What are the implications for an infant with a family history of bronchial asthma (BA) and a diagnosis of cleft palate?

From the Guidelines

Infants with bronchial asthma and cleft palate should be managed with a coordinated approach, prioritizing inhaled corticosteroids for asthma control, while considering the complexities of medication delivery due to the cleft palate, as recommended by the expert panel report 3 (epr-3) guidelines 1.

Key Considerations

• For asthma management, inhaled medications are the mainstay of treatment, typically delivered via a metered-dose inhaler with an infant spacer and mask, with short-acting beta-agonists like albuterol used for acute symptoms, and low-dose inhaled corticosteroids such as fluticasone for persistent asthma 1.
• The cleft palate complicates medication delivery, so proper positioning during inhaler use is crucial, holding the infant upright with the head slightly tilted back.
• Oral medications like montelukast may be considered if inhaled therapy is difficult, as suggested by the guidelines for young children with asthma 1.

Management of Cleft Palate

• Specialized feeding techniques using cleft-specific bottles are necessary until surgical repair, which typically occurs between 9-18 months of age.
• Regular follow-up with a multidisciplinary team including a pediatric pulmonologist, otolaryngologist, and cleft palate team is essential.

Education and Monitoring

• Parents should be educated on asthma triggers, proper inhaler technique, and signs of respiratory distress.
• The anatomical abnormality of the cleft palate can exacerbate respiratory issues, so prompt attention to any breathing difficulties is particularly important in these infants, as highlighted by the clinical practice guideline on allergic rhinitis 1.

Treatment Approach

• The decision to start long-term daily therapy should be based on consideration of issues regarding diagnosis and prognosis, taking into account the chronic airway inflammatory response in asthma and the potential for underdiagnosis and undertreatment in this age group 1.
• Monitoring response to therapy closely is crucial, with treatment adjustments made as needed to ensure optimal control of asthma symptoms and minimize potential side effects.

From the Research

Infant of Bronchial Asthma and Cleft Palate

• Bronchial asthma is a serious global problem that has steadily increased in prevalence during the past two decades 2.
• Oral manifestations of pediatric patients suffering from bronchial asthma include an increased upper anterior and total anterior facial height, higher palatal vaults, greater overjets, and a higher prevalence of posterior crossbites 2.
• Preterm infants with cleft lip and palate can be successfully stabilized using a modified continuous positive airway pressure application method, thereby avoiding primary intubation and its associated risk of complications 3.
• Patients with clefts of the lip and palate present a number of problems associated with speech and hearing during early childhood, dental anomalies and malocclusion in the developing dentition, and secondary facial deformities and emotional "burn out" in adolescence 4.
• The dentist is an important member of the cleft-palate team, providing an essential role in establishing a preventive plan, monitoring the dental needs of the patient, and motivating and educating the patient 4.
• Salmeterol/fluticasone may be more effective than montelukast alone or add-on therapy to fluticasone in the treatment of bronchial asthma in children and adolescents, especially in improving asthma control level 5.
• Salbutamol is a selective short-acting β2-agonist used as an alternative reliever in the treatment of asthma, with its therapeutic effect based on its potent smooth muscle relaxant properties 6.

Management of Infant with Bronchial Asthma and Cleft Palate

• Dental treatment of pediatric patients with bronchial asthma requires the role of a pedodontist, with behavior management techniques, conscious sedation techniques along with medical management, and comprehensive dental treatment by a pediatric dentist 2.
• A team approach to management is essential for patients with clefts, including a dentist, to provide a detailed and sequential multidisciplinary management plan 4.
• The use of salmeterol/fluticasone or salbutamol in the treatment of bronchial asthma in children and adolescents with cleft palate should be considered, with careful monitoring of efficacy and adverse effects 5, 6.

Considerations for Infant Care

• Preterm infants with unilateral cleft lip and palate can be successfully stabilized using a nasal mask continuous positive airway pressure system, but this method may not be suitable for patients with bilateral cleft lip and palate 3.
• The management of children with clefts of the lip or palate requires appreciation of the differences in velopharyngeal function, hearing, speech, growth, and dental development 4.
• Further research is needed to make firm conclusive statements on the use of salmeterol/fluticasone or montelukast in children and adolescents aged 4 to 18 years with asthma 5.