Which history and physical examination findings should prompt administration of the Pediatric Sleep Questionnaire to a child with a cleft lip and/or palate?

History and Physical Examination Findings to Trigger PSQ Administration in Children with Cleft History

Every child with a history of cleft lip and/or palate should be screened for snoring at every health maintenance visit, and any child who snores habitually (≥3 nights per week) should complete the Pediatric Sleep Questionnaire. 1, 2

Mandatory Screening Triggers

Nocturnal Symptoms

• Habitual snoring (≥3 nights per week) is the single most important trigger—this symptom alone mandates PSQ administration 1, 2
• Witnessed apneas with gasping or snorting sounds during sleep 1
• Labored breathing during sleep 1
• Sleep enuresis, particularly secondary enuresis (new-onset bedwetting after ≥6 months of continence)—this is a high-risk nocturnal symptom that should prompt immediate evaluation 1, 2
• Unusual sleep postures such as neck hyperextension or sleeping in a seated position 1
• Restless sleep with frequent position changes 2

Daytime Behavioral and Neurocognitive Symptoms

• Daytime sleepiness or others commenting that the child appears sleepy (76.2% positive predictive value for OSA) 1, 3
• Attention-deficit/hyperactivity symptoms or inattention 1
• Learning problems or poor school performance 1
• Behavioral problems including aggression, defiant behavior, anxiety, or mood disturbances 1, 4

Growth and Cardiovascular Concerns

• Failure to thrive or poor weight gain 1
• Obesity (BMI >95th percentile) 1, 2
• Hypertension on examination 1
• Headaches upon awakening 1

Physical Examination Findings

Oropharyngeal Assessment

• Tonsillar hypertrophy graded 3+ to 4+ (occupying ≥50% of oropharyngeal space between anterior tonsillar pillars) 1, 2
• Note: Children with cleft have significantly less tonsillar enlargement than non-cleft children with OSA (33% vs 79%), so absence of tonsillar hypertrophy does NOT exclude OSA risk 5

Craniofacial Features

• High-arched palate 1
• Micrognathia or retrognathia 1
• Adenoidal facies 1
• Mandibular hypoplasia 1

Growth Parameters

• Document weight, height, and BMI percentile—both underweight and overweight status increase OSA risk 1, 2

Cardiovascular Examination

• Measure blood pressure and compare to age-adjusted norms—elevated BP suggests OSA complications 1, 2

High-Risk Syndromic Populations Requiring Lower Threshold

Children with 22q11.2 deletion syndrome have approximately 50% prevalence of positive OSA screening—these patients warrant PSQ administration even with minimal symptoms 2, 3. The highest risk for positive screening occurs in:

• 22q11.2 deletion syndrome (50% screen positive) 2, 3
• Pierre Robin sequence 2, 3
• Males (increased risk compared to females) 3
• Non-Caucasian children with cleft 3

Critical Clinical Pitfalls

History and physical examination alone correctly identify OSA in only 55% of children with suspected disease—objective screening with the PSQ is essential because clinical assessment is unreliable 2. Key mistakes to avoid:

• Do not assume absence of snoring excludes OSA—caregivers may not observe intermittent nocturnal snoring 1
• Do not rely on tonsillar size—cleft patients have less tonsillar hypertrophy than typical OSA patients but similar disease severity 5
• Do not wait for daytime sleepiness—children manifest OSA differently than adults, with behavioral problems and inattention being more common than frank sleepiness 1
• Do not dismiss mild symptoms in syndromic patients—particularly those with 22q11.2 deletion syndrome who have markedly elevated OSA prevalence 2, 3

Practical Template Components

Your clinical template should include these specific yes/no checkboxes:

• Does the child snore ≥3 nights per week? 1, 2
• Have you witnessed apneas or gasping during sleep? 1
• Does the child have new-onset bedwetting? 1, 2
• Do others comment the child appears sleepy during the day? 3
• Does the child have attention problems or hyperactivity? 1
• Has growth been poor or is the child obese? 1
• Tonsillar grade (0 to 4+) 1
• Blood pressure percentile for age 1
• Underlying syndrome (especially 22q11.2 deletion)? 2, 3

If any nocturnal symptom is present OR if the child has 22q11.2 deletion syndrome, administer the PSQ immediately. 1, 2, 3