HOW CAN I HELP

MY CHILD WITH A
CLEFT PALATE TO
TALK?
By Georgia Haitas-Jammine
Speech-language Therapist

Copyright © Georgia Jammine

1 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?

 When should we see a
SPECIAL INSERT speech-language
therapist for the first
time?
HOW CAN I HELP
MY CHILD WITH Your first meeting with the
speech-language therapist
A CLEFT PALATE should take place as soon after
the birth as possible, and no later
TO TALK? than 3 months after the birth. If
the cleft is diagnosed during the
pregnancy, parents may meet
the speech-language therapist
even before the birth.
Obviously the baby is
How Can I Help My Child with a Cleft Palate to Talk not speaking at birth.
Copyright © Georgia Jammine
Edition 1 - 2017
Why should I see the
All rights reserved. No part of this book may be used or reproduced by any speech-language
means, graphic, electronic, or mechanical, including photocopying, taping or
by any information storage retrieval system without the written permission
therapist so early?
of the publisher except in the case of brief quotations embodied in critical
The speech-language therapist
articles and reviews.
can provide you with information
ISBN 978-0-6399105-4-3
on how to feed your infant with
a cleft and monitor the way the
2 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
baby is using his lips, tongue and
palate in feeding. She will discuss
the process of normal speech
and language development and
how the cleft may impact on
this. She will monitor the baby’s
speech and language develop-
ment, and suggest ways in which
you as parents can enhance your
baby’s communicative devel-
opment. She may also answer
questions that you may have
regarding the cleft. Certainly
there’s a lot that can be done
before the lip and palate are
surgically repaired. Having writ-
ten material such as this booklet
may be very helpful, but it does
not remove the need to see a
speech-language therapist.
The child with a cleft is managed
by a team of professionals. The
speech-language therapist can
refer you to see other mem-
bers of the team, including the
Surgeon who will repair the cleft,
the Ear Nose and Throat Surgeon
(ENT), the Orthodontist, a Social
Worker or Psychologist, and put
you in touch with other parents
who have experience with cleft
palate.
How often should I see
her after that?
You should see your speech-
language therapist again at
about 5-6 months, before that
baby starts to babble, to get
more specific information on
how to stimulate babbling. You
can then see her at least every
4-6 months in the early years, or
more frequently if she recom-
mends it. In this period she will
ensure that the baby’s receptive
language and early communica-
tion are developing appropriately.
At this stage you as parents are
really providing the ‘therapy’ and
the speech-language therapist
is monitoring both you and the
baby. It will be helpful if you are
provided with written material.
Your speech-language therapist
will advise you on whether and
at what stage direct, regular
and intensive speech therapy is
indicated.
3 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
What is the
function of the palate in
speech?
The palate is divided into two
main sections: the hard palate
in the front, consisting of bone
tissue, and the soft palate at the
back, consisting of muscle tissue.
The palate forms the roof of the
mouth and the floor of the nose.
Its function is to separate the
nose from the mouth thus
forming two separate cavities.
Look in the mirror at your own
palate, and see how the soft pal-
ate lifts up when you say /ah/.
The soft palate lifts up and clos-
es against the back wall of the
throat (pharynx), thus separating
the nose from the mouth. This
movement is necessary for
feeding and for speech.
There are three sounds in which
the soft palate merely rests on
the back of the tongue, and does
not function to separate the nose
from the mouth.
Soft palate at rest, and during normal
nasal breathing, and production of /m, n,
ng/ sounds (Kummer, 2014)
Air coming up from the lungs
passes behind the soft palate
into the nose, and out through
the nostrils. These 3 sounds are
/m/, /n/ and /ng/ (as in “hang”).
They are called nasal sounds, be-
cause the airstream has to flow
out of the nose to produce them.
Lightly touch the side of your
nose as you say these sounds,
and you will feel the vibration. If Soft palate lifted to close against the back
you block your nose, you cannot of the throat and separate the nose from
produce these sounds. It’s these the mouth (Kummer, 2014)
sounds that make you sound like
you’ve got a cold if your nose
is blocked. The voice quality Which aspects of a cleft
associated with a blocked nose is
known as ‘hyponasality’. It’s also palate can contribute to
these sounds which are easy a speech and language
for a child with a cleft to say, as
they require an opening between disorder?
nose and mouth.
The main factors contributing to
a speech and language
Most of the sounds in English re-
disorder in a child with a cleft
quire the soft palate to be lifted
include the following:
up and to close against the back
wall of the throat or pharynx.
• The palate may land up being
With the soft palate in this
too short to separate the nose
position, air coming up from the
from the mouth completely.
lungs flows out of the mouth. The
This results in nasal speech.
sounds produced are called oral
sounds, and these include: /p/,
/b/, /t/, /d/, /k/, /g/, /f/, /v/,
/s/, /z/, /th/, /sh/, /zh/, /ch/
and /j/
 child pronounces or produces
the various consonants in the
language. These may be distort-
ed. The second is that his speech
may have a ‘nasal’ or ‘hypernasal’
quality. We use the term “audible
nasal escape” to describe air es-
caping out of the nose during the
production of certain consonants.
Our ultimate goal for children
Short soft palate unable to reach the born with clefts is normal speech,
back of the throat to separate the nose or as close to normal as possible.
from the mouth completely (Kummer, Hearing loss frequently
2014) associated with middle ear
problems, often found in children
with a cleft may cause a delay in
• Crooked teeth associated with speech and language
a distortion in the bite. This is development. A negative reac-
known as dental malocclusion. tion to the appearance of the
• Hearing loss. This is usually child may result in poor interper-
associated with a dysfunction sonal and communication skills.
of the middle ear.
• A hole (fistula) remaining in
the palate though which air How early can you tell
can escape.
that speech and
language are developing
How does a cleft palate differently from other
affect speech? children?
There are two ways in which a In the first few months of life
cleft palate commonly affects there is little difference between
speech. The first is in the way the the sounds made by infants with
4 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
clefts and non-cleft infants. Both
of them cry and coo in much
the same way. However when
they get to the babbling stage,
children with cleft palate often
produce a smaller variety of
consonants than their non-cleft
peers, and also vocalise less
overall. They may use only the
nasal consonants /m/ and /n/.
Early surgery to repair the palate
may facilitate earlier babbling.
You as parents may encourage a
greater variety of sounds starting
with the ones the baby is already
producing, or the ones he is
ready to learn. Your speech-
language therapist will guide you
in which sounds to encourage.
Which sounds are easi-
er for a baby with a cleft How can I encourage
my baby to make more
to say? How can we
sounds?
encourage these?
The easier sounds are those that
do not require much oral air
pressure. These include the
vowel sounds such as /a/, /i/
and /u/. If you notice that your
baby has not begun to say these,
5 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
then you may heighten his
awareness of them by increasing
the length of the vowel sounds
you say to him. You could use
them while playing or singing.
Other sounds which are easier
include /w/, /y/, /m/, /n/,
/h/ and /l/. It may be helpful
to keep a diary to record which
sounds he does say, so that
your speech-language therapist
can list for you those he doesn’t
say, and which still need to be
encouraged.
Once the child is using meaning-
ful words, you may want to build
up a vocabulary of words he
should be able to say clearly.
Make a variety of sounds as you
play with your baby and especial-
ly during routine activities such
as bathing, dressing, feeding. The
sounds you make may include
non-speech sounds, such as the
“raspberry”, as well as animal
noises, clicks, and environmental
noises (hooting, banging,
coughing, knocking, sizzling and
ringing). In fact you can imitate
any noises you hear around you.
Face him as you make these
sounds, so that he can see how
you are making the sounds. Even
let him feel on your lips and in-
side your mouth. Your baby may
not copy these sounds at first,
but persevere, and eventually
he will.
What is babbling and
how is it different in
babies with a cleft?
Babbling is the type of
utterances babies make before
learning to say words. It typically
consists of the production of
consonant-vowel (CV)
sequences such as “bababa”,
“gagaga”. Sometimes they say
“mama” or “dada” at this stage,
and parents get excited that they
are calling them. These utteranc-
es, which start at about 6 months,
do not necessarily have mean-
ing. Babbling forms the building
blocks for the later development
of meaningful words.
Babies with cleft palate especial-
ly before surgery to repair the
palate, produce fewer
consonants in total, as well as a
reduced repertoire of
different consonants. They are
often delayed in the onset age
of babbling. Typically they make
more use of the consonants that
do not require high pressure in
the mouth such as /w/, /y/,
/m/, /n/, /h/ and /l/ and the
vowel sounds, and avoid the
ones that do, such as /p/, /b/,
/t/, /d/, /k/, and /g/. Thus the
order in which babies with cleft
palate learn to produce the con-
sonants may be different from
their non-cleft siblings.
When your baby begins to
babble e.g. wawawa, mamama,
nanana, lilili, nununu, copy him,
and also make other sounds. This
will encourage him to increase
the frequency and variety of
his babbling, even if he doesn’t
imitate the exact sounds that you
babble with. The aim is to have
him vocalize more, regardless of
the quality of his sounds.
 How can I prepare my and many sounds incorporate it.
Again, use a mirror. He can also
child for learning to copy as you push your tongue
imitate sounds? into each cheek.

It is useful for the child to be- Have him copy you as you puff
come familiar with the parts of up your cheeks, letting the air
the mouth and how they move. out in bursts as you press your
Have him look at your mouth cheeks. Even let him look into
as you move your lips as they your mouth with a torch, and see
open and close, spread into a the soft palate moving as you
smile and purse as you blow, and say “ah”.
moving quickly as you repeat
“p,p,p,p,p”. Use a mirror for him
to see his own mouth. Name Which words would
the ‘top lip’ and the ‘bottom lip’.
You will be using these terms to be easier for my child
teach sounds later. with a cleft to learn to
Similarly show him the top teeth say clearly, even before
and bottom teeth. Show him how the palate is completely
you hold a sucker stick between
your teeth.
closed?
The easier words are those
Show him your tongue, and name
containing sounds that do not
the ‘tongue tip’. Encourage him to
require much oral air pressure
imitate tongue movements such
such as /w/, /y/, /m/, /n/, /h/,
as lifting the tongue tip towards
/l/ and the vowels. He is likely to
the nose, or licking the chin and
begin by saying words like ‘mom-
cheeks, gently biting the tongue
my’, ‘more’, ‘no’ before he says
between the teeth, and lifting the
‘daddy’, ‘ball’ and ‘bye bye’. Here
tongue to the position behind
are some words that he should
the top teeth. This last position
be able to pronounce clearly,
is an important one for speech,
6 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
because they are not affected Once the palate is baby bang bone bin /g/
by the cleft. It’s useful to teach bib belly bed big girl gum game gun
words that contain sounds that repaired, which sounds buy book back bath goal go bag mug
the child can already pronounce: will my child be ready to baboon banana egg log leg dig
• animal noises: moo (cow), Barney bunny
meow (cat), mêê (sheep),
learn? balloon bubble
pig big hug bug
dog garden guitar
oo-oo (owl) wagon Lego mango tiger
Now we can start concentrating
• environmental noises: woo
(wind), weewee, wahwah
on the consonants that require /t/
oral air pressure. Remember tie toe two tea You may notice that children
(sirens), wa wa (baby crying), tap tire top tail with clefts frequently learn the
though that some children may
lalala (singing), mmm (aer tart tower hat mat sounds produced at the back of
even be able to produce these
oplane noise), umm umm (car cat goat pot kite the mouth i.e. /k/ and /g/ be-
sounds even before the palate is
noise) gait coat hot fore those produced in the front
repaired. Begin with the stops or
• /w/ words: where, whale, potato butter robot letter i.e. /t/ and /d/.
plosives (short sounds) /p/, /b/,
wheel, wee, warm, wow. tomato
/t/, /d/, /k/, and /g/. Exam-
• /y/ words: you, yay! yummy naughty toot towel Initially you may assist by closing
ples of words containing these
• /h/ words: hair, here, he, hen, the child’s nostrils until he gets
sounds are:
hay, who, ham, her, hi, hammer, the concept of producing sounds
hey, hello. /d/ out of his mouth. This is better
• /m/ words: mama, mommy, /p/ doll duck door dog
done with two index fingers rath-
mom, more, me, moon, money, pear pay pea pie dad red bed bird er than by pinching the nostrils
mealie, man, arm pin pan palm pen hand lady window using one hand.
• /n/ words: no, knee, in, on, pill poo up hop bad lady lid
name, nanny, mine mop map lip pipe hadedah Remember that although chil-
• /l/ words: loo, lion, lamb, pillow piano hippo dren frequently follow an order
lemon, owl happy pepper paper /k/ of difficulty when learning new
• vowel words: eye, ear, air, poppy purple cap car cow key sounds, they sometimes surprise
oh-oh. puppy people pawpaw come cake cock cat us, and learn a sound that is
pineapple peep-peep kite comb cone cup generally considered more
king queen can cook ‘difficult’, before learning one
/b/ corn cot kick walk of the ‘easier’ sounds. Allow
bear bow bee bay milk work cork talk the child to lead the way, and
boy bye ball bell bike buck lock back encourage him to practise any
boo beer web boat bike camel cookie sound that is emerging, as long
7 HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
| monkey
 as it is clear, and not accompa-
nied by a glottal stop (see
page 9).
Which group of sounds
sun swing sweet
mouse bus case horse
house goose ice face
box fox necklace
stove star school stool
stop spade spider slide
nest basket snow snail

comes next?
/z/
Now you can go on to the frica- zebra zip xylophone
tives (long continuous sounds) bees cars lizard
/f/, /v/, /th/, /s/, /z/, /sh/, / newspaper vase
zh/. Here are some words to cousin present
teach:

/f/ /sh/
fire foot fork shoe shirt shark shell
phone fly floor flag ship shout shop tissue
flower fig fat fight cushion bush brush
hoof fish wash push
leaf knife laugh fish machine sheep shower
coffee elephant
/zh/
/v/ measure treasure garage
van veil violin Finally you can go on to the af-
volcano oven river five fricates (a combination of a stop
dive dove move love and a fricative)
/ch/ = /t/ + /sh/ and /j/ = /d/
+ /zh/. Here are some words to
/s/ use:
soap soup sea saw
sit sing sad salt

8 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?

/ch/
chain chip child chop stop or plosive) when the child
chair cheese church has difficulty building up air
cherry teacher watch witch pressure in the mouth because
match peach lunch
/j/
jam jacket
pigeon soldier
engine sausage
orange fridge
Begin by babbling with these
sounds. You can even let your
baby put his hand on or in your
mouth as you do this, so that he
can see and feel that some of
them are produced with the lips
/p/, /b/ and /m/, some with
the teeth and lips /f/ and /v/,
some with the tongue tip behind
the teeth /t/, /d/, /s/, /z/, /n/,
/s/, /n/, /sh/, /zh/, /ch/, /j/
and some at the back of the
mouth /k/ and /g/.
What is a glottal stop?
A glottal stop is a cough-like
sound frequently heard in the
speech of a child with a cleft.
It develops in an attempt to
9 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
produce a short consonant (a
of the cleft. The glottal stop may
even be used right from the
babbling stage as a substitution
for the pressure sounds /p/,
/b/, /t/, /d/, /k/, and /g/.
When the glottal stop persists,
the speech-language therapist
may be concerned, because they
may become established as a
habit that continues into the word
stage, and is quite a challenge
to eradicate later. You should ask
your speech-language therapist
to help you to identify these error
sounds. You should then avoid
reinforcing them, simply by
ignoring them, while responding
positively to the ‘good’ sounds he
produces.
How can I teach my
child to blow?
Producing an oral breath stream
is important as a basis for learn-
ing oral consonants. Begin by
sighing, or breathing out, or pre-
tending to clean your glasses, or to produce an oral breath stream
to mist up a mirror. You can use a is important as a foundation for
small square of tissue and blow learning consonants, and
it off the back of your hand. Draw especially fricatives such as /f/,
an aeroplane on it and pretend /s/, /th/ and /sh/. Ultimately
you are making the aeroplane fly. the best exercise for speech is
You can practise blowing cotton speech itself.
wool, bubbles, feathers, horns,
whistles, candles, harmonicas,
etc. You may need to close the Should I correct
child’s nostrils initially until he
gets the concept. This is better my child if he
done with 2 index fingers rather mispronounces
than by pinching the nostrils
using one hand. a word?
Be sensitive to when correcting
If you find that the child is blow-
him is appropriate and when it
ing through his nose, let him blow
is not. Beware of not correcting
through a straw. That way only air
him in front of others, which may
that flows through the mouth will
embarrass him. Also, don’t cor-
be effective. You can also use a
rect him every time he speaks, as
straw to blow light objects, such
he will become discouraged. On
as paper boats on water, or make
the other hand, praise him when
a pea-shooter with a small piece
he uses good speech, especial-
of tissue paper at the end of the
ly if you know that his speech
straw.
therapist is currently correcting a
specific sound, and you hear him
A word of warning about
blowing exercises! In the past it
using it correctly in his speech.
was believed that doing blowing
exercises would strengthen the
soft palate and decrease nasality.
This has not been found to be
the case. Rather teaching a child
 How is language
development affected in
a child with a cleft
palate?
Children born with a cleft lip and
palate, and no other problems,
need not necessarily be de-
layed in their language devel-
opment. They may however be
put at risk of delayed language
development because of other
factors, such as having frequent
ear infections with associated
conductive hearing loss, frequent
hospitalizations, social and edu-
cational limitations, Children born
with cleft palate as part of a syn-
drome may be more at risk for
language delay. Sometimes be-
cause their speech is difficult to
understand, children with clefts
don’t derive the same responses
to their efforts to communicate
as their more intelligible peers. It
is therefore important to take
special care to maintain the
language stimulus, even when
the child is difficult to understand.
10 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
If you are concerned about your
child’s language development, a
useful book for parents is the one
by Pepper and Weitzman (see
the resources on page 12).
How can I stimulate
general language
development?
Begin, right from birth to talk to
your baby throughout the day.
Talk clearly about everything
happening around him, so that he
will learn to understand his world.
A good time to concentrate on
talking is during routine activities
such as bathing, dressing,
feeding, playing, going for walks,
driving in the car etc. Outings to
the shops, to the library, to plac-
es of worship, to the zoo, to the
beach, to the park, to game parks
and farms all provide
opportunities for expanding the
child’s vocabulary.
Sing to him regularly. Music is a
wonderful medium of language
stimulation. Playing children’s
songs on CDs while you are
travelling in the car provides a
good opportunity for teaching
as you have a ‘captive audi-
ence’. Also expose your baby to
pictures books from an early age.
Talk about each picture, com-
menting on its name, its parts, its
colours and shapes, its function,
the noises it makes and relate it
back to his experience. Family
photo albums are very useful for
teaching family names and for
recalling experiences to the child
e.g. a birthday party he may have
attended.
I’ve heard that it’s bad
to speak ‘baby talk’ to a
child. Is this true?
If by ‘baby talk’ you mean that
you change the words e.g. calling so much better than
a ‘dog’ a ‘woof-woof’ or changing
your pronunciation by imitating
the child’s mispronunciations
e.g. ‘bottie’ for ‘bottle, then you
would be modelling incorrectly.
The child later has to unlearn the
‘baby word’ and learn the ‘adult’
11 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?
word. Rather you should always
expose the child to an enriched
vocabulary. Children are like
sponges. They will soak up what-
ever you expose them to. So if
you know that a particular flower
is called a carnation, or that a
particular bird is a hadedah, tell
him.
On the other hand, when we
speak to babies, we naturally
exaggerate our intonation to gain
their attention. We also speak a
little louder, which is advisable
when speaking to a baby with a
cleft, in view of the high inci-
dence of fluctuating hearing loss.
This is useful, and should be
encouraged. Always speak
clearly.
Some children with
clefts seem to speak
others. Which factors
determine the final
outcome?
There are many factors that will
determine the prognosis for the parents in the
good speech. These include: management of their child.
1. How severe the cleft was to 15. The amount of language
begin with stimulation available at home.
2. When the operation was
done to repair the cleft. One can see from this list that
3. How skilled and experienced there are some factors over
the surgeon was. which we can exercise some
4. Whether there were any control, and others which we
complications of the cannot. One cannot simply look
operation. in a child’s mouth and predict
5. How well the soft palate how well he will speak. What
functioned after the surgery is most important is that we all
to separate the nose from the work together to help the child to
mouth. achieve the best speech he/she
6. Whether there are any dental is capable of.
problems and how the teeth
bite together.
7. How well the child can hear.
8. The child’s intelligence.
9. The existence of any
psychological or social
problems.
10 The child and his family’s
adjustment to the condition.
11. The existence of any other
conditions that may affect
communication.
12. The management of the child
within a team of
professionals.
13. The child’s access to speech
therapy services.
14. The level of co-operation of
 Resources:
Golding-Kushner, K.J. (2001). Therapy
Techniques for Cleft Palate Speech and
Related Disorders, Singular Thomson
Learning, Canada.
Kummer, A.W. (2014). Cleft palate
and craniofacial anomalies: Effects on
speech and resonance. (3rd Ed.). New
Georgia Jammine York: Delmar Cengage Learning.
Speech-Language Therapist
BA (Sp & H Therapy) Wits Pepper, J. & Weitzman. (2004). It takes
MA (Speech Pathology) Wits Reg. two to talk: A practical guide for parents
H.P.C.S.A. Pr. No. 082 0008208360 of children with language delays. To-
Mobile: +27 (0)82 773 8644 ronto: The Hanen Program (4th Ed.)
E-mail: georgia@jammine.com
Peterson-Falzone, S.J., Hardin-Jones,
M.A. & Karnell, M.P. (2001). Cleft Palate
Speech (3rd Ed) Mosby.
Scherer, N.J. & Kaiser, A.P. (2007).
Early intervention for children with cleft
palate. Infants & young children. 20(4).
355-366.
Stengelhofen, J. (1990). Working with
Cleft Palate Winslow Press, Oxon.
Watson, A.C.H., Sell, D.A. and
Grunwell, P. (2001). Management of
Cleft Lip and Palate Whurr Publishers,
London.
http://www.gosh.nhs.uk/gosh_families/
information_sheets/nasal_speech_
prostheses/nasal_speech_prosthe-
ses_families.html

Peterson-Falzone, S.J.,
Trost-Cardamone, J.E. (2006).
The Clinician’s Guide to Treating Cleft
Palate Speech, Mosby.

12 | HOW CAN I HELP MY CHILD WITH A CLEFT PALATE TO TALK?