Prioritizing Cleft/Craniofacial Surgical Care after the COVID-19 Pandemic

Abstract

Background: It is anticipated that in due course the burden of emergency care due to COVID-19 infected patients will reduce sufficiently to permit elective surgical procedures to recommence. Prioritizing cleft/craniofacial surgery in the already overloaded medical system will then become an issue. The European Cleft Palate Craniofacial Association, together with the European Cleft and Craniofacial Initiative for Equality in Care, performed a brief survey to capture a current snapshot during a rapidly evolving pandemic. Methods: A questionnaire was sent to the 2242 participants who attended 1 of 3 recent international cleft/craniofacial meetings. Results: The respondents indicated that children with Robin sequence who were not responding to nonsurgical options should be treated as emergency cases. Over 70% of the respondents indicated that palate repair should be performed before the age of 15 months, an additional 22% stating the same be performed by 18 months. Placement of middle ear tubes, primary cleft lip surgery, alveolar bone grafting, and velopharyngeal insufficiency surgery also need prioritization. Children with craniofacial conditions such as craniosynostosis and increased intracranial pressure need immediate care, whilst children with craniosynostosis and associated obstructive sleep apnea syndrome or proptosis need surgical care within 3 months of the typical timing. Craniosynostosis without signs of increased intracranial pressure needs correction before the age of 18 months. Conclusions: This survey indicates several areas of cleft and craniofacial conditions that need prioritization, but also certain areas where intervention is less urgent. We acknowledge that there will be differences in the post COVID-19 response according to circumstances and policies in individual countries.

Impact of COVID-19 on Elective Cleft Surgery in Low- and Middle-income Countries

“… 16 Although “elective” 17 in nature, this definition during the current global pandemic requires further discussion as there is a relationship to the timing of cleft surgery and long-term treatment outcome. 18 , 19 Though it has been suggested that a short delay in the timing of primary cleft lip surgery 7 may be appropriate during a global pandemic our data shows that the effect of the COVID-19 pandemic on decreased surgical rates continues and may become an “intermediate term” rather than “acute” problem.…”

“…In a recent publication, a consensus of providers suggested that cleft lip surgery could be postponed for up to 3 months without adverse effects on the patient. 7 , 8 With the duration of the pandemic now well into 12+ months, deferred surgery may be falling outside this prescribed window. Effects on families have also been described in literature as decreasing confidence in hospitals to provide care and fear of the risk of contracting COVID-19 when seeking routine hospital care as altering health seeking behavior for surgery.…”

Adapting cleft care protocols in low- and middle-income countries during and after COVID-19: a process-driven review with recommendations

“…Primary cleft lip repair was categorised as a medium priority as earlier lip repairs have been shown to benefit mother-infant interactions and bonding (Murray et al, 2007). Secondary speech surgery, symptomatic fistulae repair and secondary alveolar bone grafting were medium priorities due to their time-sensitive association with functional outcomes of speech and maxillary growth, although they occur at an older age and with a wider window of opportunity when compared to primary palatoplasty (Breugem et al, 2020). Secondary speech surgery and the repair of symptomatic fistulae may be warranted before the child enters primary education with an aim to achieve normal speech to help optimise educational performance (Sell et al, 2015).…”

“…In a crowded healthcare system following delays to many areas of planned services, prioritisation of care will be vital. Breugem et al, (2020) conducted a survey of cleft priorities during COVID-19 with 218 cleft professionals in Europe, Asia and the USA. The respondents viewed airway intervention for Pierre Robin Sequence to be an emergency procedure.…”

“…In Peru, children born with CL/P were having primary reconstructions at a significantly older age during the pandemic when compared to a pre-pandemic cohort, with delays most marked in primary cleft lip and nose reconstruction (Rossell-Perry & Gavino-Gutierrez, 2021). Prioritising cleft care in the overcrowded healthcare system when the pandemic ends will be challenging, even in high resource settings (Breugem et al, 2020).…”