Teleconsultation-mediated nasoalveolar molding therapy for babies with cleft lip/palate during the COVID-19 outbreak: Implementing change at pandemic speed

Dear Sir,

Cleft lip/palate is among the most common congenital anomalies, requiring multidisciplinary care from birth to adulthood. The nasolaveolar molding (NAM) revolutionized the care provided to babies with a complete cleft, with proving its benefits to patients, parents, clinicians, and society.¹ This therapeutic modality requires parents’ engagement with NAM care at home and continuous clinician-patient/parent encounters, commencing at the second week of life and finishing just before the lip repair.

The rapidly expanding COVID-19 pandemic² has challenged clinicians who are dealing with NAM therapy to fully stop it, or adjust it to protect, both, the patient/parent and the healthcare team. Based on the current WHO recommendation, to maintain social distancing, and the national regulation for the use of telemedicine,^{2 , 3} the NAM-related clinician-patient/parent relationship has timely been adjusted by implementing the non-face-to-face care model.

Babies with clefts are consulted individually by clinicians, proactively establishing the initial and subsequent telemedicine consultations, also providing an open communication channel for parents. Based on a shared decision-making process, all parents have the option to completely stop NAM therapy or use only lip tapping. Given that each patient is at a particular stage within the continuum of NAM care, numerous patient- and parent-derived issues are being addressed by video-mediated consultations. Overall, this has helped explain the current COVID-19-related public health recommendations and precautions to parents, while addressing patients’ needs and parents’ feelings, fears, expectations, and answering parents’ questions. Moreover, clinical support is provided to patients and parents by visual inspection (looking for potential NAM-derived facial irritation), and checking parents’ hand-hold maneuvers, such as feeding and placement of the lip tapping and NAM device, with immediate feedback for corrections. Thus, the use of an audiovisual communication tool has considerably reduced the number of in-person consultations.

When a face-to-face consultation could not be resolved using the telemedicine triage, an additional video-based conversation had been implemented, focusing on the key steps, established for patient/parent visits to the facility (i.e., frequent hand-cleaning, mask usage, and keeping 1 m social distance) and on the COVID-19-focused screening.⁵ Symptom- and exposure-screened negative parents/babies have been consulted in a time-specific scheduling with minimum waiting time to avoid crowded waiting rooms, by a clinician wearing personal protective equipment (cap, face shield, N95 mask, goggles, gloves, and gowns), and working in an environment with constant surface/object decontamination.⁵ Parents, who screened positive for symptoms (e.g., fever, cough, sore throat), were indicated to follow to the appropriate self-care or triage mechanism, stipulated by the WHO guidelines and local authorities.2, 3, 4, 5

In the COVID-19 era, the care provision should be aligned with the latest clinical evidence.⁴ In response to the constantly changing needs, clinicians across the globe could adapt the telemedicine-based possibilities to their own environment of national/hospital regulatory bodies, technology accessibility, and the parents’ level of technological literacy. As most of the issues addressed in the video conversations were recurrent reasons for consultations prior to the COVID-19 outbreak, future investigations could assist in truly defining the key aspects of telemedicine-based clinician-patient/parent relationship in delivering NAM therapy, and its impact on NAM-related proxy-reported and clinician-derived outcome measures.