Cleft lip, bilateral
ICD-10 Q36.0 is a billable code used to indicate a diagnosis of cleft lip, bilateral.
Bilateral cleft lip is a congenital malformation characterized by a split or opening in the upper lip that occurs on both sides of the midline. This condition arises during early fetal development when the tissues that form the lip do not fully come together. The severity of the cleft can vary, affecting not only the appearance of the lip but also potentially impacting feeding, speech development, and dental health. Children with bilateral cleft lip may also present with associated congenital anomalies, including cleft palate, which can further complicate management. The condition is often diagnosed prenatally via ultrasound or at birth. Surgical intervention is typically required to repair the cleft, with the timing of surgery varying based on the child's overall health and the presence of other congenital conditions. Multidisciplinary care involving pediatricians, surgeons, speech therapists, and genetic counselors is essential for optimal outcomes. Additionally, the presence of other congenital malformations, such as those affecting the respiratory system, may necessitate a comprehensive evaluation and tailored management plan.
Detailed records of growth, development, and feeding issues related to cleft lip; documentation of any associated congenital conditions.
Management of feeding difficulties in infants with cleft lip; preoperative assessments; postoperative follow-ups.
Consideration of the psychosocial impact on the child and family; coordination with speech therapy for developmental milestones.
Family history assessment for genetic syndromes; documentation of genetic testing results if applicable.
Genetic counseling for families with a history of cleft lip; evaluation for syndromic associations.
Awareness of the potential for chromosomal abnormalities and syndromes associated with cleft lip, such as Van der Woude syndrome.
Used during surgical intervention for bilateral cleft lip repair.
Operative report detailing the procedure and any complications.
Pediatric surgical documentation must include preoperative assessments and postoperative follow-ups.
Common associated conditions include cleft palate, dental anomalies, and respiratory issues such as choanal atresia or tracheoesophageal fistula. A thorough evaluation is essential for comprehensive management.
