Cleft Lip and Palate: Causes, Surgery & Treatment

What Is Cleft Lip and Palate?

Cleft lip and cleft palate are openings or splits in the upper lip, the roof of the mouth (palate), or both. They occur when facial structures that are developing in an unborn baby don't close completely during the first trimester of pregnancy. Cleft lip and palate are among the most common birth defects, affecting about 1 in 700 babies worldwide.

During normal fetal development, the tissues that form the upper lip and palate fuse together between the 6th and 10th weeks of pregnancy. When this fusion doesn't happen completely, it results in a cleft—a gap or split in these structures. The word "cleft" simply means "split" or "opening."

Cleft lip and palate can occur separately or together, and they can vary significantly in severity. Some clefts are very small notches in the lip, while others extend through the lip, the gum ridge, and the entire palate. Understanding the type and extent of the cleft is important because it determines the treatment approach and the specialists involved in care.

The conditions are collectively known as "orofacial clefts" in medical terminology. While they can cause functional challenges—particularly with feeding, speech, and dental development—the good news is that modern surgical techniques and comprehensive multidisciplinary care achieve excellent outcomes. Most children born with cleft lip and palate today grow up to lead healthy, normal lives with good speech and a natural-looking appearance.

Types of Orofacial Clefts

Orofacial clefts come in several different forms, and understanding these types helps parents and caregivers know what to expect from treatment. Each type presents unique challenges and requires a tailored approach to surgical repair and ongoing care.

• Cleft lip only: An opening in the upper lip that can range from a small notch to a complete split extending to the nose. May be on one side (unilateral) or both sides (bilateral).
• Cleft palate only: An opening in the roof of the mouth without involvement of the lip. This may involve the soft palate (back portion) only, or extend through both the soft and hard palate.
• Cleft lip and palate together: The most common form, where both the lip and palate are affected. This represents about 45% of all orofacial clefts.
• Submucous cleft palate: A more subtle form where the muscles of the soft palate are not properly joined, but the overlying mucous membrane is intact. This type may not be immediately visible and is sometimes diagnosed later when speech problems develop.

How Common Is Cleft Lip and Palate?

Cleft lip and palate are among the most common birth defects worldwide. According to the World Health Organization and the Centers for Disease Control and Prevention, approximately 1 in 700 babies is born with a cleft lip, cleft palate, or both. This means that roughly 180,000 children are born with orofacial clefts each year globally.

The prevalence varies somewhat by ethnicity and geographic region. Orofacial clefts are most common among Asian, Latino, and Native American populations, and less common among African-descended populations. The reasons for these differences are not fully understood but likely involve both genetic factors and environmental influences.

Cleft lip (with or without cleft palate) is about twice as common in males as in females, while isolated cleft palate is more common in females. The reasons for these sex differences are also not completely understood but may relate to differences in the timing of facial development between male and female embryos.

What Causes Cleft Lip and Palate?

The exact cause of cleft lip and palate is often unknown, but most cases result from a combination of genetic and environmental factors. Risk factors include family history, maternal smoking, alcohol use, certain medications (especially anti-seizure drugs), diabetes, and folic acid deficiency during pregnancy.

Understanding the causes of cleft lip and palate is complex because these conditions typically result from the interaction of multiple factors rather than a single cause. Researchers have identified both genetic predispositions and environmental influences that can increase the risk, though in many cases, no specific cause can be identified.

During the first trimester of pregnancy, the baby's face develops from separate tissues that grow toward each other and fuse together. The lip normally fuses by about week 7 of pregnancy, and the palate by about week 10. Any disruption to this process—whether from genetic factors, environmental exposures, or both—can result in incomplete fusion and a cleft.

For most families, a cleft occurs as an isolated birth defect without a clear underlying cause. However, in about 30% of cases, cleft lip and palate occur as part of a genetic syndrome that involves other features. Identifying whether a cleft is isolated or part of a syndrome is important because it affects medical management and genetic counseling for future pregnancies.

Genetic Factors

Genetics play a significant role in cleft lip and palate, though the inheritance pattern is complex. If a parent has a cleft, there is approximately a 2-8% chance their child will also have one. If the parents already have one child with a cleft, the risk for subsequent children is about 2-5%. Having more than one affected family member increases the risk further.

Researchers have identified numerous genes associated with orofacial clefts, including IRF6, VAX1, MAFB, and PAX7, among others. Most cases of cleft lip and palate are thought to be "multifactorial," meaning they result from the combined effects of multiple genes and environmental factors. This explains why clefts can occur even without a family history, and why not everyone with genetic risk factors develops a cleft.

In some cases, cleft lip and palate occur as part of recognized genetic syndromes, such as Van der Woude syndrome, Pierre Robin sequence, Stickler syndrome, or velocardiofacial syndrome (22q11.2 deletion syndrome). Genetic testing may be recommended to identify these conditions, especially if other health concerns are present.

Environmental Risk Factors

Several environmental factors during pregnancy have been associated with an increased risk of orofacial clefts. Understanding these risk factors can help with prevention strategies for future pregnancies.

• Maternal smoking: Women who smoke during pregnancy have about twice the risk of having a baby with a cleft compared to non-smokers. The more cigarettes smoked, the higher the risk.
• Alcohol consumption: Heavy alcohol use during pregnancy increases the risk of cleft lip and palate, along with other birth defects.
• Certain medications: Some anti-seizure medications (particularly topiramate and valproic acid), methotrexate, and some acne medications (isotretinoin) have been linked to increased cleft risk.
• Diabetes: Women with diabetes (both type 1 and type 2) before pregnancy have a higher risk of having a baby with a cleft.
• Folic acid deficiency: Inadequate folic acid intake before and during early pregnancy may increase the risk of orofacial clefts.
• Obesity: Maternal obesity has been associated with a slightly increased risk of cleft lip and palate.

How Is Cleft Lip and Palate Diagnosed?

Cleft lip can often be detected during routine prenatal ultrasound at 18-20 weeks of pregnancy. Cleft palate alone is more difficult to detect prenatally and is usually diagnosed during the newborn physical examination after birth. Additional genetic testing may be recommended to identify associated syndromes.

The diagnosis of cleft lip and palate can occur at different times depending on the type of cleft present. Early diagnosis is valuable because it allows families to prepare emotionally, connect with specialists, and develop a plan for care before the baby is born.

Prenatal diagnosis has become increasingly accurate with advances in ultrasound technology. When a cleft is detected before birth, families can be referred to a cleft palate team for counseling and to begin planning for the baby's care. This early connection with specialists can help reduce anxiety and ensure that appropriate support is in place from the moment of birth.

Prenatal Ultrasound

The standard anatomy ultrasound performed around 18-20 weeks of pregnancy can often detect cleft lip. The ultrasound technician or doctor examines the baby's facial profile and lips, looking for any irregularities in the shape of the mouth. 3D and 4D ultrasound technology has improved the ability to visualize facial clefts before birth.

However, prenatal ultrasound has limitations. Cleft lip is detected in approximately 75-90% of cases when present, depending on the skill of the sonographer, the position of the baby, and the quality of the equipment. Isolated cleft palate (without cleft lip) is much harder to detect prenatally because the palate is difficult to visualize, and detection rates are much lower.

If a cleft is suspected on ultrasound, a more detailed ultrasound or consultation with a maternal-fetal medicine specialist may be recommended to better characterize the cleft and look for other abnormalities that might suggest a genetic syndrome.

Diagnosis at Birth

Cleft lip is immediately visible at birth and is diagnosed during the initial newborn examination. Cleft palate is diagnosed when the doctor or midwife examines the inside of the baby's mouth, either visually or by inserting a gloved finger to feel the palate. This examination is part of the standard newborn assessment performed in the first hours after birth.

In rare cases, particularly with submucous cleft palate, the diagnosis may not be made until later in infancy or childhood when speech problems or feeding difficulties prompt further evaluation. A speech-language pathologist or ENT specialist may be the one to identify a previously undiagnosed cleft in these cases.

Genetic Testing

Genetic testing may be recommended for babies diagnosed with cleft lip and palate, especially if other features suggest a genetic syndrome. Testing options include:

• Chromosomal microarray: Detects missing or extra pieces of chromosomes that can cause syndromes associated with clefts
• Specific gene testing: Looks for mutations in genes known to cause syndromes that include orofacial clefts
• Whole exome or genome sequencing: Comprehensive testing that may be considered when a syndrome is suspected but specific testing is negative

Meeting with a genetic counselor can help families understand the testing options, what the results might mean, and the implications for future pregnancies.

How Is Cleft Lip and Palate Treated?

Treatment for cleft lip and palate involves a series of surgeries and ongoing care from a multidisciplinary team. Cleft lip repair is typically performed at 3-6 months, and cleft palate repair at 9-18 months. Additional surgeries, orthodontic treatment, and speech therapy may be needed as the child grows.

The treatment of cleft lip and palate is a journey that spans from infancy through adolescence, involving multiple specialists working together as a team. The goals of treatment are to restore normal function (particularly for feeding and speech), achieve good appearance, and support the child's overall development and well-being.

Treatment is highly individualized based on the type and severity of the cleft, the child's overall health, and the specific challenges they experience. While the primary surgeries are completed in the first two years of life for most children, ongoing monitoring and additional interventions may be needed throughout childhood and into the teenage years.

The Cleft Palate Team

Care for children with cleft lip and palate is best provided by a multidisciplinary cleft palate team—a group of specialists who work together to coordinate all aspects of the child's care. The American Cleft Palate-Craniofacial Association recommends that children receive care from an interdisciplinary team, and most countries have established cleft centers that provide this comprehensive approach.

A typical cleft palate team includes:

• Plastic or craniofacial surgeon: Performs the surgical repairs of the lip, palate, and any necessary revision surgeries
• Otolaryngologist (ENT): Manages ear problems, hearing issues, and may perform surgeries to improve speech
• Speech-language pathologist: Assesses and treats speech and language development
• Orthodontist: Manages dental alignment and prepares for any jaw surgeries
• Pediatric dentist: Provides dental care and monitors tooth development
• Oral and maxillofacial surgeon: May perform bone grafting and jaw surgery
• Audiologist: Tests hearing and recommends treatment for hearing loss
• Geneticist: Evaluates for genetic syndromes and provides counseling
• Psychologist or social worker: Supports the child's emotional development and family adjustment
• Nurse coordinator: Helps coordinate appointments and serves as the family's main contact

Regular team evaluations, typically annually, ensure that all aspects of the child's development are monitored and that any emerging issues are addressed promptly. Parents are considered essential members of the team and are actively involved in all decisions about their child's care.

Surgical Treatment

Surgery is the cornerstone of cleft lip and palate treatment, with the primary goal of closing the gap and restoring normal structure and function. The timing and sequence of surgeries have been refined over decades to optimize outcomes.

Cleft Lip Repair

Cleft lip repair is typically performed when the baby is 3-6 months old. By this age, the baby is usually healthy enough for anesthesia, and the lip tissues have grown enough for the surgeon to work with. The surgery takes approximately 1-2 hours and is performed under general anesthesia.

During the surgery, the surgeon carefully realigns the separated tissues of the lip, repositions the muscles, and closes the gap. The goal is to create a natural-looking lip with good function for feeding and eventually for speech. Modern surgical techniques achieve excellent cosmetic results, with scars that fade significantly over time.

Before surgery, some babies with wide clefts may benefit from nasoalveolar molding (NAM), a pre-surgical treatment that uses a custom-made plastic device to gradually shape the lip, nose, and gum tissue. This can make the surgical repair easier and improve outcomes, though not all centers use this approach.

Cleft Palate Repair

Cleft palate repair is typically performed between 9-18 months of age, ideally before the child begins speaking. Early repair allows the muscles of the soft palate to function properly for speech development. The surgery takes approximately 2-3 hours under general anesthesia.

The surgeon closes the gap in the palate by repositioning tissues and muscles. The soft palate muscles are carefully repaired to allow proper movement during speech and swallowing. This muscle repair is crucial for achieving good speech outcomes.

Most children stay one night in the hospital after palate surgery. Recovery involves a modified diet (soft foods) for several weeks while the palate heals. Arm restraints may be used temporarily to prevent the child from putting fingers or objects in the mouth that could disrupt healing.

Additional Surgeries

Many children with cleft lip and palate require additional surgeries as they grow. Common procedures include:

• Alveolar bone graft (ages 8-12): If the cleft involves the gum ridge, bone from the hip is transplanted to fill the gap, allowing teeth to grow properly and stabilizing the dental arch.
• Speech surgery (if needed): About 20-30% of children need additional surgery (pharyngoplasty or pharyngeal flap) to improve speech if the palate repair alone does not achieve adequate velopharyngeal function.
• Lip and nose revision: Some children benefit from revision surgery during teenage years to improve the appearance of the lip and nose.
• Jaw surgery (orthognathic surgery): A minority of patients (about 25%) require jaw surgery in late adolescence if jaw growth has been significantly affected.

How Do I Feed a Baby with Cleft Lip or Palate?

Babies with cleft lip alone can often breastfeed with positioning adjustments. Babies with cleft palate typically cannot breastfeed effectively and need specialized bottles with squeezable designs or modified nipples. Breast milk can still be given via these special bottles. A feeding specialist provides individualized guidance.

Feeding is often the first challenge parents face after their baby is born with a cleft. Understanding the specific feeding issues and having the right equipment and support can help ensure that babies with cleft lip and palate get adequate nutrition and grow normally.

The feeding challenges depend on the type of cleft. Babies with cleft lip alone can usually generate enough suction to feed from breast or standard bottle. Babies with cleft palate, however, cannot create adequate suction because air escapes through the gap in the roof of the mouth. This doesn't mean breastfeeding is impossible in all cases, but most babies with cleft palate need specialized feeding techniques and equipment.

Feeding with Cleft Lip Only

Babies with cleft lip (without cleft palate) can often breastfeed successfully with some adjustments. The breast tissue can conform to seal the gap in the lip, allowing effective suction. Tips for breastfeeding with cleft lip include:

• Position the baby so the cleft is oriented toward the top of the breast, where breast tissue can help seal the gap
• Support the baby's cheeks with your hand to help maintain a seal
• Work with a lactation consultant experienced with cleft feeding
• Be patient—feeding may take longer initially as you and your baby learn together

Feeding with Cleft Palate

Babies with cleft palate typically cannot generate sufficient suction to breastfeed or use a standard bottle. Specialized feeding systems have been developed to help these babies feed successfully. The key principle is that the caregiver, rather than the baby, controls the flow of milk.

Common specialized bottles include:

• Haberman Feeder (SpecialNeeds Feeder): Has a one-way valve that prevents milk from flowing back into the bottle, and the caregiver can squeeze the bottle to assist flow
• Pigeon bottle: Features a specially designed nipple with a one-way valve and can be squeezed to deliver milk
• Dr. Brown's Specialty Feeding System: Another option with a squeezable design and one-way valve
• Mead Johnson Cleft Palate Nurser: A soft, squeezable bottle with a large cross-cut nipple

Regardless of which bottle system you use, breast milk can be expressed and given to your baby. Many mothers successfully provide breast milk to their babies with cleft palate using these specialized bottles, even if direct breastfeeding isn't possible.

Feeding Tips for All Babies with Clefts

• Hold your baby in an upright position (45-90 degrees) during feeding to reduce milk entering the nasal passages
• Allow frequent breaks for burping, as babies with clefts often swallow more air
• Expect feeding to take longer than typical—30-45 minutes is common initially
• Watch for signs of fatigue and don't push the baby to finish if they're tired
• Work with a feeding specialist who can provide personalized guidance
• Monitor weight gain closely—your baby's doctor will track growth at regular visits

How Does Cleft Palate Affect Speech?

Cleft palate can affect speech because the palate is essential for directing airflow during speaking. Even after surgical repair, some children develop "hypernasal" speech where too much air escapes through the nose. Speech therapy, and sometimes additional surgery, can help most children achieve normal or near-normal speech.

The palate plays a crucial role in speech production. When we speak, the soft palate moves up and back to close off the nasal cavity, directing air through the mouth to produce most speech sounds. This movement is called velopharyngeal closure. In children born with cleft palate, the muscles that control this movement may not function normally even after surgical repair.

The good news is that with early palate repair, speech therapy, and additional treatment when needed, the vast majority of children with cleft palate develop good speech that is easily understood by others. Early intervention is key to achieving the best outcomes.

Common Speech Issues

Several speech patterns are commonly seen in children with cleft palate:

• Hypernasality: Too much air escapes through the nose during speech, giving speech a "nasal" quality
• Nasal air emission: Audible air escaping from the nose during certain consonant sounds
• Compensatory articulation: Children may learn to produce sounds in the back of the throat (glottal stops) instead of the proper location, as a way to compensate for velopharyngeal dysfunction
• Articulation errors: Difficulty producing certain sounds correctly, particularly sounds that require high oral pressure like /p/, /b/, /t/, /d/, /k/, /g/, /s/, /z/, and /sh/

Speech Therapy

Speech-language pathologists (SLPs) specializing in cleft palate work with children from early childhood to address speech and language development. Early speech therapy focuses on language stimulation and monitoring, while later therapy addresses specific articulation and resonance issues.

Speech therapy for cleft palate typically includes:

• Regular assessment of speech development starting in infancy
• Language stimulation activities for toddlers
• Articulation therapy to correct specific sound errors
• Techniques to redirect airflow and reduce nasal emission
• Working on the correct placement and manner of producing sounds

When Additional Surgery Is Needed

If significant hypernasality persists despite therapy, it may indicate that the palate isn't functioning adequately for speech—a condition called velopharyngeal insufficiency (VPI). In these cases, additional surgery may be recommended. About 20-30% of children with cleft palate require a secondary speech surgery.

Surgical options for VPI include pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. The choice of procedure depends on the specific anatomy and movement patterns identified through nasendoscopy (a camera examination) and speech evaluation.

What Dental Issues Are Associated with Cleft Lip and Palate?

Children with cleft lip and palate commonly experience dental problems including missing teeth, extra teeth, malformed teeth, teeth in abnormal positions, and bite problems. A pediatric dentist and orthodontist work together to manage these issues throughout childhood and adolescence.

Dental development is closely linked to the development of the lip, gum ridge (alveolus), and palate. When a cleft involves the gum ridge, it directly affects the area where teeth develop, leading to various dental abnormalities. Even when the gum ridge is not directly involved, the growth of the jaw and alignment of the teeth can be affected.

Regular dental care starting early in life is essential for children with cleft lip and palate. The cleft team's pediatric dentist monitors tooth development and provides preventive care, while the orthodontist plans for alignment correction as the child grows.

Common Dental Problems

• Missing teeth: Teeth near the cleft site (particularly the lateral incisor) may fail to develop
• Extra teeth (supernumerary teeth): Sometimes extra teeth form near the cleft
• Malformed teeth: Teeth may be smaller, abnormally shaped, or have enamel defects
• Displaced teeth: Teeth may erupt in the wrong position or at abnormal angles
• Delayed tooth eruption: Teeth may come in later than expected
• Increased cavity risk: Enamel defects and difficulty cleaning near cleft areas can increase cavity risk

Orthodontic Treatment

Most children with cleft lip and palate require orthodontic treatment. Orthodontic care is typically provided in phases:

• Early childhood: Expansion appliances may be used to widen a narrow upper jaw
• Before bone graft (ages 8-12): Orthodontic preparation aligns teeth and creates space for the bone graft
• After bone graft: Continued orthodontic treatment as permanent teeth come in
• Teenage years: Comprehensive braces to achieve final alignment and prepare for any needed jaw surgery

Alveolar Bone Graft

The alveolar bone graft is an important surgery for children whose cleft involves the gum ridge. Typically performed between ages 8 and 12, this surgery involves taking a small amount of bone from the hip and placing it in the cleft area of the gum ridge. The bone graft:

• Provides bone for teeth to erupt into
• Stabilizes the dental arch
• Provides support for the base of the nose
• Closes any remaining opening between the mouth and nose

The timing of the bone graft is coordinated with the orthodontist to optimize the position of teeth before and after surgery.

How Does Cleft Palate Affect Hearing?

Children with cleft palate have a higher risk of ear infections and fluid buildup in the middle ear (otitis media with effusion), which can cause temporary hearing loss. Many children need ear tubes (ventilation tubes) to drain fluid and protect hearing. Regular hearing monitoring is essential.

The connection between cleft palate and ear problems relates to the Eustachian tube—the small tube that connects the middle ear to the back of the throat. Normally, this tube allows air into the middle ear and drains fluid. The muscles that open the Eustachian tube are the same muscles affected by cleft palate, so these tubes often don't function properly in children with cleft palate.

When the Eustachian tube doesn't work well, fluid accumulates in the middle ear. This fluid can become infected (acute otitis media) or simply persist without infection (otitis media with effusion). Either way, the fluid interferes with the movement of the eardrum and middle ear bones, causing hearing loss that is usually temporary but can affect speech and language development if persistent.

Ear Tube Surgery

Because of the high rate of middle ear problems, many children with cleft palate have ear tubes (also called ventilation tubes, pressure equalization tubes, or grommets) placed. This brief surgery is often performed at the same time as the palate repair to minimize the number of anesthesia exposures.

Ear tubes are tiny cylinders placed through the eardrum that allow air into the middle ear and fluid to drain out. They typically remain in place for 6-18 months before falling out on their own as the eardrum heals. Some children need multiple sets of tubes throughout childhood.

Hearing Monitoring

Regular hearing tests are an important part of cleft care. The cleft team's audiologist will test hearing at regular intervals throughout childhood to identify any hearing loss early. Even mild hearing loss can affect speech and language development, so prompt identification and treatment are important.

If hearing loss is detected, treatment depends on the cause. If related to middle ear fluid, ear tubes may be recommended. In rare cases where hearing loss is more permanent, hearing aids or other interventions may be needed.

What Is It Like Living with Cleft Lip and Palate?

With comprehensive treatment, children with cleft lip and palate typically achieve good speech and appearance, and studies show they are generally as satisfied with their lives as other children. Support from family, the cleft team, and sometimes psychological services helps children adapt and thrive.

Living with cleft lip and palate involves ongoing medical appointments and treatments throughout childhood, but the long-term outlook is excellent. Research consistently shows that with proper treatment, children born with cleft lip and palate grow into healthy adults who are satisfied with their lives, relationships, and careers at rates similar to the general population.

The journey does require resilience and adaptation, both for the child and for the family. There are medical appointments, surgeries, therapies, and occasionally challenges related to appearance or speech. However, most families find that cleft care becomes a manageable part of their lives, and many describe the experience as bringing their family closer together.

Psychological and Social Considerations

Children with visible differences like cleft lip may face questions or comments from peers, particularly when starting school or entering new social situations. Preparing children with age-appropriate explanations and responses can help them handle these interactions confidently.

The cleft team typically includes a psychologist or social worker who can help children and families with:

• Adjustment to diagnosis (for parents)
• Preparation for surgeries
• Building self-esteem and confidence
• Handling teasing or bullying
• Navigating school and social situations
• Addressing any anxiety or depression

Most children with cleft lip and palate adapt well and do not experience significant psychological problems. However, if concerns arise, early intervention is important.

Support for Parents

Learning that your child has cleft lip and palate—whether during pregnancy or at birth—can bring a range of emotions including shock, sadness, guilt, and anxiety about the future. These feelings are normal and shared by many parents in the same situation.

Support resources for parents include:

• The cleft palate team: The nurse coordinator and social worker are there to answer questions and provide support
• Parent support organizations: Groups like the Cleft Palate Foundation and Smile Train connect families and provide resources
• Online communities: Social media groups and forums allow parents to connect with others who understand their experience
• Mental health support: Counseling is available for parents who are struggling with adjustment

Can Cleft Lip and Palate Be Prevented?

While not all cases of cleft lip and palate can be prevented, certain measures may reduce risk: taking folic acid before and during early pregnancy, avoiding smoking and alcohol during pregnancy, managing diabetes, and discussing medications with your doctor before becoming pregnant.

Because cleft lip and palate result from a combination of genetic and environmental factors, complete prevention is not possible, especially when genetic factors are involved. However, research has identified several modifiable risk factors that women can address before and during pregnancy to potentially reduce the risk.

Prevention Strategies

• Take folic acid: Women planning pregnancy should take a prenatal vitamin containing at least 400 micrograms of folic acid daily, starting before conception and continuing through the first trimester. Some evidence suggests this may reduce cleft risk.
• Avoid smoking: Don't smoke during pregnancy. If you smoke, seek help to quit before becoming pregnant.
• Avoid alcohol: Don't drink alcohol during pregnancy. No amount of alcohol is considered safe during pregnancy.
• Manage diabetes: If you have diabetes, work with your doctor to achieve good blood sugar control before becoming pregnant.
• Review medications: Talk to your doctor about all medications you take before becoming pregnant. Some medications increase cleft risk and may need to be changed or stopped.
• Maintain a healthy weight: Achieve a healthy weight before pregnancy if possible.