CRANE Report 2019

In partnership with The CRANE Database, CLAPA are pleased to publish the findings of their 2019 summary report for patients, parents and carers below.

Since 2012, these reports have given us so much insight into cleft lip and palate in the UK, and have helped clinicians push for higher standards across the board.

As part of the UK cleft community, we hope you enjoy reading about the latest statistics CRANE have collected on children born (or registered with the database) between 1st January 2000 – 31st December 2018.

Please note: These figures are for births in England, Wales and Northern Ireland only. Figures from Scotland are collected slightly differently, though CRANE hopes to produce reports in the future which contain these as well.

Download the 2019 Report (PDF)

More About CRANE

What is a Cleft Lip and/or Palate?
What is the CRANE Database?
What other information does CRANE collect and use?
What we know about children born in 2018 with a cleft lip and/or palate
What we know about 5 year old children (born 2005-12) with a cleft lip and/or palate
Educational attainment at 5, 7 and 11 years of age in England
What is the impact of findings like these on children’s care?
Finding out more
Glossary

What is a Cleft Lip and/or Palate?

A cleft is a gap in the upper lip, the roof of the mouth (palate), or sometimes both. This is a common birth condition that can affect a number of functions including feeding, speech and hearing. Children’s dental and psychosocial health may also be affected (see the Glossary for more information on psychosocial health).

The cleft can involve part or all of the lip and/or palate and there are 4 types of cleft: Cleft palate (CP), cleft lip (CL), one-sided clefts known as a unilateral cleft lip and palate (UCLP) and clefts that affect both sides of the lip and palate known as bilateral cleft lip and palate (BCLP) (see the Glossary for more information on clefts).

Surgery usually takes place in the first year of life. Children may have further surgery to address function or appearance as they grow. Other non-surgical help and support such as speech therapy, hearing support and psychological support may also be needed by some children.

What is the CRANE Database?

The Cleft Registry and Audit NEtwork (CRANE) database has collected information about all children born with cleft lip and/or cleft palate in England, Wales and Northern Ireland since 2000, when the database was set up by the Department of Health*. We now have records for over 20,000 children born with a cleft.

Typically, children with a cleft lip and/or palate need cleft team care from birth to adulthood. This is why it is important to record information on these children at birth or at diagnosis, and into childhood to inform their care.

With the informed consent of parents/carers, CRANE collects and reports on the following information for children with a cleft:

The surgical treatments they have received,
how they are getting on in terms of their growth (their height & weight),
how they are getting on in terms of their speech,
their dental health,
their facial growth,
their psychological support, and
how well they are doing at school.

CRANE is also a national clinical audit. An audit in healthcare is used to improve the care of patients. CRANE is committed to helping professionals provide the best evidence-based cleft care through the information we make available in our reports.

We do not use any information in our reports that could be used to identify patients or their families.

For more information on why CRANE collects this information and how the information is handled, please read our CRANE Database Information Leaflet, available on the CRANE website.

*CRANE is overseen and guided by the Cleft Development Group – see the Glossary for more information on this.

What other information does CRANE collect and use?

With parent’s/carers’ consent only, CRANE follows the health and education of children with a cleft by linking to their official records held by the health and education systems.

This is called data linkage. It gives CRANE more information about the treatments that children with a cleft receive, as well as the outcomes of these treatments. For example, children’s educational assessments tell us about their speech, language and hearing, which may be influenced by the healthcare they receive.

This information is difficult to record by asking parents/carers directly or at a clinic, as this may not be easy to remember in detail. For example, the precise dates of each of their child’s surgical treatments.
Allowing CRANE to link to this information in children’s official records is voluntary and parents/carers and their child are free to withdraw their child’s information from the database at any time, without giving any reason, and without this affecting the treatment that they receive.
For a full list of the official records that we currently link to and intend to link to, please read CRANE’s Privacy Policy.

No ‘data linkage’ information is collected without the consent of parents/carers. Children and their families cannot be identified from CRANE’s findings and publications.

If you want to find out more about the other sources of data already collected and stored about your child, please read our CRANE Database Linkage Leaflet.

What we know about children born in 2018 with a cleft lip and/or palate

How many babies were recorded?

Number of children with data recorded in the CRANE database: 1,002
This is the total number of children recorded in CRANE as born between 1 January 2017 and 31 December 2018.
This is just below the average – of about 1,053 recorded per year – since CRANE records started in 2000.
These 1,002 children bring the total number of children recorded in CRANE since 2000 to 20,013.

Kinds of Cleft

Most children born in 2018 had a cleft palate (CP), at 43%.
Fewer children had a unilateral cleft lip and palate (UCLP (23%)), or a cleft lip (CL (22%)). A bilateral cleft lip and palate (BCLP) was the rarest type of cleft (12%).
The cleft type of 9% was unknown or had not been confirmed at the time of producing this report

Collecting Consent

99% of parents/carers approached for consent to collect data on their child in the CRANE Database had agreed to this.

Timing of diagnosis

Most babies with cleft had their condition spotted either before or at birth (accounting for 87% of diagnoses).
6% were diagnosed within a week of birth, and a further 7% did not receive a diagnosis until more than a week had passed.
Early diagnosis is very important to avoid unnecessary distress for families as babies can have difficulties feeding and then gaining weight.

Who were these children?

55% of the babies born with a cleft were male

What Happened After Diagnosis?

87% of children were referred by the maternity unit to a unit specialising in cleft care within 24 hours of the baby being born.

96% of parents/carers were contacted by the unit specialising in cleft care within 24 hours of hearing from the maternity unit.

What we know about 5 year old children (born between 2004-12) with a cleft lip and/or palate

The section summarises information on children at 5 years of age (born between 2004 and 2012) whose parents/carers have consented to information on their speech, growth, dental health and overall health being recorded in the CRANE Database.

Dental Health

At least 2 in 5 children (41%) had at least one decayed, missing or filled tooth (DMFT). This is more than the rate found in the general population (31%). This means rates of DMFT in children born with cleft lip and/or palate are higher than the general population (see the Glossary for more information on dmft).

Facial Growth

A quarter (26%) of children with unilateral cleft lip and palate (UCLP) had what is known as ‘poor facial growth’ when examined by orthodontists (using an assessment called the Five Year Old Index – see the Glossary for more information on the index).

This is better than the 36% reported in 1998 before cleft services were centralised.

Psychology screening

16% of children born with a cleft, and assessed with the ‘Strengths and Difficulties’ questionnaires, have high or very high scores*, meaning they may need extra support in certain areas. This is more than the rate found in children without a cleft (10%).

Psychologists offered support to the children, as needed, for the majority of children with high scores, and to 18% of those with lower scores. (see the Glossary for more information on the Strengths and Difficulties questionnaire).

*Based on information from 2011 and 2012 births only.

Speech

61% of children had scores suggesting their speech was not significantly different from their non-cleft peer group. This means there has been improvement in rates of normal speech.

Educational attainment at 5, 7 and 11 years of age in England

832 Children with a cleft and no other abnormalities or syndromes were included in the study looking at educational achievement.

Children with a cleft tend to have lower educational attainment levels than children in the general population. The educational gap between children with a cleft and the general population is similar across English, Maths and Science, and is consistent at 5, 7 and 11 years of age.

Further analysis is required to identify the reasons why this gap exists.

What is the impact of findings like these on children’s care?

National standards state that clefts should be diagnosed within 24 hours of birth to enable immediate referral to a specialist hospital. However, CRANE reports since 2012 show that almost a third of babies with cleft palate have their condition missed at birth, and called for national and local guidelines to be reviewed to reduce the risk of missed diagnosis of cleft palate.

As a response to our work, the Royal College of Paediatrics and Child Health (RCPCH) — in collaboration with key partners including the CRANE Database team — drafted and published a best practice guide to help healthcare professionals identify cleft palate in newborns in 2015.

This NICE accredited guide provides recommendations to ensure early detection of a cleft palate, and to improve and standardise the way the palate is routinely examined at birth. A parent/carer guide is also available.

The RCPCH also launched a training module to reduce delays in detection of cleft palates in 2018, entitled ‘Cleft Palate: Examination of the Newborn’. This aims to ensure that best practice guidance for the assessment of the palate in newborns is followed consistently.

Among children born with a cleft in 2018, the proportion of children referred to a Cleft Unit within 24 hours rose to 87%, showing improvement in immediate referral to a specialist hospital.

We also demonstrated that lower education attainment levels are found among children born with a cleft compared to those in the general population. This information serves to make decision makers involved in commissioning and planning special educational services aware that children born with a cleft may require support to reduce the gap in educational attainment with their non-cleft peers.

How can I find out more?

If you have any other questions about the CRANE Database that are not answered by our information leaflet, you can get more information by:

Talking to a member of your local cleft team;
contacting us directly by phone on 020 7869 6610 or by email at [email protected];
looking at the CRANE Annual Reports – available on the Publications page; and
contacting the Cleft Lip and Palate Association (CLAPA) directly on 020 7833 4883 or by email at [email protected].

Glossary

Cleft Development Group (CDG)	NHS group representing all stakeholders in cleft care (including the Cleft Lip & Palate Association (CLAPA)). The CDG is responsible for providing data for cleft births and cleft treatment for England and Wales and it endeavours, with the cooperation of the health services in Scotland and Northern Ireland, to do so for the whole of the UK. If you want to find out more about the CDG, please visit the Cleft Development Group page on – www.crane-database.org.uk.
Cleft Lip	A condition that creates an opening in the upper lip between the mouth and nose. It looks as though there is a gap in the lip. It can range from a slight notch in the coloured portion of the lip to complete separation in one or both sides of the lip extending up and into the nose. A cleft on one side is called a unilateral cleft. If a cleft occurs on both sides it is called a bilateral cleft. A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts.
Cleft Lip & Palate Association (CLAPA)	The only UK-wide voluntary organisation specifically helping those with, and affected by, cleft lip and palate. If you want to find out more about CLAPA, please visit: www.clapa.com.
Cleft Palate	This occurs when the roof of the mouth has not joined completely. The back of the palate (towards the throat) is called the soft palate and the front (towards the mouth) is known as the hard palate. If you feel the inside of your mouth with your tongue, you will be able to notice the difference between the soft and the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).
Decayed, missing or filled teeth (dmft)	This is a measure of oral health and describes the total amount of tooth decay / dental decay or cavities in children – specifically the total number of teeth or surfaces that are decayed (d), missing ((m), which includes teeth that do not develop and those removed due to dental disease), or filled (f). Children’s scores can range from 0 to 20 for affected teeth and 0 to 88 for affected surfaces.
Five Year Old Index	An assessment used to examine dental models of the teeth with five-year old children with a Unilateral Cleft Lip and Palate (UCLP). The index evaluates the effects of children’s main surgery on their facial growth before any other interventions, such as orthodontics or alveolar bone grafting, which may influence this growth further. Patients categorised as ‘1’ and ‘2’ on the index are considered to have the best possible outcomes, while those categorised as ‘4’ and ‘5’ are thought to have worst outcomes in terms of facial growth (the upper jaw has not grown as far forward as the lower jaw generally), and they may benefit from further surgery to correct this once facial growth is complete.
Psychosocial health	Health and well-being based on the combination of both a person’s thoughts and behaviours (the psychological part) and a person’s social environment (the social part).
Strengths and Difficulties Questionnaire	An emotional and behavioural screening questionnaire for children and young people (both with and without conditions like cleft) used by psychologists to guide the care they provide to them. It asks about 25 attributes (e.g. how they interact with other children), and allows psychologists to understand whether children’s symptoms or behaviours are close to average, slightly raised, high or very high. A higher score indicates a child may need more support in a certain areas.