Self Examination

The purpose of a systematic physical assessment in the newborn period is to examine for any anomalies, establish a baseline for observations and comparisons, and initiate referrals for continued care of identified or potential problems. With a Cleft, it is imperative that this systematic examination be completed before a feeding, due to the potential presence of a Cleft Palate.
Begin by assessing the infant's head size, shape, symmetry, and general appearance.
Observe the infant's face, looking for symmetry of the eyes, nose, and mouth when the infant is both quiet and crying. Note atypical features and evaluate for asymmetry of features or movement. Assess the spacing of the eyes and the width of the nasal bridge
When evaluating the mouth, note the length of the philtrim and size of the mouth, tongue, and jaw. The mouth should be in the midline of the face and appear symmetrical in shape and movement. It should be in proportion with the tongue and chin. The lips should be fully formed, continuous, and without scars or irregularities.
The width and thickness of the lips may reflect the infant's race. A thin upper lip can also be related to fetal alcohol syndrome or other conditions, such as submucous clefts or defects in the orbicularis oris muscle. Shallow lip pits can occur in up to 3% of infants. They are often located at the area where the upper and lower lip meet. If the pit is found elsewhere along the lip, it may indicate a sinus tract or subepithelial cleft. Sinus tracts of the lower lip are often associated with a CL with or without CP in the following syndromes :
- Van der Woude Syndrome
- Popliteal Pterygium Syndrome
- Orofacial Digital Syndrome
- Ankyloblepharon Filiforme Adnatum
Examine the inner surface of the upper lip. Locate the frenulum, a thick band of pink tissue that lies under the inner surface of the upper lip and extends to the alveolar ridge of the maxilla. The frenulum is a normal finding; it is most evident when the infant yawns or smiles and will disappear as the maxilla grows. It should be attached to the underside of the tongue, between the ventral surface of the tongue and the tip of the lower palate. An attachment to the roof of the mouth occurs in ankylogossia, a rare anomaly that results in respiratory obstruction. Micrognathia, macroglossia, and CP are frequently associated with this anomaly.
Visually inspect the infant's palate; use a light and maneuvers that encourage the infant to open his or her mouth. The normal action of the tongue against an intact palate results in a smooth, rounded palate. A palate that is narrow or has a high arch may indicate a decrease in neuromotor activity or sucking in utero. Note the alveolar ridge. A common normal finding is Epstein's pearls, small white epithelial cysts that are located on both sides of the hard palate and disappear in several weeks.
Visualize the uvula and posterior structures. The uvula should be a cone-like projection in the back of the mouth. If the uvula is bifid, a submucosal cleft is present. This type of cleft is often initially undetected; however, it can interfere with feedings.
Palpate the hard and soft palates with a gloved finger to rule out the presence of a hard or soft palate cleft . Assess the infant's suck; note the pattern, coordination, and strength of propulsion. The strength of the suck depends on the infant's gestational age and environmental state. Assess for the presence or absence of a gag reflex
If a Cleft lip is present, assess the infant's work of breathing. An infant with an isolated CL will typically have no problems with breathing. Infants with CP may have a tongue that falls into the cleft and obstructs the airway. Some infants with CP require the use of an oropharyngeal airway to alleviate this problem.
If the infant has been fed, obtain a complete feeding history, focusing on feeding interest, vigor, and coordination of suck and swallow. Note reports of choking episodes that may suggest a CP. Observing the infant during a feeding provides excellent insight into feeding tolerance and effectiveness.
Complete a systematic head-to-toe physical examination to assess the infant for other malformations. Other minor or major anomalies, when associated with an isolated CP, may indicate an underlying syndrome. Infants with CL/CP have a 10% chance of having an associated syndrome.