INTRODUCTION
Cleft lip (CL) and/or cleft palate (CP) are the most common visible craniofacial anomalies throughout the world. CL and CP occur due to a failure of the bony components of the mid-face to fuse. The affected individual may have an isolated defect or a combination of both. The incidence of cleft lip and/or palate worldwide is 1:600 while in India, 1 out of every 500 to 800 live births suffer from the defect.[ 1 , 2 ] Isolated cleft palate is more frequently observed in females while CL is common in males.[ 3 ] An oral cleft is a complex developmental trait initiated in the first trimester of pregnancy and involves genetic and environmental risk factors such as consanguinity, fetal environment, and other factors such as maternal drug exposure, alcohol consumption, and smoking.[ 4 ]
Due to feeding difficulties, most cleft lip and palate (CLP) children undergo nutritional deficiencies. The growth problems of children with CLP have largely been allocated to inadequate nutrition. It is a difficult task to meet the nutritional needs of children with cleft lip and palate which further leads to feeding complications along with nutritional deficiencies in the growing years.
It is necessary to overcome nutritional deficiencies and implement nutrition education for the parents to combat feeding challenges to optimize the right nutrition for their children. Malnutrition in these children is predominantly due to the inability to feed or to take in nutrients starting from the first month of life and due to recurrent infection of the upper airways and middle ear. Along with insufficient nutrition intake, environmental and social factors also play a major role in the nourishment of these children.
Growth impairment in these children with CP ± L is majorly associated with feeding difficulties including the failure to generate sufficient suction pressure during feeding hence affecting the attachment to the breast/artificial nipple, milk extraction, bolus organization, and retention of the bolus before swallowing initiation.[ 5 ]
The aim of the study is to assess the anthropometric status and micronutrient deficiencies in children with cleft lip and palate.
METHODS
This is a cross-sectional study of 18 months duration conducted at SGT medical college, Gurugram, a tertiary care center in Haryana, India between June 2020 to December 2021 involving assessment of patients with cleft lip and palate between the age 3 months to 5 years of either gender who visited pediatric unit for complete evaluation before surgery. Syndromic children or those with associated major malformations were excluded.
The following information of the patients enrolled in the study during this time period was recorded: age, gender, and type of cleft which was either an isolate cleft lip with alveolus, cleft palate, or a combination of both. These patients underwent anthropometric and clinical assessments.
The anthropometric parameters included were weight, height, mid arm circumference, and head circumference. These were subsequently plotted on the WHO growth chart. The cut off values given were overweight (>95th percentile), risk of overweight (85th to < 95th ), healthy weight (25th percentile), and underweight (<5th percentile).[ 6 ] The patient underwent hemoglobin analysis while micronutrient levels measured included serum ferritin, Vitamin D and Vitamin B12.
Hemoglobin levels were assessed by using automatic analyzer (Sysmex XN-550, Kobe, Japan).
Concentration of vitamin D (25 Hydroxy Vitamin D) was measured by fully automated analyzer (MAG LUMI 1000) by chemiluminescence immunoassay (CLIA) while serum Vitamin B12 and serum ferritin were analyzed by MAGLUMI 800 using chemiluminescence binding assay. Vitamin D concentrations of >20 ng/mL (50 nmol/L) was considered as sufficient; between 12-20 ng/mL (30-50 nmol/L) as insufficient.[ 7 ]
A vitamin B12 deficiency in children (under 19 years) was defined as a serum B12 value of <229 pmol/L while serum ferritin levels <12 mcg/Dl was considered as low.
Patients were enrolled in the study after taking informed consent from parents/guardians. Approval was taken from the Institutional ethical committee before starting the study with the IEC number SEC/FMHS/F/12/06/21-59.
RESULTS
A total of 100 patients were included in the study, of which, 53 (53%) were males and 47 (47%) were females.
The majority (45.0%) of the children with cleft lip and palate were in the age group of <1 year as shown in Figure 1 and most (53.0%) of them were males.
Figure 1: Bar graph showing percentage distribution of the children with cleft lip and palate based on age in years
In the current study, the majority (75.0%) of the participants had moderate wasting, around 17.0% of them had no wasting while 8.0% of them were severely wasted as shown in Figure 2 .
Figure 2: Bar graph showing percentage distribution of the children with cleft lip and palate based on (weight for height) category of nutritional deficiency
The majority (76.0%) of the participants had moderate stunting while 8% of the cases had severe stunting as shown in Table 1 .
Table 1: Frequency and percentage distribution of children with cleft lip and palate based on height for age
The majority of children did not have microcephaly (92%) while the assessment of Mid upper arm circumference showed 87% of the cases having moderate wasting i.e., between -2 SD to -3 SD.
One-way ANOVA was computed to find the significant difference in levels of hemoglobin and micronutrients with nutritional deficiency category among children with cleft lip and palate. It revealed that, there was no statistically significant (P > 0.05) mean difference between nutritional deficiency category for hemoglobin (g/dL), Vitamin D3 (ng/mL), Vitamin B12 (ng/mL), and serum ferritin (μg/dL) as shown in Table 2 .
Table 2: Comparison of age category with levels of haemoglobin and micronutrients among children with cleft lip and palate
The comparison of nutritional deficiency with levels of hemoglobin and micronutrients among children with cleft lip and palate showed a statistically significant (P < 0.05) mean the difference between nutritional deficiency category for hemoglobin (g/dL), vitamin B12 (ng/mL), and serum ferritin (μg/dL) whereas mean difference in Vitamin D3 (ng/mL) was not statistically significant (P > 0.05) as shown in Table 3 .
Table 3: Showing Comparison of nutritional deficiency with levels of hemoglobin and micronutrients among children with cleft lip and palate. (n =100)
DISCUSSION
Cleft lip and palate is a condition occurring usually in children when their mothers are in 6th to 10th week of pregnancy, which involves the development of the oral cavity and facial structure at extremities such as the bones and tissues of a baby’s upper jaw, nose, and mouth that fail to come together to form the roof of the mouth at the time of birth.[ 8 ] Owing to feeding challenges, children with cleft lip and palate have low nutritional status because they undergo surgeries, have feeding difficulties, and hence low nutrient intake.
This leads to nutritional deficiencies, imposing a greater risk of stunted growth, less closure of the scars of the lip or palate and tooth decay. The growth impairment in these children is predominantly due to the inability to feed or to take in nutrients starting from the first month of life and due to recurrent infection of the upper airway, and middle ear.[ 9 ]
The prevalence of malnutrition among infants with cleft lip and/or palate in the literature varies between 30% and 50%.[ 10 , 11 ]
Chattopadhyay et al .[ 12 ] observed malnutrition in cleft lip and cleft palate using WHO standards, and the Z score was calculated. Out of the 81 patients, 41 (50.61%) had moderate wasting, and three (]3.7%) had severe wasting. On the other hand, in the control group, only 23.3% (21) had moderate wasting, and none had severe wasting.[ 12 , 13 ]
According to the WHO classification, 83% of patients had moderate to severe wasting in our study. The prevalence of wasting in the present study is much higher than the national average of 19.3% and Haryana state’s average of 11.5% according to NFHS-5.[ 14 ]
Anemia was prevalent in 71.1% of cases in the current study. Females had a higher preponderance. This was similar to studies conducted by Singhal et al .[ 15 ] and Fadeyibi et al .[ 16 ] The prevalence of anemia was higher than the national average in our study which was indistinguishable from a study done by Chattopadhyay et al .[ 12 ] The cause of anemia in these patients is multifactorial. A low amount of stored iron in the body due to poor oral intake leads to nutritional anemia where as various complications like recurrent or persistent infections associated in these patients further aggravate anemia requiring blood transfusions and hematinics.
Vitamin D3 deficiency was seen in 88% of the study population while 37% of cases had Vitamin B12 deficiency. This was similar to a study conducted by Chattopadhyay et al .[ 12 ] (2012) in the hilly Himalayan region showing Twenty-nine patients (35.80%) have vitamin B12 deficiency. The correlation between anthropometric assessment and nutritional deficiency suggested that children of the cleft with severe wasting had significant iron as well as vitamin B12 deficiency anemia. However, Vitamin D deficiency was not statistically significant in severe wasting group.
CONCLUSION
A large number of children with cleft lip and/or palate are not exclusively breastfed due to anatomical deficits. They need supplemental iron and vitamin D to meet the demands.
A standard policy to provide auxiliary iron by health care professionals and meticulous counseling of parents to provide breast milk and colostrum to the child should be made at the first visit to the health center because nutritional anemia and recurrent infections negatively affect the physical and cognitive development of a child. It also unnecessarily prolongs the date for optimum and safe surgery.
Macro and micronutrient deficiencies along with recurrent infection lead to moderate to severe wasting and stunting in these children causing severe malnutrition with complications and failure to thrive.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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