Service provision for children with cleft lip / palate / VPI

The speech pathology department at John Hunter Children’s Hospital provides a consultative tertiary service to babies, children and adolescents with cleft lip / palate and /or velopharyngeal inadequacy (VPI). This service encompasses diagnostic assessment of speech, resonance and nasal airflow, collaborative decision making with the cleft palate team, and consultation with the child’s local therapist. Therapy for speech, and any other aspects of communication, is conducted at the local community level, either through Community Health Services, Ageing Disability and Home Care (ADHC), or private speech pathology services.

I am a community speech pathologist seeing a child already known to JHCH Cleft Palate Clinic. How does my service and JHCH fit together?

John Hunter Children’s Hospital speech pathology department will:

• Conduct an assessment of speech, resonance and nasal airflow prior to the child’s cleft palate clinic appointment. This will occur annually for most children from the age of approximately 12 months.
• Provide a written report of the assessment.
• Liaise with the local speech pathologist regarding treatment planning as appropriate.

It is helpful if the local community therapist can provide:

• A written or verbal summary to JHCH before the clinic visit. If treatment has occurred in blocks, then it may be easier to provide a summary at the end of the child’s last treatment block prior to the clinic, even if the clinic visit is several months away.

A summary could include:

• the child’s phonemic repertoire
• therapy goals
• progress in therapy.

How will I know when the cleft palate clinic appointment is coming up?

• It is usually around the time of the child’s birthday
• The child’s parents are responsible for booking the clinic appointments, so they will know when the next appointment is due. Parents are encouraged to inform the local therapist of the clinic booking and ask for relevant information to be passed on.
• Users of CAP (Clinical Applications Portal) can look up the schedule summary to view upcoming appointments.

I am a community speech pathologist referring a child to JHCH for specialist consultation

When should I refer?

JHCH provides a specialist consultation service, including assessment of suspected velopharyngeal inadequacy. Prior to initiating a formal referral, it is helpful to contact the JHCH speech pathology department to discuss the case.

“Red flags” which could indicate the need for referral for specialist assessment are:

Nasality

• the child has nasal air emissions during speech
• the child has hypernasal sounding speech, noticeable on voiced consonants and vowels.

Speech

• the child’s phonemic inventory shows a preference for nasal sounds /m, n, ?/ and approximants /w, j, h/
• there are few or no oral plosives /p, b, t, d/ in the child’s phonemic inventory
• there is a lack of development of the phonemic inventory over time
• speech sounds muffled, quiet or weak
• lack of progress in therapy

Nasal regurgitation

• of fluids or solids, although there is no known fistula of the palate

Difficulty sucking on breast / bottle / straw

Difficulty blowing – eg candles, balloons, party blowers. Blows air out of nose.

Note: if a child is presenting with hyponasality, then a referral to the GP and / or ENT would be an appropriate starting point for management.

What information do I need to provide with my referral?

• what is the child’s phonemic inventory?
• which specific sounds are affected by nasal air emission or hypernasality?
• information about oral muscle function and the appearance of the hard and soft palate.
• details about therapy progress to date.
• any relevant medical history, eg removal of tonsils and adenoids, cardiac problems, syndrome diagnosis.

What assessment can JHCH do?

• clinical assessment, including perceptual evaluation of speech, resonance and nasal air flow.
• diagnostic and instrumental assessment, for example, palatal videofluoroscopy, nasometry.