Nasoalveolar Molding: Assessing the Burden of Care

Abstract

Over the last 3 years a shift at our institution has taken place in which patients who would have been offered nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2–5 weeks of life) without NAM. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.

The Burden of Care in Nasoalveolar Molding Treatment in Cleft Patients

“…10 Instead of presurgical NAM, early cleft lip repair (ECLR) provides another option in a protocol that decreases the burden of health costs. 14 In our study, however, the NAM therapy was covered by state insurance. Travel costs of public transport were also covered by state insurance.…”

Rethinking the Rule of 10s: Early Cleft Lip Repair Improves Weight Gain

“…While advantages of ECLR include improved aesthetic outcomes, wound healing, and parental mental health (Burianova et al, 2017), there is persistent concern regarding the effects of anesthetic agents on neonatal neurological development. Our institution developed a novel DBNAP for patients undergoing ECLR without any increase in adverse events compared to traditional volatile anesthetic agents (Wlodarczyk et al, 2021b). Several primate and rodent models have shown neuronal apoptosis with the use of GABA agonist and NMDA receptor antagonists (Ikonomidou et al, 1999; Jevtovic-Todorovic et al, 2003; Lee et al, 2015).…”

“…NAM, however, has several disadvantages: biweekly dental clinic visits, parental adherence to an appliance protocol, and significantly higher costs to the healthcare system and families compared to ECLR (Abbott and Meara, 2012;Esmonde et al, 2018;Wlodarczyk et al, 2021b). In one study by Wlodarczyk et al (2021b), diverting the first 100 ECLR patients from NAM resulted in a decreased cost burden of $ 368 700 ($ 111 727 per year) on the healthcare system. Included in this cost burden is lost wages for families with a child receiving NAM, which totals $2738.…”

“…At this senior author's institution, a paradigm shift has occurred where many neonates and young infants undergo early primary cleft lip repair in patients with unilateral defects at 2 to 5 weeks of age rather than presurgical nasoalveolar molding (NAM) followed by a traditionally timed repair at 3 to 6 months of age (Hammoudeh et al, 2017; Wlodarczyk et al, 2021b). A novel dexmedetomidine-based neonatal anesthetic protocol (DBNAP), with perioperative equivalence to traditional anesthetics using a volatile gas-based regimen, was developed for patients undergoing ECLR (Wlodarczyk et al, 2021a).…”

A Point-of-Care Digital Workflow for 3D Printed Passive Presurgical Orthopedic Plates in Cleft Care

“…It was shown that these costs could be reduced with passive presurgical treatment [ 31 ]. This could also counteract early cleft lip surgery in the first weeks of life, which has been propagated to reduce the burden of health care costs [ 32 ].…”