Submucosal cleft palate and feeding issues in infants

A submucous cleft palate can be particularly difficult to identify because the surface of the palate may appear intact. The underlying muscles may not have formed or joined in the usual way, even though there is no obvious opening in the roof of the mouth.

This article explains how a submucous cleft can be missed, what signs may raise the possibility, how it can affect feeding and speech, what treatment may be considered and how to seek a review if you are unsure.

What is a submucous cleft palate?

The term cleft describes a gap or separation that occurs when the developing lip and/or palate do not join completely during pregnancy (CLAPA, n.d.).

There are several different terms used when describing cleft lip and palate:

• Cleft lip – a gap or split in the upper lip. It may affect one side (unilateral) or both sides (bilateral), and may be complete or incomplete. The gum or alveolus may also be affected.

• Cleft palate – a gap in the roof of the mouth. It may affect the soft palate alone or extend into the hard palate.

• Cleft lip and palate – both the upper lip and palate are affected. Where the lip is affected, this may be unilateral or bilateral.

• Isolated cleft lip – a cleft lip without a cleft palate.

• Isolated cleft palate – a cleft palate without a cleft lip.

• Submucous cleft palate – a cleft affecting the underlying muscles of the palate while the oral lining remains intact, meaning there may be no obvious opening in the roof of the mouth.

• Occult submucous cleft palate – a more subtle form in which some of the usual visible features of a submucous cleft may not be present.

Terms such as unilateral, bilateral, complete, incomplete and isolated describe the pattern or extent of a cleft rather than being separate types of cleft (CLAPA, n.d.).

A submucous cleft is therefore not simply a small or minor cleft. The underlying structures of the palate may be affected even though the surface appears intact, which can make identification more difficult (CLAPA, n.d.; Cambridge University Hospitals NHS Foundation Trust, 2023).

How can a cleft palate be missed?

Cleft lip is often identified during the routine antenatal ultrasound scan at around 20 weeks, although not every cleft lip is visible. An isolated cleft palate is much more difficult to identify on an ultrasound scan because the gap is inside the mouth and may not be visible (NHS, n.d.; CLAPA, n.d.).

If a cleft palate has not been identified antenatally, the palate should be examined after birth as part of the newborn examination. However, seeing the whole palate can be challenging, particularly when examining the soft palate.

Submucous clefts can be even more difficult to recognise because the oral lining may appear intact. Some may remain undetected for months or years and may only become apparent when feeding, speech, hearing or other concerns develop.

The Royal College of Paediatrics and Child Health recommends that the hard and soft palate are visually inspected using a torch and an appropriate method of depressing the tongue so that the whole palate can be seen. This applies not only to the newborn examination but also to the 6–8 week examination and to infants whose palate is examined at any other time by a healthcare professional (RCPCH, 2025).

The Cleft Palate Assessment Poster produced for healthcare professionals also highlights the importance of appropriate palate assessment across the different professional groups involved in infant care and feeding (Cleft Nursing Clinical Excellence Network, 2024, updated 2025).

If the whole palate cannot be seen, that limitation is important. An inability to see the palate properly should not automatically be taken as evidence that the palate is normal.

What might a submucous cleft palate look like?

A traditional description of a submucous cleft palate includes three features:

• a bifid or split uvula

• a zona pellucida, where the middle part of the soft palate appears thin or translucent

• a notch in the back edge of the hard palate.

Not every child with a submucous cleft will have all three features. In an occult submucous cleft, these visible features may be absent altogether (Kaplan, 1975; Reiter et al., 2011).

A bifid uvula on its own does not necessarily mean that a child has a submucous cleft palate. It can occur without an associated palatal problem, although it can also be associated with a submucous cleft (Cambridge University Hospitals NHS Foundation Trust, 2023).

The appearance of the palate is therefore only part of the assessment. Palatal function, feeding history, speech and other clinical findings may also be relevant.

What feeding signs may raise concern?

The signs associated with a submucous cleft palate are not specific to a cleft and can occur for many other reasons. However, a combination of difficulties may indicate that the palate needs closer assessment.

Possible feeding signs include:

• milk coming through the nose during or after feeds

• clicking during feeding

• continued difficulty attaching at the breast

• difficulty maintaining suction

• tiring during feeds

• prolonged feeds

• faltering growth

• a bifid uvula

• increased work of breathing associated with feeding difficulties.

These are among the signs highlighted in the Cleft Palate Identification Poster (Cleft Nursing Clinical Excellence Network, 2024, updated 2025).

A palatal difference can affect the ability to create an effective seal and may affect milk transfer (Cambridge University Hospitals NHS Foundation Trust, 2023; Moss, Jones and Pigott, 1990).

However, a baby with a submucous cleft palate may breastfeed or bottle-feed effectively and may have no obvious feeding difficulties. Equally, the absence of milk coming through the nose does not exclude a submucous cleft.

Why might milk come through my baby's nose?

The palate separates the mouth from the nasal cavity. During feeding, the baby needs to coordinate sucking, swallowing and breathing while creating an effective seal within the mouth.

Where there is a structural or functional difference affecting the palate, milk can sometimes enter the nasal cavity and come through one or both nostrils.

Milk coming through the nose does not, by itself, indicate a cleft palate. Nasal milk can occur for other reasons, particularly while a young baby is developing feeding coordination.

However, persistent or repeated nasal regurgitation, particularly when it occurs alongside other feeding difficulties or an unusual appearance of the palate, warrants further assessment.

What happens as my child gets older?

A submucous cleft palate may become apparent during infancy, but some children have few or no obvious symptoms initially.

Speech concerns may become more apparent as speech develops. The soft palate needs to move effectively to separate the mouth from the nose during speech. Where the palate does not achieve effective velopharyngeal closure, this can contribute to increased nasal resonance or a nasal quality to the voice and nasal air emission.

Some children may also have difficulty developing particular speech sounds or develop compensatory speech patterns. These findings are not specific to submucous cleft palate and should not be used on their own to make a diagnosis.

Where there are concerns about hypernasality, nasal air emission or speech sound development, a speech and language assessment may form part of a wider cleft assessment.

Hearing can also be relevant. Children with cleft palate can have an increased risk of middle-ear problems because the muscles of the palate are involved in Eustachian tube function (Reiter et al., 2011; NHS, n.d.).

A submucous cleft does not inevitably cause feeding, speech or hearing difficulties. Some children require monitoring only, while others may need additional assessment or treatment depending on how the palate is functioning.

What if the palate looks normal?

An intact-looking palate does not exclude a submucous cleft palate.

A quick look at the front of the mouth is not sufficient to assess the whole palate. The hard and soft palate need to be visualised properly.

The RCPCH best practice guide recommends using a torch and an appropriate method of depressing the tongue to visualise the whole palate, including the full soft palate (RCPCH, 2025).

If the whole palate cannot be seen, this should be recognised as a limitation of the examination rather than assumed to mean that the palate is normal.

This is also relevant when assessing feeding difficulties where a tongue-tie or restrictive lingual frenulum is being considered. Looking only at the lingual frenulum and tongue movement may overlook other anatomical or functional factors that could be contributing to feeding.

Could a submucous cleft be mistaken for a tongue-tie restriction?

There can be an overlap between some of the feeding signs associated with a submucous cleft palate and those associated with a restrictive lingual frenulum.

Clicking, difficulty maintaining suction, difficulty attaching, prolonged feeds and difficulties with milk transfer can have many possible causes. A restrictive lingual frenulum may be one contributing factor, but it should not automatically be assumed to explain every feeding difficulty.

There is also a recognised genetic association between cleft palate and ankyloglossia. Research into the TBX22 gene identified X-linked cleft palate with ankyloglossia, with the associated clinical features including cleft palate, submucous cleft palate, bifid uvula and ankyloglossia in some affected individuals (Braybrook et al., 2001; Braybrook et al., 2002). TBX22 variants have also been identified in a small proportion of apparently nonsyndromic cleft palate cases (Pauws, Moore and Stanier, 2009).

This does not mean that every child with a cleft palate will have a tongue-tie, or that a tongue-tie indicates a genetic cause. Rather, it demonstrates that the development of the palate and tongue can be linked in some genetic conditions.

Where a baby has a cleft lip or palate alongside a restrictive lingual frenulum, assessment should therefore consider the wider oral anatomy and overall clinical picture.

A multidisciplinary team (MDT) approach can be particularly important where cleft palate is suspected or confirmed, bringing together relevant aspects of feeding, oral anatomy, speech and language, hearing and wider clinical needs rather than considering the lingual frenulum in isolation.

If division of a lingual frenulum is being considered in a baby with a cleft palate, specialist consideration is required. It may need to take place within a hospital or other specialist setting rather than a routine infant tongue-tie setting. The appropriate NHS specialist team should determine whether division is indicated and where it should take place.

A comprehensive tongue-tie assessment should consider the wider oral anatomy, tongue movement and feeding function. The aim is not to attribute feeding difficulties to one anatomical feature automatically, but to understand the feeding dyad and identify whether further assessment or support is appropriate.

What treatment is available for a submucous cleft palate?

Treatment depends on the type of cleft, how the palate is functioning and whether it is causing difficulties.

A submucous cleft palate does not automatically mean that surgery is required. Some children are monitored by their Cleft Team without needing an operation.

Where there are feeding, speech, hearing or other functional concerns, assessment may involve several members of the cleft multidisciplinary team, including cleft specialist nurses, paediatrics, speech and language therapy, audiology, dental or orthodontic services and specialist surgeons where appropriate.

For babies experiencing feeding difficulties, specialist feeding support can be provided while the palate is being assessed. This may include consideration of positioning, attachment, feeding efficiency and, where necessary, alternative or specialised feeding equipment. The priority is that the baby receives sufficient milk safely and effectively (NHS, n.d.).

Speech and language assessment may be appropriate where there are concerns about speech development, resonance or velopharyngeal function.

Where there are significant functional problems associated with the palate, surgery may be considered. This is an individual decision based on functional assessment and the wider clinical picture rather than the appearance of the palate alone.

If surgery is being considered, the Cleft Team can discuss the potential benefits, risks and timing with the family or caregivers. The approach is not the same for every child.

The important consideration is therefore not simply whether a submucous cleft is present, but whether it is affecting function and what support or treatment is appropriate.

What should you do if you are unsure?

If you are unsure, ask for a review.

There is no need to be certain that a submucous cleft is present before asking for further assessment. If the palate has not been fully visualised, an unusual palatal feature has been noticed, or feeding difficulties raise concerns about palatal function, further assessment may be appropriate.

Submucous clefts can be subtle and not every child will have the classical visible features.

Where a cleft palate is identified or suspected, assessment by the appropriate NHS Cleft Team allows feeding, hearing, speech and development to be considered alongside the anatomy of the palate (NHS, n.d.; RCPCH, 2025).

For families and caregivers, asking for a review does not mean that a cleft will necessarily be found. It means that the possibility can be considered rather than overlooked.

What about feeding support while assessment is taking place?

Families and caregivers should not necessarily have to wait for a definitive diagnosis before receiving feeding support.

Assessment can consider attachment, milk transfer, feeding duration, coordination, growth and hydration, as well as the experience of the feeding dyad.

Support can be provided whether the baby is breastfeeding, bottle-feeding, receiving expressed milk, formula feeding or combination feeding.

Some babies with a submucous cleft feed effectively without specialised equipment, while others may need additional or alternative feeding methods.

The priorities are safe and effective feeding, adequate milk intake, growth and the wellbeing of the baby and feeding dyad while any further assessment is arranged.

Where can families find support?

A baby or child with a diagnosed cleft lip or palate will normally be referred to an NHS specialist Cleft Team for multidisciplinary assessment, treatment and ongoing care (NHS, n.d.; CLAPA, n.d.).

If a cleft has not been diagnosed but there are concerns about a possible submucous cleft palate, families or caregivers can speak to their GP, health visitor or another healthcare professional involved in the baby's care and ask for an assessment or referral.

If the baby or child is already known to a Cleft Team, the team can be contacted using its usual contact details if new concerns about feeding, speech, hearing or palatal function arise. It may not be necessary to wait for a routine appointment.

The NHS provides information about specialist cleft services, and the appropriate healthcare professional can advise on the relevant service for the family's area.

CLAPA, the Cleft Lip and Palate Association, provides information and support for families affected by cleft lip and palate, including information about postnatal diagnosis and submucous cleft palate. It can also provide opportunities to connect with other families. This support does not replace specialist clinical assessment and care.

If you are unsure whether your baby's feeding difficulties could be related to a palatal difference, ask for a review rather than trying to diagnose the problem yourself.

References

Braybrook, C., Doudney, K., Marcano, A.C.B., Arnason, A., Bjartmar, C., Patton, M.A., Goodfellow, P.J., Moore, G.E. and Stanier, P. (2001) ‘The T-box transcription factor gene TBX22 is mutated in X-linked cleft palate and ankyloglossia’, Nature Genetics, 29(2), pp. 179–183.

Braybrook, C., Lisgo, S., Scambler, P. and Stanier, P. (2002) ‘Craniofacial expression of human and murine TBX22 correlates with the cleft palate and ankyloglossia phenotype observed in CPX patients’, Human Molecular Genetics, 11(22), pp. 2793–2804.

Cambridge University Hospitals NHS Foundation Trust (2023) Bifid Uvula and Submucous Cleft Palate.

Cleft Nursing Clinical Excellence Network (2024) Cleft Palate Identification. Updated with CRANE data June 2025.

CLAPA (n.d.) Postnatal diagnosis.

CLAPA (n.d.) What is cleft lip and palate?

Kaplan, E.N. (1975) ‘The occult submucous cleft palate’, The Cleft Palate Journal, 12, pp. 356–368.

Moss, A.L.H., Jones, K. and Pigott, R.W. (1990) ‘Submucous cleft palate: a review’, British Journal of Plastic Surgery, 43(3), pp. 273–278.

NHS (n.d.) Cleft lip and palate.

NHS (n.d.) Cleft lip and palate – Treatment.

Pauws, E., Moore, G.E. and Stanier, P. (2009) ‘A functional haplotype variant in the TBX22 promoter is associated with cleft palate and ankyloglossia’, Human Mutation, 30(9), pp. 1260–1266.

Reiter, R., Brosch, S., Wefel, H., Schlöndorff, G. and Pickhard, A. (2011) ‘The submucous cleft palate: an overview’, International Journal of Pediatric Otorhinolaryngology, 75(4), pp. 500–505.

Royal College of Paediatrics and Child Health (2025) Palate examination: Identification of cleft palate in the newborn and infant. Best practice guide.