The impact of changing cigarette smoking habits and smoke-free legislation on orofacial cleft incidence in the United Kingdom: Evidence from two time-series studies

Background Both active and passive cigarette smoking have previously been associated with orofacial cleft aetiology. We aimed to analyse the impact of declining active smoking prevalence and the implementation of smoke-free legislation on the incidence of children born with a cleft lip and/or palate within the United Kingdom. Methods and findings We conducted regression analysis using national administrative data in the United Kingdom between 2000–2018. The main outcome measure was orofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland. First, we conducted an ecological study with longitudinal time-series analysis using smoking prevalence data for females over 16 years of age. Second, we used a natural experiment design with interrupted time-series analysis to assess the impact of smoke-free legislation. Over the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2–16.2 in England, Wales and Northern Ireland and 13.4–18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (RR 0.92, 95%CI 0.85 to 0.99; P = 0.024) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation (RR 1.16, 95%CI 0.94 to 1.44; P = 0.173). Conclusions These two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.

Do Orofacial Clefts Impair Breastfeeding and Increase the Prevalence of Anemia?

Objective This study aimed to correlate the prevalence of iron deficiency anemia and breastfeeding with orofacial clefts in children. Design Data on the participant profile, presence and type of the cleft lip and/or palate (CL/P), and records on anemia and breastfeeding were collected from patients’ charts, and submitted to statistical analysis by χ2 test ( p < .05; software SPSS 23.0). Results Two-hundred and ten files were divided according to: CL/P presence (cleft group; n = 132) or absence (control group; n = 78). Group CL/P was subdivided according to the type of cleft: CL/P-I (cleft lip; n = 35); CL/P-II (cleft lip and palate; n = 45); CL/P-III (cleft palate; n = 43); and CL/P-IV (rare orofacial clefts; n = 9). Group CL/P had significantly more records on anemia ( p = .016) and fewer records on breastfeeding (P<.01) than controls. More records on anemia occurred in CL/P-II ( p = .004) and CL/P-IV ( p = .006) than the control group. The comparison among the orofacial cleft types regarding the anemia records showed no statistically significant differences ( p = .123). Group CL/P-I had more records on breastfeeding than the other cleft types ( p < .01). Conclusions Thus, it is suggested that the breastfeeding process is more complex, and the history of anemia is more frequent, in children with cleft lip and palate or rare orofacial clefts than in children without clefts.

Speech Outcomes of a National Cohort of Children with Orofacial Cleft at 5 and 10 Years of age

Objective To assess speech outcomes at five and ten years of age in a nationwide study of children with orofacial cleft. Design Prospective study. Participants Children born with orofacial cleft and having primary surgery in New Zealand. Speech samples were available for 151 five-year-old, and 163 ten-year-old children. Main outcome measures Intelligibility, Acceptability, Velopharyngeal function, Hypernasality, Hyponasality, severity of airflow evaluated by perceptual speech assessment (using the standardised Rhinocleft assessment), and overall assessment of requirement for clinical intervention. Results A large proportion of five-year-old children had speech that was considered to be not completely intelligible, was not acceptable, and had inadequate velopharyngeal function. The noted deficiencies led to a clinical judgement that further speech and/or surgical intervention was required in 85% with cleft lip and palate, 65% with cleft palate and 26% with cleft lip. The proportion of children with poor speech outcomes in the ten-year-old children was lower, though of clinical importance, further intervention required for 25% with CLP, 15% with CP and 3% with CL. The number of sound production errors in both age groups followed the same pattern with fewest in those with CL and most in those with CLP. Conclusions A significant proportion of children with orofacial cleft were found to have poor speech outcomes requiring further treatment. The outcomes are poor compared to centres reported in the UK and Scandinavia. New Zealand requires a review of the current services for individuals born with cleft to improve speech outcomes and interdisciplinary care.

High incidence and regional distribution of cleft palate in Finns are associated with a functional variant in an IRF6 enhancer

In Finland the frequency of isolated cleft palate (CP) is higher than that of isolated cleft lip (CL) or cleft lip with cleft palate (CLP). This trend contrasts to that in other countries but its genetic underpinnings are unknown. We performed a genome-wide association study for orofacial cleft, which includes CL, CLP, and CP in the Finnish population. We identified rs570516915, a single nucleotide polymorphism that is virtually specific to Finns and Estonians, as being strongly associated with orofacial cleft, and predominantly with CP (p = 5.25 x 10-34, OR = 8.65, 95% CI 6.11-12.25). The risk allele frequency for rs570516915 parallels the regional variation of CP prevalence in Finland, and the association was replicated in an independent sample of CP cases from Estonia (p < 1.3 x 10-11). The rs570516915 variant lies in an IRF6 (Interferon Regulatory Factor 6) enhancer active in ectodermal and oral epithelial cells. Other variants in the IRF6 locus, including those in the same enhancer, are associated with orofacial cleft, but predominantly with CL or CLP, suggesting shared mechanisms in the distinct processes of lip and palate development. By luciferase and transgenic mouse reporter assays we found that the risk allele of rs570516915 diminishes the activity of the enhancer. CRISPR-Cas9 edited oral epithelial cells demonstrate that rs570516915 disrupts an IRF6 binding site and decreases the expression of IRF6, suggesting impaired IRF6 autoregulation as the molecular mechanism underlying risk for CP.

Key Points on Short Term Medical Mission International organization on Orofacial cleft

Background: Children suffering from congenital facial malformations in underdeveloped countries are the main objective of the STMMIs with the aim of easing their lives. Clarós Foundation (CF) has carried out 115 missions worldwide with the aim, among others, of treating patients with this type of orofacial cleft malformation. We think that the experience we have acquired in this field can be transmitted to new NGOs institutions that want or wish to continue in this line. The optimization of the use of means and human resources, both from the NGO and the local health workers, will make it possible to achieve greater outcomes and results when applied in the development of Short Term Medical Mission International (STMMIs) missions. Material and Methods: We present the experience CF has acquired throughout the various STMMIs it has accomplished, during a period of 7 days each, specifying the details of its organization, patient selection, preparation of the surgery and its performance, in a well- organized manner to be fast, effective and safe in its results. During each of the 115 missions, the medical team has treated patients with this congenital pathology, in different proportions that go from 90% of the total cases to only 10% of the patients attended. The surgical techniques applied are those used in our medical center in Barcelona, which we may say, are the state-of-the-art surgical techniques used by the most advancedcenters. Results: A total of 1725 patientsunderwent surgery throughout 115 STMMIs, averageduration of 7 days each,115 STMMIs by 15 cases average. During this time 925 patients were operated for cleft lip and 800 patients for cleft palate. Male patients accounted for 58% and female for 42%. According to the age of the patients we found that the majority of cases were operated on babies 68.35% (1.179 neonatal period); 20.2% on children (300 cases) and (19.76%) adolescents (233 cases); and 1.10% adults in the 20-67 age range (13 cases). Of the total number of operated patients(1.725), there have been few immediate and late postoperative complications, but we estimate them at 11%. Conclusion: International cooperation between experienced NGOs and local medical teams turn out to be much more effective, less expensive and with better clinical results than those obtained without this collaboration. This organizational model can be very useful in order to know the details that these missions entail and apply them in your own activities.

Genome-wide association study of multiethnic non-syndromic orofacial cleft families identifies novel loci specific to family and phenotypic subtypes

Orofacial clefts (OFCs) are among the most common craniofacial birth defects and constitute a high public health burden around the world. OFCs are phenotypically heterogeneous, affecting only the lip, only the palate, or involving both the lip and palate. Cleft palate alone is demonstrably a genetically distinct abnormality from OFCs that involve the lip, therefore, it is common to study cleft lip (CL) in combination with cleft lip plus cleft palate (CLP) as a phenotypic group (i.e. cleft lip with or without cleft palate, CL/P), usually considering CLP to be a clinically more severe form of CL. However, even within CL/P, important genetic differences among subtypes may be present. The Pittsburgh Orofacial Cleft (Pitt-OFC) multiethnic study is a rich resource for the study of non-syndromic OFC, comprising a large number of families (~12,000 individuals) from multiple populations worldwide: US and Europe (whites), Central and South America (mixed Native American, European and African), Asia, and Africa. In this study we focused on the CL/P families from this resource grouped into three non-overlapping family types: those with only CL affected members, only CLP affected members, or both CL and CLP. In all, seven total subtypes besides the combined CL/P phenotype, were defined based on the cleft type(s) that were present within pedigree members. The full sample for these analyses includes 2,218 CL and CLP cases along with 4,537 unaffected relatives, as well as 2,673 pure controls with no family history of OFC. Genome-wide association analyses were conducted within each subset, as well as the combined sample. Five novel genome-wide significant associations were observed: 3q29 (rs62284390, p=2.70E-08), 5p13.2 (rs609659, p= 4.57E-08), 7q22.1 (rs6465810, p= 1.25E-08), 19p13.3 (rs628271, p=1.90E-08) and 20q13.33 (rs2427238, p=1.51E-09). In addition, five significant and four suggestive associations confirmed regions previously published as OFC risk loci - PAX7 , IRF6 , FAM49A , DCAF4L2 , 8q24.21, ARID3B, NTN1 , TANC2 and the WNT9B:WNT3 gene cluster. At each of these loci, we compared effect sizes of associated SNPs observed across subtypes and the full sample, and found that certain loci were associated with a specific cleft type, and/or specific family types. Our findings indicate that risk factors differ between cleft and family types, but each cleft type also exhibits some degree of genetic heterogeneity.

The Role of Paternal Age and Occurrence of Orofacial Clefts in South Indian Population

BACKGROUND The association between orofacial cleft and parental age is evident. This study focuses on paternal age playing a vital role in the birth of children with orofacial clefts. We wanted to assess the role of paternal age as a factor in the development of congenital anomalies in this study. METHODS A case control study was performed on 1000 cases and 250 controls in Mangalore. The parents were interviewed regarding their age at the time of conception. RESULTS 46.4 % of fathers of the cleft children belonged to 30 - 34 years of age group and 25 % belonged to 25 - 29 years of age group at the time of conception. In the control group, 38 % belonged to 30 - 34 years of age group and 24.8 % belonged to 25 - 29 years of age group. CONCLUSIONS Paternal age in the age group of 30 - 34 years has significant contribution in the birth of orofacial children with cleft deformities. KEY WORDS Orofacial cleft, Paternal Age, Congenital anomalies