Academic Capacities of Children With Cleft Lip and Palate.

S ando and Jurkiewicz wrote that “. cleft lip and palate pose the quintessential challenge of plastic surgery. More than any other area of the specialty, these afflictions demand closely allied reconstructive and cosmetic principles, tightly intertwined form and functional goals, and exacting technique. ” In response to this challenge, plastic surgeons have made great technical contributions. The lip repair of Millard and the palate repair of Furlow redefined the operative approaches to these disorders. Millard's rotation-advancement lip repair shifted the surgical strategy of this problem away from wound and defect concepts toward the reassembly of distorted parts, leading to ongoing refinements of muscle realignment and management of nasal deformities. Furlow's Z-plasty procedure for cleft palate changed the concept of cleft palate from deformity to defect. The Z-plasties mobilize tissue components to compensate for inadequate original tissues, and the results appear to give more reliably satisfactory outcomes for speech development. Arguably, these 2 innovations are the most significant technical developments in modern cleft surgery. Publication of surgical innovations and refinements, however, appear monthly in the surgical literature. The role of the plastic surgeon in the care of these patients includes more than surgical management. Sando and Jurkiewicz go on to observe that “the surgeon must also serve as primary care physician, observing and treating a patient for 15 years or longer and sensitively responding to the patient's physical and emotional needs. ” From this extended and complex pattern of caregiving, plastic surgeons can offer a critical analysis of a species of research that uses collective databases to examine the academic performance of children with clefts. The general structure of such studies consists of using a registry to identify cleft children and using school performance and testing databases to compare the academic measures of children with clefts to variously defined control groups. Problems with these studies include flaws in database entries and utilization; selective use of data and statistical analyses to amplify differences and de-emphasize findings contrary to the study's thesis; and extrapolation of data analyses into speculations about intrinsic cognitive deficiencies and differences in brain morphology. A recent publication by Gallagher et al exemplifies many of the anomalies intrinsic to database studies of academic capacities and children with clefts. These authors used Iowa state data registries to explore “relationships between laterality of oral clefts and academic achievement. ” Children with clefts were identified by accessing the Iowa Registry for Congenital and Inherited Disorders. The authors state that they screened for “children with isolated unilateral cleft lip with or without cleft palate (ie, without syndromes or other unrelated major birth defects). ” By linking registry data with ITP (Iowa Testing Programs) data, the authors identified 468 children with “cleft lip with/without palate” born “from January 1983 through December 2003” and attempted to perform an analysis of cleft site and academic performance. The authors state that “414 children had data on laterality, and 292 had unilateral cleft lip. Consistent with previous studies, most cases had left-sided clefts (n = 189, 65%). ” At this point, the data sets and the authors' derivative categorizations indicate that their study population is substantially different from general data describing populations of cleft children. Excluding cases without data on “laterality,” 414 cleft children were identified. A total of 292 (71%) had unilateral cleft lip. Their breakdown indicates that 29% of this subpopulation had bilateral clefts, an abnormally high incidence of bilateral clefts, which generally account for 10% of clefts. The 54 patients without “data on laterality” represent 12% of identified patients, and this group further testifies to the incompleteness and possible collection biases of their registry. From this compromised beginning, the authors proceed to identify 189 left-sided clefts (65%) and 103 rightsided clefts (35%), a ratio consistent with generally reported epidemiology. The cleft children, divided into right and left laterality groups, were matched with classmates (2 noncleft children per cleft child) based on “sex, month and year of birth, grade, and school. ”Academic data were obtained by comparing “affected children to all their matched controls with available ITP data. ” This level of analysis also contains an anomaly. The authors note that “the classmate group for the children with the left-sided clefts had consistently better achievement outcomes than the classmate groupwith right-sided clefts. ” The