Airway Infections and In-Hospital Complications in Cleft Lip and Palate
Lynne G. Maxwell MD, Rita Agarwal MD, Walid Habre MD PhD, and Myron Yaster MD
“The Swiss health care system provides universal coverage (access) with governmental control of many costs.”1 In today’s PAAD1 and accompanying editorial,2 Laager et al. looked at 10 years of all hospital admission data from Switzerland comparing airway infection–related morbidity and mortality in cleft and non-cleft patients derived from 857, 806 patients during the first 2 years of life. And as we’ve highlighted in several previous PAADs (08/26/2024, https://ronlitman.substack.com/p/qiits-all-about-easy-access-to-the ) the results of this study once again reveal the crucial importance of data in quality and safety studies.3 Myron Yaster MD
Editorial
Tatum SA. Patient Screening and Selection for Cleft Lip and Palate Surgery Procedures. JAMA Netw Open. 2024 Sep 3;7(9):e2428057. doi: 10.1001/jamanetworkopen.2024.28057. PMID: 39264635.
Original article
Laager R, Gregoriano C, Hauser S, Koehler H, Schuetz P, Mueller B, Kutz A. Hospitalization Trends for Airway Infections and In-Hospital Complications in Cleft Lip and Palate. JAMA Netw Open. 2024 Sep 3;7(9):e2428077. doi: 10.1001/jamanetworkopen.2024.28077. PMID: 39264632; PMCID: PMC11393727.
“Cleft lip or palate is among the most prevalent birth defects, with an incidence of approximately 1 to 2 per 1000 newborns and may be an early indication of a congenital malformation or associated syndromes.4 Nonetheless, 45% of cleft palates and 60% of cleft lips are diagnosed without any associated syndrome. Beyond feeding complications, long-term speech issues, sleep apnea, and hearing problems, cleft lip or palate has been identified as a risk factor for bronchiolitis. However, the link between these defects and other airway infections remains poorly explored.”1 The “primary goal of this study by Laager et al was to examine the incidence rates of hospitalizations due to respiratory infections or any cause during the first 2 years of life, considering the necessity and timing of corrective surgery. Our secondary aim was to assess clinical outcomes of newborns and young children with cleft lip or palate compared with those without clefts. Thus, this analysis aims to enhance our comprehension of the disease burden among hospitalized patients with cleft lip or palate.”1
“Of 857 806 newborns included, 1197 (0.1%) had a cleft lip and/or palate, including 170 (14.2%) with a cleft lip only, 493 (41.2%) with a cleft palate only, and 534 (44.6%) with cleft lip and palate. Newborns with cleft lip or palate were more likely to be male (55.8% vs 51.4%), with lower birth weight (mean [SD] weight, 3135.6 [650.8] g vs 3284.7 [560.7] g) and height (mean [SD] height, 48.6 [3.8] cm vs 49.3 [3.2] cm). During the 2-year follow-up, children with a cleft lip or palate showed higher incidence rate ratios (IRRs) for hospitalizations due to airway infections (IRR, 2.33 [95% CI, 1.98-2.73]) and for any reason (IRR, 3.72 [95% CI, 3.49-3.97]) compared with controls. Additionally, children with cleft lip or palate had a substantial increase in odds of mortality (odds ratio [OR], 17.97 [95% CI, 11.84-27.29]) and various complications, including the need for intubation (OR, 2.37 [95% CI, 1.95-2.87]), extracorporeal membrane oxygenation (OR, 2.89 [95% CI, 1.81-4.63]), cardiopulmonary resuscitation (OR, 3.25 [95% CI, 2.21-4.78]), and respiratory support (OR, 1.94 [95% CI, 1.64-2.29]).Thus, the key findings of this study is that children with cleft lip and or palate “exhibited higher hospitalization rates for airway infections and other causes, both before and after surgery. Additionally, compared with children without these conditions, children with cleft lip or palate had increased risks of in-hospital complications and mortality, and greater resource use.”1 The occurrence of hospitalization for airway infection was believed to be responsible for delays in scheduling surgery later than what is thought to be the optimal time.
Unfortunately, this study excluded all hospitalizations specifically for surgical repair, which is of major interest for anesthesiologists. A major explanation for the increase in hospitalization and morbidity in these children is the relatively high incidence of associated congenital malformations with cardio-vascular anomalies being around 17%. Another potential bias for the increase incidence of hospitalization for airway infections may be related to the Swiss Health system, which is not favorable for outpatient care as families have to contribute for at least 10% of the ambulatory care bill while in-patient care is completely covered by the basic medical insurance and/or canton. Nevertheless, this study highlights an important source of complication and adverse airway events in children with these conditions. While many of us suspected that this was the case, it is nice to have it confirmed by a large study such as this.
Although the results of this study cannot inform the need for overnight admission to the hospital in young children undergoing cleft palate repair because admissions for surgical repair were excluded, this information is available in the plastic surgery literature and most institutions admit children for at least one night after cleft palate surgery, with discharge being dependent on oral intake.5
What do you do in your practice? For those of you who do mission work, what do you do on your missions? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Laager R, Gregoriano C, Hauser S, et al. Hospitalization Trends for Airway Infections and In-Hospital Complications in Cleft Lip and Palate. JAMA network open 2024;7(9):e2428077-e2428077. DOI: 10.1001/jamanetworkopen.2024.28077.
2. Tatum SA. Patient Screening and Selection for Cleft Lip and Palate Surgery Procedures. JAMA network open 2024;7(9):e2428057-e2428057. DOI: 10.1001/jamanetworkopen.2024.28057.
3. Hansen EE, Chiem JL, Low DK, Rampersad SE, Martin LD. Enhancing Outcomes in Clinical Practice: Lessons Learned in the Quality Improvement Trenches. Anesthesia and analgesia 2024 (In eng). DOI: 10.1213/ane.0000000000006713.
4. Prevalence at birth of cleft lip with or without cleft palate: data from the International Perinatal Database of Typical Oral Clefts (IPDTOC). Cleft Palate Craniofac J 2011;48(1):66-81. (In eng). DOI: 10.1597/09-217.
5. Wood BC, Boyajian MJ, Zurakowski D, Rogers GF, Oh AK. Evaluating the Need for Routine Admission following Primary Cleft Palate Repair: An Analysis of 100 Consecutive Cases. Plastic and reconstructive surgery 2015;136(4):502e-510e. (In eng). DOI: 10.1097/prs.0000000000001583.