Cleft lip can be unilateral or bilateral and associated with cleftpalate and defects of the alveolar ridge and dentition. When present, palatal defects allow direct communication between the nasal and oral cavities, creating problems with speech and feeding. Management includes squeeze-bottle feedings, special nipples, nipples with attached shields to seal the palate, and gastrostomy in severe cases. Surgical closure of the cleftlip is usually done by 3 months of age. Closure of the palate follows, usually before 1 year of age. Missing teeth are replaced by prostheses. Cosmetic results are often good, but depend on the severity of the defect.
Speech is nasal as a result of the cleft palate. Surgical treatment is effective, but sometimes does not restore palatal function completely. Speech therapy or, occasionally, the use of a speech-assisting appliance may help. Frequent episodes of otitis media are common, as are defects of teeth and the alveolar ridge.
Oropharyngeal Candida albicans infection, or thrush, is common in healthy neonates. The organism may be acquiredin the birth canal or from the environment. Persistent infection is common in breastfed infants as a result of colonization or infection of the mother’s nipples. Thrush in healthyolder patients can occur, but should suggest the possibilityof an immunodeficiency, broad-spectrum antibiotic use, ordiabetes.
Thrush is easily visible as white plaques, often with a “fuzzy” appearance, on oral mucous membranes. When scraped with a tongue depressor, the plaques are difficult to remove, and the underlying mucosa is inflamed and friable. Clinical diagnosis is usually adequate, but may be confirmed by fungal culture or potassium hydroxide smear. Oropharyngeal candidiasis is sometimes painful (especially if associated with esophagitis) and can interfere with feeding.
Thrush is treated with topical nystatin or an azole antifungal agent such as fluconazole. When the mother’s breasts are infected and painful, consideration should be given to treating her at the same time. Because thrush is commonly self-limited in newborns, withholding therapy in asymptomatic infants and treating only persistent or severe cases is a reasonable approach.
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Gastroesophageal reflux (GER) is defined as the effortless retrograde movement of gastric contents upward into the esophagusor oropharynx. In infancy, GER is not always an abnormality.Physiologic GER (“spitting up”) is normal in infants youngerthan 8 to 12 months old. Nearly half of all infants are reportedto spit up at 2 months of age. Infants who regurgitate meet thecriteria for physiologic GER so long as they maintain adequate nutrition and have no signs of respiratory complications oresophagitis. Factors involved in causing infantile GER includeliquid diet; horizontal body position; short, narrow esophagus;small, noncompliant stomach; frequent, relatively large-volumefeedings; and an immature lower esophageal sphincter (LES).As infants grow, they spend more time upright, eat more solidfoods, develop a longer and larger diameter esophagus, have a larger and more compliant stomach, and experience lower caloric needs per unit of body weight. As a result, most infantsstop spitting up by 9 to 12 months of age.