A submucous cleft palate may be hard to spot, because it is a cleft palate that’s hidden under the skin, or “mucosa” of the roof of the mouth. Because of this, parents sometimes wonder if their child has a submucous cleft. The road to discovering if this is the cause of speech and communication challenges can be long and frustrating. This article summarizes some of the signs and symptoms of submucous cleft palate speech, as well as next steps if you suspect that your child may have a submucous cleft palate.
What is a submucous cleft palate?
In a cleft palate, the muscles and skin tissue that make up the hard and soft palate (the bony part of the roof of the mouth in the front and the soft, muscle part of the roof of the mouth in the back) don’t fuse together properly during embryological development. As a result, functional problems with speech and early feeding can occur. While cleft lip is fairly easy to spot on a routine 20 week ultrasound, a cleft of the palate only is more likely to be missed until the baby is born. A routine check for a cleft palate, along with feeding and latching trouble in the first days of life, usually clue in parents and health care providers to the cleft palate. It’s hard to miss when you look in a baby’s mouth!
In a submucous cleft palate, the diagnosis takes longer. First, it’s typically not something that gets picked up on a routine ultrasound during pregnancy. This is because the submucous cleft palate occurs when the muscle sling of the soft palate failed to form, but the skin layer over the muscles does fuse together. As a result, you don’t automatically see the cleft when you look in the mouth. What’s even trickier is a diagnosis called occult submucous cleft palate, in which the hidden cleft is only visible when looking through the nose with a scope at the top of the muscle. This is because an occult submucous cleft occurs when there’s simply underdeveloped, or not enough, muscle of the uvula.
To make matters even more complicated, some individuals with submucous cleft palate never have any symptoms! We don’t fully understand why this is the case, but it may have something to do with natural differences between size of different structures in the mouth and the throat across different people. Because so many individuals have a submucous cleft palate without any symptoms, it’s hard to know how often submucous cleft actually occurs.
What symptoms may my child with submucous cleft have?
Luckily, although submucous cleft palate can be difficult to spot to an untrained eye, there are fairly predictable patterns that we see that can help determine if we need to treat the submucous cleft. If you’re not sure if your child has a submucous cleft, the following descriptions may help you think more about what sorts of challenges you’re observing in your little one.
Feeding problems—Specifically, problems with sucking
One of the earliest symptoms of submucous cleft palate that parents notice is difficulty with breast or bottle feeding. The soft palate muscles help to seal the nose from the mouth to create suction in the mouth. This ability to suck is actually what helps babies to pull milk from a nipple, so when babies aren’t able to suck well because of problems with their palate, they’re slow, inefficient feeders. They get tired and expend a lot of energy trying to feed. They may not gain weight well. A good feeding evaluation with a speech-language pathologist or feeding specialist can help identify causes of poor feeding and weight gain, and trouble shoot solutions. When the problem is caused by issues with the palate’s structure, a modified bottle can work wonders. These bottles can reduce the need for suction, and make feedings much less stressful for caregivers and babies! Some have reported success with hand expression to continue breastfeeding for babies with cleft palate, but most mother-baby pairs have an easier time pumping and using breast feeding as comfort after a bottle feeding.
If your baby is showing any signs of distress, like coughing, choking, turning blue, or arching away from the bottle and screaming, it’s best to bring these concerns up with your pediatrician. Having a feeding specialist evaluate the cause of the distress is important to make sure feeding is safe for your baby. It’s also important to know that a submucous cleft doesn’t cause problems with swallowing function, so even if a baby has a submucous cleft or cleft palate diagnosis, any issues with swallowing in the throat need to be investigated because they won’t be solved with the palate surgery. Usually, a swallow study, which allows the medical team to see where the liquid goes during a swallow, helps to better manage these types of problems.
Early signs of speech problems that may suggest your child has a submucous cleft palate
While some submucous cleft palates will never cause any signs of speech difficulty, some create as many problems as if the cleft were wide open. If your child shows any of these symptoms, it’s important to have them evaluated by a cleft palate team. These are the professionals who will be most quickly able to determine if there is a submucous cleft palate, and if your child would benefit from surgery to repair the underlying problem with the muscles.
Problems with high pressure consonants
In English, we have a number of consonants that require that we use our soft palate to seal our nose from our mouth so that we can build up pressure and release it. These are sounds like /p/, /b/, /t/, /d/, /k/, /g/, /s/, /z/, /f/, /v/ and “sh.” We don’t think about the fact that we’re using our soft palate when making these sounds because we can’t feel it moving and we’re not aware of the pressure we’re creating for speech. When a child has a submucous cleft palate that’s preventing them from using the soft palate muscles well, it causes problems with how these pressure consonants develop.
A child with this type of speech difficulty may not babble with “babababa” or “gagaga” the same way other babies would. Instead, they may be slower to babble entirely, or they may only use nasal sounds like “m” and “n.” They may have a tendency to growl or use sounds in their throat to get attention. This early difficulty with pressure build up in the mouth can turn into a habit where the child uses his or her throat or nose to substitute sounds for the high pressure consonants. This can make toddlers and kids hard to understand. Kids who develop these types of compensatory articulation habits need intensive speech therapy to help them learn to use their tongue, lips, and teeth as articulators, and to try to build up pressure in their mouth when they make these sounds. That leads us to the second speech symptom of cleft palate speech.
Hypernasality or nasal emission
The other key speech characteristic that lets us know when a child may have a submucous cleft palate that’s causing problems for speech is the presence of nasal speech. Kids may have been able to develop the placement for pressure consonants pretty well, but whenever they try to articulate these sounds, they have air leak through their nose. Hypernasality and nasal emission can be mild, moderate, or severe, and the severity can influence how hard the individual is to understand. If a child is mildly hypernasal, has good articulation, and is easy to understand, the surgery team and family may opt to wait and watch. If a child has severe hypernasality and nasal emission, and has been struggling to make or maintain progress in speech therapy for six months with a lot of difficulty being understood by others, it may be time to consider surgery.
I think my child has a submucous cleft palate—what happens next?
If you’ve noticed some of these speech or feeding symptoms, or had your current speech therapist point them out to you, it’s a good idea to have your child evaluated by a therapist who specializes in cleft palate speech disorders. These speech-language pathologists frequently work on interdisciplinary cleft palate teams. There, the work alongside a pediatric ENT, an oral or plastic surgeon, and have access to testing equipment that allows them to measure air leaking through the nose, or do direct imaging to view the muscles of the palate.
Perceptual Assessment of Velopharyngeal Function for Speech
Perceptual Assessment is just a technical term meaning that the therapist will listen to your child while they talk to them! This isn’t ordinary listening, because the therapist is trained to listen for specific patterns to help determine the cause of your child’s speech difficulty. If your child isn’t talking yet, the therapist may engage them in play and try to entice them to attempt some words or speech sounds, or may ask you many questions about your child’s speech and language history. If pressure consonants are present during babbling or jargon (speech-like utterances that don’t have apparent meaning to adults), this is a good sign that your child has the physical ability to use the palate for speech. If no pressure consonants are present, the therapist listens for patterns—what’s happening instead? From that, they’ll make recommendations for more therapy, or more testing.
One of the first steps in diagnosing a submucous cleft palate is to look in the baby or child’s mouth. The most obvious clinical sign of a submucous cleft is a bifid uvula, where the very end of the roof of the mouth is split in two. However, many individuals with a bifid uvula have normal speech, so that alone isn’t enough to warrant surgery.
Other signs that the speech pathologist or surgical team look for is a zona pellucida, which is a whitish-blueish translucency down the middle of the palate. They also feel for a bony notch in the hard palate. These three signs together are the classic signs of a submucous cleft palate and are pretty easily recognized by professionals who look for them regularly.
Instrumental Testing for Submucous Cleft Palate
Even if there are no obvious signs of the submucous cleft palate when looking in the mouth, if speech symptoms exist that suggest a submucous cleft palate, the team will most likely recommend further testing. Some tests measure air that comes out of the nose during speech. Other tests allow the team to watch how the muscles of the palate move during speech, either with X-ray (videofluoroscopy) or with a video camera (videonasopharyngoscopy). Newer technology includes doing an MRI of the muscles of the palate to directly view their size, shape, and location.
When is surgery recommended for submucous cleft palate?
Surgery is often recommended after the team has determined that 1) a submucous palate exists, 2) it is having a negative impact on speech that can only be corrected with surgery, and 3) the expected benefits from the surgery outweigh the risks to the child from having the surgery. Once surgery is recommended, parents discuss the plan with the team and ultimately decide if they’d like to move forward. There are many excellent centers that complete many submucous cleft palate repairs each year, and finding a team that has that experience is important for a good outcome!
Will my child still need speech therapy after a surgery for submucous cleft palate?
Often, if your child has any articulation errors, these will still need to be treated with regular speech therapy even after the surgery has taken place. If compensatory articulation errors were present before surgery, the expected progress for high pressure oral consonants is faster after the surgery takes place, but the habits don’t change from surgery alone. Additionally, kids with submucous cleft palate are kids like any other, and can have the types of developmental articulation errors that other kids tend to have, like challenges with the /r/ and /l/ sounds. Speech therapy is very effective at teaching kids to improve their articulation skills. Other types of goals may include working on language skills, or early reading skills.
Click here to read more about how Verboso can help you improve your child’s communication skills. We’re happy to work as a part of your treatment team, and are here for any questions you may have regarding if your child has a submucous cleft palate!