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Most parents meet this condition in one of two moments: on an ultrasound screen at around 20 weeks, or in the first seconds after delivery. In both moments the question is the same — will my child be alright?
The answer is yes. Cleft lip and cleft palate are among the most thoroughly solved problems in children’s surgery. Repaired at the right ages and followed up properly, children eat normally, speak clearly, attend ordinary schools, and grow into adults whose only trace of the condition is a thin line on the upper lip that fades with every passing year.
But there is something this page will tell you that most articles leave out, and it is the most useful thing a parent can learn in week one: surgery is not the urgent part. Surgery has a schedule, and that schedule waits. What cannot wait is feeding. In the first weeks, a baby with a cleft needs to gain weight — and gaining weight is precisely what makes surgery possible later. Many of the difficult cleft cases seen in our region are not difficult because of the cleft itself. They are difficult because the baby arrived underweight and undernourished, months after birth, having never been taught to feed properly.
But there is a right order to the journey, and it starts somewhere unexpected — not with surgery, but with feeding. This page walks you through the whole road, stage by stage, the way our team at Kids Care International Hospital walks it with families in Rawalpindi and Islamabad.
A baby’s face is built in pieces. Between the 4th and 7th weeks of pregnancy, tissue growing from each side of the head travels toward the midline and fuses to form the upper lip. Between the 6th and 9th weeks, the same process closes the roof of the mouth — the palate — separating the mouth below from the nose above.
A cleft is simply that joining left incomplete.
Because the lip and the palate close at different times, a child may be born with a cleft lip alone, a cleft palate alone, or both together — the most common combination.
Two points parents rarely hear clearly, and both matter:
A cleft lip is visible; a cleft palate is not. A cleft confined to the back of the palate is easy to miss on a quick newborn check, and is often discovered only when a baby struggles to feed or milk starts appearing at the nose. Any newborn feeding poorly deserves a proper look inside the mouth, with a torch.
A cleft is a gap, not a missing part. The tissue needed to close it is present. The surgeon’s work is to bring it together and rebuild the muscle underneath — not to replace something absent. That, in one sentence, is why the results are so good
In most children no single cause is ever identified. A cleft forms from a combination of inherited tendency and chance events very early in pregnancy. Recognised risk factors include:
And now the part that needs saying plainly, because in our region it causes real harm:
A cleft is not caused by a solar or lunar eclipse. It is not caused by a mother cutting cloth, using scissors or a knife during an eclipse, going outdoors, or failing to observe any ritual. It is not caused by the evil eye, by an argument during pregnancy, by something she ate, or by any fault of either parent.
The biology settles it: the lip has finished closing by the 7th week of pregnancy and the palate by the 9th — often before a mother even knows she is pregnant, and long before any eclipse she may remember. The timing makes these explanations impossible.
Mothers here are blamed for clefts more often than for almost any other birth condition, sometimes within their own homes. That blame delays hospital visits, discourages families from seeking feeding support, and occasionally costs a baby the weight they needed to reach surgery on schedule. If you are being told this is your fault, you are being told something untrue.
Many clefts of the lip are visible on the routine anomaly ultrasound between 18 and 22 weeks, because they alter the shape of the fetal face. A cleft palate on its own is far harder to see — most are not detected before birth, so a normal scan never fully rules one out.
If a cleft is seen on your scan, that is genuinely useful news. It converts minutes into months: time to meet the surgical team, learn feeding technique before your baby arrives, arrange the right bottle in advance, and walk into the delivery room informed rather than ambushed. Families who knew beforehand consistently have an easier first month. If your scan has shown a cleft, book a consultation during pregnancy — not after.
This is the section to read twice.
A baby feeds by sealing the lips around the breast or teat and generating suction — negative pressure that draws milk out. A cleft palate breaks that seal, because the mouth is open to the nose and no vacuum can form. A cleft lip alone often still allows enough of a seal for direct breastfeeding; a cleft palate usually does not.
The result is a baby who works desperately hard, tires within minutes, swallows air, brings milk back through the nose, and falls asleep exhausted before taking enough. Weight stalls. Parents conclude the milk supply is the problem. Usually it isn’t — the delivery system is.
The answer is not to feed harder. It is to change how the milk is delivered:
A little milk appearing at the nose is common with a cleft palate and is not dangerous in itself, as long as your baby isn’t choking or turning blue and is gaining weight. What matters is the trend on the weight chart. A cleft baby who is gaining weight steadily is a cleft baby who will reach surgery on time
Cleft care is not one operation. It is a sequence spread across childhood, each step timed to your child’s growth and development. Seeing the whole map at the start makes the journey far less frightening.
Age | What happens | Why then |
Birth – 2 weeks | Full examination, feeding plan, weight monitoring | Nutrition first; confirm whether other conditions are present |
3–6 months | Cleft lip repair | Baby is strong enough for anesthesia; early repair helps feeding and bonding |
9–18 months | Cleft palate repair | Closed before real speech develops, so sounds form correctly |
1–5 years | Yearly hearing checks; ear tubes (grommets) if fluid collects | Untreated glue ear steals hearing during the language-learning years |
3–5 years | Speech assessment and therapy; occasional speech surgery around age 5 | Speech patterns are still flexible and readily corrected at this age |
8–11 years | Alveolar bone graft if the gum is cleft | Timed to when the permanent canine tooth is developing |
Teenage years | Braces; occasionally jaw surgery or lip/nose refinement | Done once facial growth is largely complete |
Before lip repair, surgeons confirm the baby is thriving — traditionally around 10 weeks of age, roughly 4.5 kg in weight, and with a healthy hemoglobin level. These are anesthesia safety thresholds, and they are the practical reason the feeding section above matters so much.
Performed under general anesthesia, usually in a single operation. The surgeon closes the skin and the red lip border and — most importantly — reconnects the ring of muscle around the mouth that the cleft interrupted, so the lip can move, purse and smile naturally. The nostril on the affected side is reshaped at the same time. Most babies feed again within hours and go home in a day or two.
A scar is unavoidable, but it is a fine line running from the lip up toward the nostril. It looks red and firm for the first few months, then softens and fades steadily over the following two to three years. Protecting it from strong sun and massaging it as your surgeon directs makes a visible difference.
Usually done between 9 and 18 months. The surgeon closes the opening in layers and — the part that matters most — repositions the palate muscles into their correct sling across the back of the mouth. That muscle sling is what allows a child to seal off the nose while speaking, which is why this is as much a speech operation as a feeding one, and why it is done before your child starts talking properly.
Recovery takes a little longer than lip repair: a few days of soft or liquid diet, nothing hard or sharp, no spoons or straws pushed into the mouth, and a follow-up to confirm complete healing. Most children are back to normal within two weeks.
Closing the cleft is the beginning of the care plan, not the end of it. Three areas need watching for years — and quietly, this is where long-term outcomes are won or lost.
Ears and hearing. Children with a cleft palate are highly prone to fluid collecting behind the eardrum (“glue ear”), because the muscles that ventilate the middle ear are the very ones the cleft disrupted. It rarely hurts, so it is easily missed — the child simply doesn’t hear well, and therefore doesn’t learn to speak well. Small drainage tubes (grommets) solve it. Book a hearing test every year, even when everything seems fine.
Speech. Most children speak normally after palate repair. Some develop a nasal-sounding voice or difficulty with sounds like p, b, s and k, because air escapes into the nose. This is a mechanical problem, not a learning problem — and it responds well to speech therapy, with a further small operation around age 5 if therapy alone isn’t enough. Therapy started early is far shorter than therapy started late.
Teeth and jaws. Where the cleft crosses the gum, teeth may be missing, extra, rotated, or late to appear. Children need dental care from the first tooth, a bone graft to the gum in the 8–11 year window so the permanent teeth have bone to grow into, and usually braces in the teenage years. Regular dental visits from toddlerhood prevent most later problems.
A child whose cleft was repaired on schedule and followed up properly eats every food, speaks clearly, attends ordinary school, plays sport, and has no restrictions of any kind. What remains is a fine scar on the upper lip — often barely noticeable by adolescence — and sometimes slight asymmetry of the nostril that can be refined later if the young person wishes.
The part worth preparing for is social rather than medical. Children notice differences and sometimes comment on them. Children who have been given a simple, matter-of-fact account of their own history — “I had a small opening in my lip when I was a baby, and the doctors fixed it” — handle those moments with striking confidence. Secrecy is what makes a scar feel shameful. Ordinariness is what makes it just a scar.
If your baby has been diagnosed with a cleft, or your child’s cleft care was interrupted, our pediatric team at KCIH can help you restart the plan from wherever you are today.
Yes. Both are correctable with surgery, and results are excellent when repairs are done at the right ages and followed up properly. Children who complete treatment eat normally, speak clearly, and have no lasting limitations. What remains is a fine scar on the upper lip, which fades considerably as the child grows.
Cleft lip repair is usually performed between 3 and 6 months of age, once the baby is feeding well, gaining weight, and strong enough for safe anesthesia. Cleft palate repair follows later, generally between 9 and 18 months, so the palate is closed before your child begins forming real words.
A baby with a cleft palate usually cannot create suction, so milk must be delivered rather than sucked. Use a specialised cleft feeding bottle with a squeezable reservoir, hold your baby upright at about 45–60 degrees, burp frequently, and keep each feed to around 30 minutes. Ask for a feeding assessment early rather than waiting for weight to drop
Most children need two main operations: lip repair in infancy and palate repair before 18 months. Depending on the cleft, some also need a bone graft to the gum between ages 8 and 11, occasional speech surgery around age 5, and refinement of the lip or nose in the teenage years. Many children need nothing beyond the first two.
The scar is a fine line running from the upper lip toward the nostril. It appears red and firm for the first few months, then softens and fades progressively over two to three years. Protecting it from strong sun and massaging it as advised speeds that fading. In most adolescents it is barely noticeable in ordinary conversation.
No. Lip and palate repair can be carried out successfully well beyond infancy, and older children gain enormously from it — in eating, in being understood, and in confidence. Speech results are best when the palate is closed early, so an older child may need speech therapy alongside surgery. Bring your child for assessment; treatment starts from where they are now.
At Kids Care International Hospital (KCIH) Rawalpindi, babies with clefts are assessed by our pediatric surgery and pediatric medicine teams — beginning with feeding support and weight monitoring in the newborn weeks, then surgical repair at the appropriate ages, with NICU care available for babies who need it. Antenatal consultation is available if a cleft was seen on your pregnancy ultrasound.
