A cleft palate is an opening in the roof of the mouth that forms when the tissue doesn’t fully close during early pregnancy. The gap can be small, affecting only the soft tissue near the back of the mouth, or it can extend from the front of the palate all the way to the back. In the United States, about 1 in 1,563 babies is born with a cleft palate alone, and about 1 in 1,031 is born with a cleft lip that may also include a cleft palate. Most children born with this condition go through a series of surgeries and therapies that close the gap and address its effects on feeding, hearing, and speech.
How a Cleft Palate Forms
During the first trimester of pregnancy, separate plates of tissue grow from each side of the developing face and move toward the center, where they fuse together to form the roof of the mouth. When those plates don’t meet completely, a gap remains. The result is a cleft palate. This happens very early in development, often before many parents even know they’re pregnant.
About 70% of cleft palate cases are “nonsyndromic,” meaning the cleft occurs on its own without any other birth differences. The remaining 30% are associated with a broader genetic syndrome that may involve other parts of the body. In nonsyndromic cases, the cause is usually a combination of inherited genetic factors and environmental influences during pregnancy, such as maternal smoking, certain medications, or nutritional deficiencies. Often, no single clear cause can be identified.
Types of Cleft Palate
Not all cleft palates look the same. The size and location of the opening determine how it’s classified and what kind of treatment a child will need.
- Complete cleft palate: The opening extends from the front of the palate all the way to the back, affecting both the hard bony roof of the mouth and the soft tissue behind it.
- Incomplete cleft palate: The opening doesn’t run the full length. It may affect only part of the hard palate, only the soft palate, or some portion in between.
- Submucous cleft palate: A gap exists in the muscle of the soft palate near the back of the mouth, but a thin layer of tissue covers it. Because the surface looks intact, this type is often difficult to diagnose and may not be noticed until a child develops speech problems.
A cleft palate can occur with or without a cleft lip. When a cleft lip is also present, the gap extends from the upper lip into the palate. Isolated cleft palate, without a cleft lip, is considered a separate condition with its own set of genetic and developmental factors.
Detecting a Cleft Palate Before Birth
Cleft lip is relatively easy to spot on a routine prenatal ultrasound because it changes the visible profile of the face. Isolated cleft palate, however, is much harder to detect. The roof of the mouth is difficult to image clearly, and standard 2D ultrasound often misses the gap entirely. Even in high-risk patients referred for specialist ultrasound, one study found that cleft palate was suspected in only about 22% of cases, though when it was suspected, the diagnosis turned out to be correct every time. Three-dimensional ultrasound improves detection somewhat, but many cleft palates are still first discovered after a baby is born, during a physical examination of the mouth.
Feeding a Baby With a Cleft Palate
Feeding is typically the first challenge parents face. To drink from a bottle or breast, a baby needs to create suction by pressing the tongue against a sealed palate. A cleft breaks that seal, making it hard for the infant to generate enough negative pressure to draw milk out efficiently. Milk can also flow upward through the gap and into the nose.
Specialty bottles are designed to work around this problem. Systems like the Dr. Brown’s Specialty Feeding System use a one-way valve that releases milk when the baby compresses the nipple, rather than requiring suction. The nipples come in different flow rates, from ultra-preemie to level 4, so parents can adjust based on how easily their baby handles the flow. If feedings take longer than 30 minutes or the baby seems exhausted, that’s a sign the nipple flow rate may need to go up. If the baby is coughing, gagging, or milk is spilling from the corners of the mouth, a slower nipple is a better fit.
Holding the baby in a more upright position helps keep milk from going back up into the nasal passages. Frequent burping, roughly every half ounce to one ounce, is also important because babies with a cleft tend to swallow more air during feeds.
Surgical Repair
The initial surgery to close a cleft palate is typically performed when a child is between 9 and 15 months old. The timing balances two priorities: the palate needs to be closed before speech develops in earnest, but the baby needs to be old enough to tolerate surgery safely. During the procedure, a surgeon repositions the tissue from each side of the gap and brings it together in the midline, creating a functional palate that can separate the mouth from the nasal cavity.
For many children, this single surgery is enough. But some will need additional procedures later. A secondary speech surgery, performed anywhere between ages 4 and 18, strengthens the tissue around the throat to improve the seal between the mouth and nose during speech. The decision to operate again is made based on how a child’s speech develops after the initial repair, usually in close collaboration with a speech-language pathologist. Children with wider or more complex clefts may also need bone grafting in the upper jaw as they grow, and some require orthodontic work or jaw alignment surgery during adolescence.
Speech and Language Development
Even after a successful surgical repair, up to 50% of children with a cleft palate will need some form of speech therapy. The core issue is that the repaired palate may not move well enough to fully close off the nasal passage during speech. When air leaks through the nose instead of being directed out of the mouth, sounds come out nasal or muffled. Children may also develop compensatory habits, learning to produce sounds like “s,” “sh,” or “r” through the nose rather than the mouth, or substituting sounds made deeper in the throat for ones that should be made with the lips or tongue tip.
Speech therapy for cleft palate focuses on building precise movements. Early work often starts with lip sounds like “p,” “b,” and “m,” since pressing the lips together is the most straightforward way to redirect airflow through the mouth. From there, therapy moves to tongue-tip sounds like “t,” “d,” and “n,” which require the child to develop strength and flexibility in the tongue and learn to make crisp contact with the ridge just behind the upper teeth. Sounds made at the back of the mouth, like “k” and “g,” can be especially tricky because children may substitute a sound made at the vocal cords instead. Hissing and buzzing sounds like “s” and “z” require the child to learn to direct a narrow stream of air through the mouth, a skill that takes focused practice.
Starting therapy early, ideally as speech is first emerging, gives the best results. The goal is to prevent compensatory patterns from becoming habits rather than trying to undo them later.
Ear Infections and Hearing
Children with a cleft palate are unusually prone to middle ear fluid buildup and ear infections. The reason is mechanical: the muscles that open the eustachian tube (the small channel connecting the middle ear to the back of the throat) attach to the soft palate. When the palate is cleft or has been repaired but doesn’t function perfectly, those muscles may not open the tube effectively. Without regular ventilation, the middle ear absorbs its trapped air, creating negative pressure that pulls the eardrum inward and draws fluid into the space. This condition, called serous otitis media, causes temporary hearing loss that can interfere with language development during critical early years.
The standard treatment is a small pressure equalization tube placed through the eardrum to ventilate the middle ear. These tubes typically stay in place for 6 to 12 months, and by the time they fall out naturally, the eustachian tube has often matured enough to function on its own. Some children need repeat tubes if the problem persists. Regular hearing checks are a standard part of cleft palate care throughout childhood, since even mild, fluctuating hearing loss can slow down speech and learning if it goes unnoticed.
The Long-Term Picture
Cleft palate care isn’t a single event. It’s a process that spans childhood and sometimes extends into the late teens, involving surgeons, speech therapists, audiologists, orthodontists, and sometimes psychologists. The timeline looks different for every child depending on the type and severity of the cleft, whether other conditions are present, and how the palate heals after surgery. But the outcomes for children who receive coordinated care are overwhelmingly positive. Most reach adulthood with normal speech, stable hearing, and a fully functional palate.