For nine months in the womb, fetuses are constantly in development. Even at eight months, they are still only the building blocks of the person they will later become, fine-tuning the sensory and motor skills that will become crucial later. However, in such a constant state of flux, inevitably there is confusion in the process.

In utero, every person had a cleft lip and cleft palate during the early weeks of development, a brief step before the tissues that form the palate and the upper lip come together in the middle and fuse. The remnants of this process can still be seen in the “Cupid’s bow” under the nose, as well as the ridge and line in the middle of the palate. Yet, for approximately 700 infants born in the United States each year, this stage of development is never completed.

A cleft in the lip or palate is usually identifiable at birth, characterized as only a small slash in the lip. In some severe cases it can extend from the lip through the upper gum and palate, and even all the way into the nose. In less common cases, a cleft can also occur in the muscles of the soft palate; since the mouth’s lining hides it, this type of cleft is sometimes not diagnosed straight away.

Infants with these craniofacial disorders have been observed to have problems with feeding, ear disease, speech, and even socialization. While modern medicine is quick to surgically correct these congenital deformities after diagnosis, speech pathologists are called in to curtail the possible long-term effects on speech and language through the patient’s infancy and adolescence.

The Struggle for Speech

“Cleft lip and/or palate places the individual at risk for speech production and feeding difficulties,” says Jenny McGlothlin, MS, CCC-SLP, from the University of Texas (UT) Dallas Callier Center for Communication Disorders in Richardson, Texas. “Palatal and lip clefts require surgical intervention, but the child may still have velopharyngeal inadequacy that leads to articulatory compensation strategies that reduce speech intelligibility.”

She adds, “Other disabilities associated with craniofacial syndromes include conductive hearing loss related to middle ear anomalies, facial asymetry related to varying degrees of mandibular and soft tissue deficiency, ear tags or pits, brain malformations, hypotonic upper airways that can cause collapse of the airway, dental problems, and even complications from multiple surgeries.”

Due to lack of suction, infants with clefts often have trouble feeding – according to experts, it is advisable to feed these infants in a more upright position, in which gravity will help prevent milk from coming through their nose. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder, or simply by using a protruding nipple and rhythmically squeezing the bottle to create a controllable flow for the infant.


“Approximately 80 percent of children born with non-syndromic cleft palate who undergo palate repair by 18 months of age develop speech free from compensatory errors without any type of therapeutic intervention,” says McGlothlin. “However, for the other 20 percent of these children, and for the many others with syndromes associated with clefts or velopharyngeal insufficiency (VPI), related to other causes, intervention is necessary.”

If a child with cleft palate develops compensatory errors prior to palate repair, it is likely that these errors will continue following surgery. For example, instead of producing the /s/ sound in the mouth, the child might use the vocal cords as a substitute, or even snort air through the nose to produce the sound. Often, in order to get a head start on compensatory errors, therapists will recommend that speech therapy begin prior to surgery, especially for older children who are undergoing secondary surgery to correct persistent VPI.

According to McGlothlin, parent training for recognition of undesirable abnormal compensations, such as glottal stops and pharyngeal fricatives, should be initiated early in therapy, and direct intervention involves directing the child in using their speech mechanism in a more functional way for “good” speech sounds.

“[Also,] a speech evaluation should be accomplished early, by 12 months to 15 months of age,” says McGlothlin. “Clefts of the palate or lip are usually detected at birth, although more subtle clefting – such as submucous cleft palate – may go undetected for years. Velopharyngeal function is difficult to validly assess in a child younger than three years of age, but articulation errors associated with VPI can be diagnosed as soon as speech is initiated.”

A Patient At Risk

Hypernasality is among the most common speech disabilities afflicting patients with a cleft. Children will sound “nasal” and/or audible puffs of air will escape from the nose while talking; even if the child does not have articulation errors, the degree of hypernasality and nasal emission may cause speech to be difficult to understand and present social problems.

“As the child becomes accustomed to this problem, the way the vocal tract is wired, the voice box will instead start closing to make those sounds,” says John Riski, PhD, CCC-S, FASHA, the clinical director of the Center for Craniofacial Disorders at Children’s Healthcare of Atlanta.

He continues, “Once those problems get ingrained, as they will early in life, then patients will begin develop severe speech problems. While they have the physical problem of the clef palate, they also have all the ingrained, mislearned speech problems that come from speaking with the cleft. So while many of these kids need surgery to fix the cleft palate and stop the air from coming out the nose, they will also require speech therapy from someone skilled in recognizing and working with all of these speech problems.”


In these cases, it is important for both the parents and professionals to recognize that the goal of speech therapy is to correct faulty placement of articulation, and not necessarily to correct obligatory symptoms, such as hypernasality. When working with a child who has compensatory articulations prior to surgery, it is critical that the therapist occlude the child’s nostrils to prevent nasal air escape and allow the child to focus on correct tongue placement for articulation.

“When we see kids that are hypernasal, talking through their nose – and this was true when I looked at the kids about 20 to 30 years ago back at Duke Medical Center, it is true here, when we do our outcome studies – 70 percent of the time, there’s an identifiable cleft palate that makes the kid hypernasal,” says Riski.  “The other 30 percent of the time there is no cleft; instead, the problem is that the throat or the pharynx is too big. Those are kids I really worry about because there’s no outward sign of where the problem is.”

He adds, “When I lecture the speech pathologists, I always tell them, ‘I don’t care how normal it looks when you look in a child’s mouth, if their speech is coming out of their nose, they need to be referred to a craniofacial team.’ We need to take X-rays. That’s the definitive way to look at how deep the pharynx is.”

In a push to ease the socialization problems children with clefts face, there are several speech therapy techniques designed to mask symptoms of hypernasality and audible nasal air emission, including talking louder, opening the mouth more while talking, and reducing contact pressure of the articulators while talking.

However, a basic problem with all of these techniques is that the child is required to consciously monitor how they are talking. Typically, children – especially young children – are unwilling to monitor their speech for extended periods of time.

A Different Camp of Thought

In an effort to improve the effectiveness of patient self-monitoring and speech therapy techniques, the UT Dallas Callier Center for Communication Disorders has instituted a unique summer camp program called Camp CARE. Bringing together children suffering from articulation and resonance errors due to craniofacial disorders or differences, Camp CARE combines intensive individual therapy sessions with fun activities, such as a motor lab – outside gross motor play – arts and crafts, and snack time.

“Many of these kids are in small-group therapy in public school and may be the only ones who are working on reducing nasal emission or achieving adequate velar closure,” says Christina Molloy, MS, CCC-SLP, from the UT Dallas Callier Center for Communication Disorders. “So even though everyone in the group may be working on the /s/ sound, the speech therapist’s feedback to other children with simple placement errors would not apply to a child with a craniofacial disorder who may be blowing the air out of his nose or not using any air at all.”


She adds, “When everyone in the group is in therapy because of the craniofacial disorder, everyone is working on similar goals. When giving feedback to one child, another child can also apply it to his speech. Additionally, being around other children with similar sounding speech helps them understand that they are not the only ones who speak that way.”

Taking place on the UT Dallas campus, Camp CARE typically lasts six weeks during June and July, with groups meetings two days per week for three hours each time in classrooms or sometimes in shaded outdoor areas. The majority of the therapy that is done is by graduate students in the Communication Disorders program at UT Dallas, who are trained by the licensed speech pathologists on techniques for therapy. The graduate students are also closely supervised to ensure that each child is working on appropriate goals and received effective therapy.

“At Camp CARE, we first do a screening to see what kinds of errors each child is making,” says Molloy. “We look at their articulation and resonance and write two or three goals to focus on. Most of these children start out with many errors and could be working on goals for all of those sounds, but because camp is short, we want to really focus on what three goals will make the biggest difference in how their speech is perceived by listeners. After goals are written, we target those sounds or resonance goals very specifically, with a target of 100 correct productions for each session.”

“[Also] We use visual and tactile feedback methods to really help them understand how to correctly make a sound. The sounds are practiced in the beginning, middle, and end of words with increasing levels of complexity – first just the sound, then the sound and a vowel, then the sound in a word, then the sound in a phrase. By focusing only on two or three sounds or resonance skills, we are able to really impact the production of those sounds and impact each child’s overall intelligibility.”

– Bob Stott is the senior editor for Therapy Times. Questions and comments can be directed to bstott@therapytimes.com.