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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 26-29

Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya


Department of Surgery, University of Nairobi, Nairobi, Kenya

Date of Submission18-Apr-2020
Date of Acceptance23-May-2020
Date of Web Publication13-Jan-2021

Correspondence Address:
Dr. Gathariki Mukami
P. O. Box: 2897.01000, Thika
Kenya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_8_20

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  Abstract 


Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.

Keywords: Cleft lip, cleft palate, county referral facility, free cleft outreach camp


How to cite this article:
Mukami G, Angela M, Wanjala NF. Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya. J Cleft Lip Palate Craniofac Anomal 2021;8:26-9

How to cite this URL:
Mukami G, Angela M, Wanjala NF. Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2021 Apr 11];8:26-9. Available from: https://www.jclpca.org/text.asp?2021/8/1/26/295379




  Introduction Top


Clefts involving lip and palate are the most common craniofacial anomalies.[1] The prevalence varies widely according to various factors. Previous studies have shown a wide acceptance that these clefts are highest in Native Americans and Asians (1 in 500 births), followed by Caucasians (1 in 1000 births) and lowest in Africans (1 in 2400–2500 births).[1],[2],[3] It is, however, plausible that due to the paucity of epidemiological data on cleft deformities in African populations, the actual prevalence might be much higher than what has been reported.

Management of patients with cleft lip and palate is complex due to the various functional and esthetic goals.[4],[5],[6],[7] It also requires individualization as they may present in isolation or as part of a syndrome. Ideally, management should begin antenatally and may involve a multidisciplinary team made up of plastic surgeons, oral and maxillofacial surgeons, otolaryngologists, audiologists, speech pathologists, pediatricians, orthodontists, and nutritionists among others.[4],[8],[9] This approach is particularly challenging in developing countries due to financial, infrastructural, and socioeconomic barriers.[10] Cleft outreach programs were initiated to counter these challenges with the goal of providing integrated, skilled surgical care to populations with this affliction. They can be also used to describe the characteristics of cleft lip and palate deformities in various regions.

Previous studies done in Africa present conflicting data with some suggesting that the various patterns of craniofacial clefts differ significantly from what has been seen in other populations and others showing striking similarities.[4],[5],[6],[7] The national and regional prevalence in Kenya is yet to be intensively documented.


  Subjects and Methods Top


The study was a prospective cohort study. It was conducted at Kitale County Referral Hospital (a government-run facility in Trans-Nzoia County, Kenya) during five free cleft lip and palate surgical outreach camps facilitated by the Kenya Society of Plastic and Reconstructive Surgeons, between January 2016 and January 2018.

The data were collected from the files of patients with cleft lip and palate deformities who were reviewed and operated on during the surgical camp. A total of 84 documents were included and structural questionnaires filled from these retrospective data which included: demographic characteristics, antenatal histories, family history, type of cleft and laterality, surgical management, and complications in the early postoperative period.

The data were then transferred into Microsoft® Excel (Microsoft corp., Redmond, Washington,USA) datasheets and analyzed using a IBM SPSS Statistics for Windows, version 21, (IBM Corp., Armonk, N.Y., USA).


  Results Top


A total of 84 patients were seen during the five free cleft lip/palate surgery camps from January 2016 to January 2018; of these, 74 (88%) patients underwent surgical procedures.

The age range for the study population was from 5 weeks to 35 years. Majority of the patients were below 2 years of age (58.3%), with patients under 12 months accounting for 46.4% and patients aged 1 year to 23 months accounting for 11.9%; 21 patients (25%) were above the age of 5 years.

The study population was noted to have come from nine different counties in Kenya, that is, Trans-Nzoia, Kisii, Kakamega, West Pokot, Turkana, Baringo, Nairobi, and Nandi. One patient seen was from Uganda. The patients were recorded to have traveled a distance of between 3 and 450 km with majority using public means of transport. Only 38 patients (45.2%) traveled <50 km to access the services.

Antenatal history was missing in all, but 10 (11.9%) cases, of which twin gestation was reported in five patients, with no positive history of cleft in the twin, and preterm delivery reported in five cases. Only four patients were documented to have a positive family history in the first-degree relatives, and two patients were documented to be syndromic: van der Woude Syndrome and spina bifida cystica. Nonetheless, neither of the syndromic patients had a positive family history.

The clinical diagnosis of the patients reviewed revealed that most of the cases were cleft lips (46.4%), followed by both cleft lips and palates (34.6%). Three patients had secondary defects postrepair: one naso-palatal fistula postcleft lip repair and two palatal fistulae postcleft palate repair [Table 1].
Table 1: Clinical diagnosis

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Of the 39 patients who had a diagnosis of cleft lip alone, majority were unilateral complete(65.8%). Of the 29 patients who had a diagnosis of cleft lip and palate, 69% had unilateral cleft lip and 31% had bilateral cleft lip. Of the 13 patients who had a diagnosis of cleft palate alone, 30.8% were incomplete/clefts of the secondary palate and 69.2% were complete. Of the 53 patients with unilateral cleft lip (33 cleft lip alone and 20 cleft lip and palate), 18 (38.3%) were right sided and 29 (61.7%) were left sided [Table 2].
Table 2: Laterality of unilateral cleft deformity

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The male-to-female ratio for the patients was 1.6:1. Of the 39 patients with a diagnosis of cleft lip, males comprised the majority (69.2%). Of the 13 patients with a diagnosis of cleft palate alone, females comprised 53.9% and males comprised 46.2%. Of the 29 patients with both cleft lip and palate, males comprised the majority (62.1%). Of the three patients with secondary defects, there were two males and a single female.

The most frequent surgeries performed were cleft lip repair (73%) and cleft palate repair (18.9%). Of the ten that were reviewed and discharged home, seven were below 3 months of age and significantly underweight, two had pneumonia, and one was a difficult intubation.

Only two (2.7%) complications were documented, that is, dehiscence of a lip following a fall and a secondary defect post cleft lip repair.


  Discussion Top


Most of the cases were below 2 years of age, with majority being under 12 months. This is in concert with findings by Onyango and Noah, who recorded a majority case representation aged between 0 and 5 years (75%) from a sample whose ages ranged from 0 to 45 years.[5] Studies done in Nigeria by Ibrahim et al. showed a similar distribution.[6] This suggests that children below 5 years are the target population in most need of surgical intervention.

Majority of the patients had traveled distances >50 km (54.8%) in search of free surgical intervention, mostly using public means of transport. The wide catchment area and long distances traveled of up to 450 km could be indicative of the urgent need for skilled, affordable cleft surgical care, particularly in the rural areas. This mismatch may also be due to the wide advertisement base reaching even the border country of Uganda and relative infrequency of such outreach programs in the region. Based on this, similar programs could be recommended at regular intervals. To our knowledge, this variable is yet to be published.

The small number of cases with possible familial or syndromic predispositions is in keeping with previous local and regional studies despite the small study sample size.[5],[10],[11] It can, therefore, be inferred that the overall preponderance of familial and syndromic cases is low. It could also be related to the fact that the associated syndromes are quite rare.[11] More studies with the relevant sample sizes are recommended to establish the strengths of association.

We found a leaning predominance of cleft lip alone (46.4%) than the combination of cleft lip and palate (34.6%). This is similar to the study done by Spritz et al. in another Kenyan sample where cleft lip deformities also made up the majority (53%).[12] However, it was at variance with studies done in Nigerian and Caucasian and Asian populations that had more combination defects than solitary cleft lips.[10],[13],[14] This finding might hint at a racial influence on the prevalence of the cleft deformities.

In addition, the number of cases with a diagnosis of cleft palate was found to be higher (15%) than that of studies done in Kenya by Wanjeri and Wachira (6%–8%), and other studies done in the region Uganda (13%), Tanzania (12%), and Zambia (4%).[10],[13],[15] The difference could be attributed to the sampling technique whereby this study utilized the benefits of patients presenting for management in outreach programs. The contrasting results indicate the need for more studies as the prevalence has been shown to be higher than previously recorded.

The most common deformities were unilateral complete clefts. This is in keeping with previous studies done within the country.[5] Regionally, our study is also similar to studies done in Nigeria, Ghana, and Tanzania.[13],[15] The data were comparable to that produced by Eman et al. whose sample was from the USA.[16] The reason for this global left-sided dominance is, however, yet to be established.

Cleft deformities in this study were found to be more common in males than females with a male-to-female ratio of 1.6:1. Male preponderance has been reported in other studies done in Kenya by Nangole and Khainga, Onyango and Noah, and Wanjeri and Wachira, as well as studies done in other parts of Africa and the rest of the world.[4],[5],[10],[16],[17],[18],[19] However, as the dominant age range was 0–5 years, a study stratified for age could aid to create a better picture about the sex distribution of these conditions.

The study showed that the left side experienced more of the cleft deformities, regardless of the sex. This result is in accordance with that found by Ibrahim et al.[20] However, it is in variance with other studies done in Caucasians that revealed more female presenting with cleft palates than male.[11] The variate results could imply regional and racial influences in the laterality of the conditions with reference to sex.

The overall surgical rate in percentage was 88% for the cases reviewed with a very low complication rate (<3%). This result shows the positive influence of outreach surgical programs and the positive impact of multidepartmental collaboration. Of note was the lack of long-term follow-up, which in addition to being able to document complications that fall outside the immediate postoperative period, would have the added benefit of continued multidisciplinary cleft management for the affected study population. A wider scale study that follows up respective cohorts could better document the success rates of the surgical interventions.


  Conclusions Top


There is a high prevalence of cleft lip and palate deformity with majority of the afflicted coming from rural backgrounds and low socioeconomic status, with limited access to skilled, surgical, and multidisciplinary cleft care. Regular outreach programs are recommended to address the unmet needs of the cleft lip and palate cases in various parts of the region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Croen LA, Shaw GM, Wasserman CR, Tolarová MM. Racial and ethnic variations in the prevalence of orofacial clefts in California, 1983-1992. Am J Med Genet 1998;79:42-7.  Back to cited text no. 3
    
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Nangole FW, Khainga SO. Retrospective review of patients operated on with bilateral cleft lip through surgical outreaches in Kenya. Int Sch Res Notices 2013;7:32-7.  Back to cited text no. 4
    
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Onyango JF, Noah S. Pattern of clefts of the lip and palate managed over a three year period at a Nairobi hospital in Kenya. East Afr Med J 2005;82:649-51.  Back to cited text no. 5
    
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Iregbulem LM. The incidence of clefts lip and palate in Nigeria. Cleft Palate J 1982;19:201-5.  Back to cited text no. 6
    
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Wanjeri JK, Wachira JM. Cleft lip and palate: A descriptive comparative retrospective and prospective study of patients with cleft deformities managed at 2 hospitals in Kenya. J Craniofacial Surg 2009;20:1352-5.  Back to cited text no. 10
    
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Conway JC, Taub PJ, Kling R, Oberoi K, Doucette J, Jabs EW. Ten-year experience of more than 35,000 orofacial clefts in Africa. BMC Pediatr 2015;15:8.  Back to cited text no. 11
    
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Spritz RA, Arnold TD, Buonocore S, Carter D, Fingerlin T, Odero WWR, et al. Distribution of orofacial clefts and frequent occurrence of an unusual cleft variant in the Rift Valley of Kenya. Cleft Palate Craniofac J 2007;44:374-7. pmid:17608554.  Back to cited text no. 12
    
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Butali A, Adeyemo WL, Mossey PA, Olasoji HO, Onah II, Adebola A, et al. Prevalence of orofacial clefts in Nigeria. Cleft Palate Craniofac J 2014;51:320-5.  Back to cited text no. 13
    
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Cooper ME, Ratay JS, Marazita ML. Asian oral-facial cleft birth prevalence. Cleft Palate Craniofac J 2006;43:580-9.  Back to cited text no. 14
    
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Kesande T, Muwazi LM, Bataringaya A, Rwenyonyi CM. Prevalence, pattern and perceptions of cleft lip and cleft palate among children born in two hospitals in Kisoro District, Uganda. BMC Oral Health 2014;14:104.  Back to cited text no. 15
    
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Eman A, Cynthia S, Windsor JL. Cleft lip and palate: Etiology, epidemiology, preventive and intervention strategies. Anatomy Physiol 2014;4:3.  Back to cited text no. 16
    
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Diwana VK, Gupta G, Chauhan R, Mahajan K, Mahajan A, Gupta R, et al. Clinical and epidemiological profile of patients with cleft lip and palate anomaly: 10-year experience from a tertiary care center in the sub-himalayan state of Himachal Pradesh in Nothern India. J Nat Sci Biol Med 2019;10:82-6.  Back to cited text no. 17
    
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Fujimoto M, Yamamoto K, Kawakami M, Kajihara A, Morisaki A, Murakami K, et al. “Clinico-statistical study on Cleft Lip and palate in the past 20 years at the dept of oral & maxillofacial surgery, Nara Medical University,” Journal of Japanese Cleft Palate Association vol. 28, no. 3, 2003. p. 338-349.  Back to cited text no. 18
    
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Mossey PA, Little J. Chapter 12: Epidemiology of oral clefts: an international perspective. In: Wyszynski DF, editor. Cleft lip and palate. From origin to treatment. Oxford University Press; 2002. p. 127-58. ISBN: 0-19-513906-2. 2002.  Back to cited text no. 19
    
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Ibrahim A, Mshelbwala PM, Obiadazie AC, Ononiwu CN, Asuku ME, Ajike SO, et al. A descriptive study of clefts of the primary and secondary palate seen in a tertiary institution in Nigeria. Niger J Surg Res 2015;15:7-12.  Back to cited text no. 20
    



 
 
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