parents of a newborn with cleft palate. The structural abnormality in the palate directly impairs the suction and swallowing mechanics necessary for effective feeding. Without the intact seal between the oral and nasal cavities, infants struggle to generate negative pressure — the mechanism that drives efficient breast or bottle feeding.
The consequences of poorly managed feeding difficulties can include inadequate caloric intake, slow or faltering weight gain, and aspiration of milk into the airway. Early and specialist-led feeding support is therefore a priority from day one.
Breastfeeding with Cleft Palate
Breastfeeding is possible for some infants with cleft palate, though it typically requires modification and expert support. Lactation consultants experienced in cleft feeding can advise on positioning strategies such as laid-back breastfeeding or use of a breastfeeding pillow to maximise skin contact and improve latch mechanics. The degree of success is highly variable and depends on the type and severity of the cleft.
Specialist Bottles and Nipples
For many infants, specialist feeding equipment offers the most effective solution. Several options are available:
- Squeezable bottles with compressible sides allow the caregiver to assist milk delivery, compensating for reduced suction.
- Nipples with a one-way valve prevent air intake and reduce feeding-related wind and discomfort.
- Nipples with cross-cut or enlarged openings allow milk flow to be regulated according to the infant’s feeding pace and ability.
Nutritional Requirements and Monitoring
Children with cleft palate often expend significantly more energy during feeding than unaffected peers, placing them at greater risk of malnutrition and micronutrient deficiencies. Paediatric dietitians can assess nutritional status regularly and recommend adjustments to feeding schedules, caloric density of feeds, or supplementation as needed. Proactive nutritional monitoring is particularly important in the pre-operative period and following surgical repair.
Feeding Strategies Across Developmental Stages
Feeding challenges do not necessarily resolve with surgical repair. As children grow, the clinical focus shifts from basic caloric adequacy to developing independent feeding skills and oral motor function. Occupational therapists and speech-language pathologists play key roles in supporting children through the introduction of solids, texture progression, and any residual oral motor difficulties.
The Role of the Multidisciplinary Feeding Team
Optimal feeding outcomes depend on coordinated input from a team that typically includes a paediatrician, lactation consultant, specialist feeding nurse, speech-language pathologist, occupational therapist, and registered dietitian. Regular team reviews allow feeding strategies to be adapted as the child develops, and ensure that no aspect of nutritional or oral health is overlooked.
Associated Health Conditions in Cleft Palate
Cleft palate rarely occurs in isolation. A range of associated health conditions — extending well beyond the immediate structural defect — can significantly affect a child’s quality of life if not identified and managed proactively. Early diagnosis and multidisciplinary intervention are the cornerstones of effective management.
Ear Infections and Hearing Loss
Ear infections (acute otitis media) are substantially more common in children with cleft palate than in the general paediatric population. The anatomical abnormality in the palate impairs the normal function of the Eustachian tube — the channel connecting the middle ear to the back of the throat. This dysfunction prevents the middle ear from draining effectively, creating conditions in which fluid accumulates and infection takes hold.
Recurrent or persistent middle ear disease carries a real risk of conductive hearing loss. Even a mild, intermittent hearing impairment at a young age can delay speech and language development significantly. Otolaryngological (ENT) review should be initiated early, and insertion of tympanostomy tubes (grommets) is frequently recommended to maintain hearing function during the critical window of language acquisition.
Dental and Orthodontic Issues
Cleft palate is associated with a range of dental anomalies, including:
- Malocclusion — misalignment of the upper and lower teeth and jaws — which affects chewing, facial aesthetics, and self-esteem.
- Missing, supernumerary (extra), or malformed teeth, particularly in the region of the cleft.
- Delayed tooth eruption and ectopic tooth position requiring early orthodontic monitoring.
Early and ongoing orthodontic involvement is essential. A cleft team orthodontist will typically begin monitoring from infancy and coordinate treatment across the different phases of dental development. Bone grafting of the alveolar cleft (the bony ridge of the upper jaw) is frequently performed in early adolescence to facilitate tooth eruption and provide a stable base for orthodontic and prosthetic work.
Speech and Language Delays
Speech difficulties are among the most pervasive consequences of cleft palate. The structural abnormality directly impairs the ability to create the intraoral air pressure necessary for clear articulation. Common speech characteristics include hypernasality (sound resonating excessively through the nasal cavity), nasal air escape, and articulation errors — particularly with pressure-sensitive consonants such as stops, fricatives, and affricates.
Speech therapy should begin as early as possible — ideally in the pre-surgical period — and continue throughout childhood. See the dedicated speech therapy section below for a full exploration of therapeutic approaches.
Velopharyngeal Insufficiency (VPI)
Velopharyngeal insufficiency (VPI) is a closely related condition that deserves specific attention. It occurs when the soft palate and surrounding pharyngeal muscles fail to close off the nasal cavity from the oral cavity during speech. While cleft palate is a leading cause of VPI, the condition can also arise following surgical repair if the soft palate is too short or insufficiently mobile. Symptoms include a notably nasal voice quality, air escape through the nose during speech, and difficulty producing high-pressure consonants. VPI is diagnosed through nasopharyngoscopy and/or videofluoroscopy, and managed through a combination of speech therapy, palatal prosthetics, and — where necessary — further surgery such as pharyngeal flap or sphincter pharyngoplasty.
Psychosocial and Emotional Wellbeing
The visible nature of cleft conditions, combined with the challenges of speech intelligibility and multiple medical appointments, can affect a child’s social confidence and emotional development. Children with cleft palate are at higher risk of teasing, bullying, and social withdrawal. Proactive psychological support — including access to clinical psychologists, peer support groups, and school liaison — should be embedded within the multidisciplinary cleft team from an early age.
After Cleft Palate Surgery: A Complete Care Guide
Surgical repair of the cleft palate — typically performed between 6 and 18 months of age — is a major milestone in a child’s care pathway. The success of the procedure depends not only on surgical skill, but on the quality of post-operative care in the days, weeks, and months that follow. This guide covers every aspect of recovery.
Immediate Post-Operative Care
In the immediate post-operative period, the surgical team will provide specific instructions tailored to your child’s needs. Core principles include:
- Restricting strenuous physical activity to minimise bleeding risk and protect the surgical site.
- Maintaining appropriate head elevation during sleep to reduce post-operative swelling.
- Preventing the child from placing fingers, toys, or other objects in the mouth — arm restraints (no-no’s) are commonly used during the healing phase.
- Monitoring the repair site for signs of dehiscence (wound breakdown) and contacting the surgical team if any separation is observed.
Pain Management
Post-operative pain is to be expected and should be managed proactively. The surgical team will prescribe an appropriate analgesic regimen, which typically includes regular paracetamol and/or ibuprofen, with stronger pain relief available if needed. Non-pharmacological techniques — such as gentle comfort, skin-to-skin contact, and appropriate distraction — also play a meaningful role, particularly in younger infants. Caregivers should not wait for a child to show signs of significant distress before administering prescribed analgesia; a regular schedule is usually more effective than reactive dosing.
Dietary Modifications Post-Surgery
Protecting the palatal repair during healing requires careful attention to diet. In the immediate post-operative period, the child will be restricted to liquids, progressing through soft and pureed foods over several weeks. Hard, crunchy, or sharp-edged foods must be avoided throughout the initial healing phase. The surgical team or specialist nurse will provide a staged feeding guide — following this closely is essential to prevent disruption to the repair. Cup feeding or soft-tipped syringes may be recommended during the early recovery period, as bottle or spoon feeding can place mechanical stress on the suture line.
Wound Care
The palatal wound heals from the inside, so external wound care is less of a focus than following many other surgical procedures. However, keeping the oral cavity clean is important. Gentle oral hygiene using a damp gauze or soft infant toothbrush should be implemented as directed by the clinical team. Caregivers should avoid any manipulation of the repair site and ensure that feeding implements do not come into contact with the sutured tissue.
Recognising Complications
Families should be aware of the warning signs that warrant urgent contact with the surgical team:
- Increasing rather than resolving pain beyond the expected post-operative period.
- Signs of wound infection, including redness, swelling, discharge, or fever.
- Any visible separation or opening of the palatal repair (fistula formation).
- Significant changes in feeding behaviour, breathing pattern, or general alertness.
Most complications, when identified and addressed early, can be managed effectively without long-term consequences.
Rehabilitation: Oral Motor Exercises and Speech Therapy
The post-surgical period is also the time to begin or intensify rehabilitation. Oral motor exercises — designed to strengthen the palatal musculature and promote normal movement patterns — are typically introduced by a speech-language pathologist several weeks after surgery, once initial healing is established. Speech therapy is usually recommended to begin or resume as soon as the child is well enough, as early post-surgical intervention produces the best long-term speech outcomes.
Psychological Support for the Whole Family
Surgery, however routine from a clinical perspective, is a significant emotional experience for families. Parents and caregivers may experience anxiety, grief, or guilt that deserves acknowledgement and support. Accessing counselling, connecting with peer support groups (such as those offered by national cleft charities), and maintaining open communication with the clinical team all contribute to a positive recovery experience. Children themselves may need support processing their experiences as they grow, particularly as they become more aware of their scars and surgical history.
The Role of Speech Therapy for Cleft Palate Patients
Of all the interventions available to children with cleft palate, speech therapy is among the most impactful and the most consistently underutilised. Approximately 68% of pre-schoolers with repaired cleft palates receive speech therapy to address speech-related issues — a figure that underlines both the prevalence of speech difficulties and the critical importance of early referral.
How Cleft Palate Affects Speech Development
The palate plays a central role in speech production. It acts as a barrier between the oral and nasal cavities, allowing speakers to build the intraoral air pressure necessary for consonant production. When the palate is structurally compromised — whether due to an unrepaired cleft, residual tissue insufficiency following repair, or associated VPI — a characteristic cluster of speech difficulties emerges:
- Hypernasality: all speech sounds take on a nasal quality due to uncontrolled airflow through the nasal cavity.
- Nasal air escape: audible or inaudible escape of air through the nose during the production of pressure consonants.
- Compensatory articulation errors: the child develops atypical sound production strategies to work around their structural limitations. Common examples include glottal stops (produced deep in the throat) replacing front-of-mouth plosives.
- Reduced speech intelligibility: the cumulative effect of the above can make a child’s speech significantly difficult to understand, with real consequences for social and educational participation.
Children with clefts specifically involving the soft palate are at particularly elevated risk of speech difficulties, as this is the structure most directly involved in velopharyngeal closure.
The Importance of Early Assessment and Intervention
Early assessment by a speech-language pathologist (SLP) — ideally as part of the multidisciplinary cleft team — is essential. Pre-surgical speech assessment establishes a baseline and allows clinicians to monitor the trajectory of development. Some SLPs advocate for targeted speech input even before surgical repair, to establish correct placement for sounds and reduce the likelihood of compensatory errors becoming entrenched.
When VPI is identified, the SLP’s role is to determine whether the insufficiency can be managed through therapy alone, or whether surgical or prosthetic intervention is required first. In cases of severe VPI that cannot be addressed through therapy, pharyngeal flap surgery or a palatal prosthetic device may be recommended. Critically, speech therapy remains necessary after these interventions to help the child adjust to the structural changes and maximise speech clarity.
What Happens in Speech Therapy Sessions?
Speech therapy for cleft palate is highly individualised, but typically encompasses the following elements:
- Assessment: Detailed assessment of speech patterns
- The SLP conducts a systematic evaluation of articulation, resonance, voice quality, and speech intelligibility, identifying specific errors and their likely structural or behavioural basis.
- Articulation work: Targeted articulation exercises
- Exercises focus on establishing correct placement and manner of production for specific sounds, typically beginning with sounds in isolation before progressing through syllables, words, phrases, and conversational speech.
- Resonance: Resonance and airflow management
- Techniques to improve velopharyngeal function, regulate breath support, and reduce hypernasality are practised and refined across sessions.
- Monitoring: Progress monitoring and plan adaptation
- The SLP regularly reassesses and adjusts the treatment plan in response to the child’s progress, changing needs, and any surgical or dental interventions that occur along the way.
Evidence for the Effectiveness of Speech Therapy
The evidence base for speech therapy in cleft palate is robust. Research by Kummer (2008) demonstrated significant improvements in speech intelligibility and resonance following intensive speech therapy for children with cleft palate. A case study by Peterson-Falzone et al. (2014) documented the transformative impact of targeted speech intervention on the communication abilities and quality of life of a young adult with cleft palate. Consistent, well-targeted therapy — combined with appropriate surgical management — produces outcomes that allow the vast majority of affected individuals to communicate clearly and confidently.
Supporting Your Child’s Speech Therapy Journey
Parents and caregivers are integral members of the speech therapy team. The following principles support optimal outcomes:
- Attend therapy sessions consistently and participate actively — understanding the exercises means you can support home practice effectively.
- Establish a regular home practice routine, using the exercises prescribed by the SLP.
- Provide positive, low-pressure encouragement — celebrate effort rather than outcome.
- Communicate openly with the SLP about any concerns, changes in speech, or emerging social difficulties.
- Create a supportive home environment where your child feels comfortable practising and expressing how they feel about their speech.
- Be patient — speech development is a gradual process and progress is rarely linear.
Understanding Velopharyngeal Insufficiency (VPI) in Cleft Palate
Velopharyngeal insufficiency (VPI) is a condition that frequently accompanies cleft palate and deserves dedicated attention. It occurs when the soft palate and surrounding pharyngeal muscles fail to create an adequate seal between the oral and nasal cavities during speech — allowing air to escape through the nose and producing the characteristic nasal voice quality associated with the condition.
Causes of VPI
VPI may arise as a direct consequence of the structural defect in the palate itself, or it may emerge following surgical repair if the repaired soft palate is too short, too scarred, or insufficiently mobile. In some cases, the muscles of the velopharyngeal mechanism simply do not coordinate as they should, even in the absence of overt structural abnormality — a condition known as velopharyngeal mislearning or velopharyngeal dysfunction (VPD).
Diagnosing VPI
Accurate diagnosis of VPI requires a combination of clinical assessment and instrumental investigation:
- A detailed speech evaluation by an experienced SLP to characterise the resonance and airflow profile.
- Nasopharyngoscopy — flexible or rigid endoscopic visualisation of the velopharyngeal mechanism in real time during speech.
- Videofluoroscopy — dynamic imaging of velopharyngeal closure during speech.
- Pressure-flow studies to quantify nasal air escape objectively.
- Imaging (MRI or CT) where detailed anatomical information is required to guide surgical planning.
Treatment of VPI
Management of VPI is tailored to the individual and may involve one or more of the following approaches:
- Speech therapy remains the first-line approach for mild to moderate VPI and for VPI arising from mislearning rather than structural insufficiency.
- Palatal prosthetics — including palatal lifts and obturators — can be highly effective for individuals with structural insufficiency who are not candidates for further surgery, or as a bridge while awaiting surgical intervention.
- Surgical intervention — including pharyngeal flap surgery or sphincter pharyngoplasty — is indicated for significant structural VPI that cannot be adequately managed through therapy or prosthetics alone.
- Augmentative and Alternative Communication (AAC) devices may be appropriate for a small number of individuals where communication barriers remain despite other interventions.
Conclusion: A Whole-Child Approach to Cleft Palate Care
Cleft palate is a complex condition that touches every aspect of a child’s life — from the first feed to the first day at school, and beyond. The good news is that with the right team around them, the right interventions at the right time, and the right support for the whole family, children with cleft palate achieve excellent outcomes.
The key themes throughout this guide bear repeating: early intervention matters; multidisciplinary collaboration is not optional; speech therapy is one of the most powerful tools available; and the emotional wellbeing of the child and family deserves as much attention as the physical management of the condition.
