Prenatal Ultrasound Detection and Neonatal Nasogastric Tube Feeding Follow Opposite Gradients Across Orofacial Cleft Phenotypes: A Nationally Ascertained Referral-Centre Cohort Study

Background/Objectives: Cleft palate is developmentally and clinically distinct from cleft lip with or without cleft palate. Prenatal ultrasound reliably identifies clefts involving the lip but performs poorly for the secondary palate, whereas early feeding difficulty is concentrated in palatal clefts. These two observations have not previously been quantified within a single cohort. We aimed to determine whether prenatal detectability and neonatal feeding support requirements follow opposite gradients across cleft phenotypes. Methods: We conducted an ambispective study of a nationally ascertained referral-centre cohort of 328 consecutive children with an orofacial cleft and no clinically recognised syndrome, managed at the national referral centre for cleft surgery in Croatia. The cohort comprises children reaching surgical care and is not a population-based birth registry. Documented prenatal ultrasound diagnosis and feeding method during the first weeks of life were abstracted from medical records; cleft phenotype was confirmed by clinical examination. Proportions were compared with chi-square tests and exact binomial confidence intervals, and factors independently associated with each outcome were identified by multivariable logistic regression. Results: Overall prenatal detection was 76/316 (24.1%; 95% CI 19.4–29.2). Detection differed markedly by phenotype: 38.2% for cleft lip only, 34.0% for cleft lip and palate and 2.0% for cleft palate only (p < 0.001). Nasogastric tube feeding was required by 46/325 children (14.2%; 95% CI 10.6–18.4) and followed the opposite gradient: 0.0%, 14.2% and 24.8%, respectively (p < 0.001). Isolated cleft palate showed the strongest independent negative association with prenatal detection (adjusted OR 0.037; 95% CI 0.009–0.154) and was independently associated with tube feeding (adjusted OR 3.07; 95% CI 1.37–6.89). Of children requiring tube feeding, 43/46 (93.5%; 95% CI 82.1–98.6) had not been detected prenatally. Observed detection rose with year of birth in unadjusted analysis (OR 1.095 per year; 95% CI 1.012–1.185; p = 0.023) but was attenuated and no longer significant after adjustment (OR 1.071; 95% CI 0.991–1.157; p = 0.082); the temporal trend is therefore reported descriptively. An initial refer result at newborn hearing screening was markedly more frequent in children with palatal involvement than in those with cleft lip only (2.8%, 31.6% and 25.5% for cleft lip only, cleft lip and palate and cleft palate only; p < 0.001), contrasting cleft lip only with clefts involving the palate rather than following a monotonic gradient. Conclusions: Prenatal detectability and neonatal nasogastric tube use follow opposite gradients across cleft phenotypes. Children with cleft palate only are simultaneously the least likely to be identified before birth and the most likely to require assisted feeding, and almost all tube-fed infants arrive without a prenatal diagnosis. These findings support, as a practice consideration, routine structured neonatal feeding assessment for every newborn with a palatal cleft irrespective of prenatal findings.