Study Considers Whether Sleep Position Affects Obstructive Sleep Apnea in Children with Cleft Palate

Alyssa KirkmanACPA News, Journal, Research

  • Patients with cleft palate have a greater risk for developing obstructive sleep apnea
  • Polysomnography testing can help determine if parents should deviate from AAP guidelines for infants’ safe sleep

CHAPEL HILL, N.C. / Aug. 20, 2019 – Children with craniofacial abnormalities are at a higher risk for developing obstructive sleep apnea (OSA), and those with cleft palate may be up to five times more likely to develop OSA. A recent study, “Obstructive Sleep Apnea and Sleep Position: Does It Matter for Infants With a Cleft Palate?”, examined whether sleep position might affect the incidence of OSA in children with cleft palate. The research was published in the August 2019 issue of The Cleft Palate-Craniofacial Journal (CPCJ).

“We know that a nonsupine sleeping position (prone or lateral) is a treatment option for adult patients with OSA, but body positioning in pediatric patients is less conclusive,” said lead researcher Christopher J. Greenlee. “In addition, positioning interventions with infants are further complicated by the increased risk of sudden infant death syndrome (SIDS) when children are in nonsupine positions. Our investigation evaluated the effect of sleep position on infants with cleft palate who underwent a polysomnography (PSG) for suspected OSA.”

Researchers reviewed the medical records of infants with cleft palate at Children’s Hospital of Colorado who underwent PSG testing between May 2012 and November 2015. This study included 27 patients who completed PSG between one month and one year of age and had PSG results that contained at least 60 minutes of sleep without oxygen/positive airway pressure. Age, ethnicity, date of PSG, cleft lip and palate status, and comorbidities were noted for each participant. Both supine and nonsupine positions were evaluated during the PSGs. Some patients had multiple PSGs and, in total, 35 PSGs were included in the analysis. PSGs were scored using the American Academy (AAP) of Sleep Medicine guidelines. The average age at the time of PSG testing was 6.0 months.

“One of the biggest challenges for a cleft palate surgeon is counseling families with infants who are struggling to breathe due to their craniofacial anomaly. Although parents may be tempted to place their infants in the prone position since they appear less restless, this contradicts recommendations by the American Academy of Pediatrics and its safe infant sleep practice guidelines,” co-author Melissa A. Scholes stated.

Overall, the study revealed no significant improvement in OSA metrics during nonsupine sleep. Similarly, PSG results showed no significant changes between supine and nonsupine positions
for patients who spent at least 20 minutes in each position.

“Though under powered, this study contains some important and intriguing findings that are somewhat unexpected. The first is the 100% increase in the CAHI (Central Apnea-Hypopnea Index) when infants sleep in the non-supine position from 1.7 to 3.4,” said Jack C. Yu, DMD, MD, MS ED, Editor of CPCJ.  “The second is the high agreement in the correlation of variation (ratio of standard to mean, s/m) between supine (0.799) and non-supine OAHI (0.800), indicating excellent homogeneity of the two samples and measurements. The third point is that even in non-supine positions, babies with Pierre Robin sequence a mean OAHI of 21, challenging the traditional notion of using prone positioning as a potential first line non-surgical intervention.”

After acknowledging their study’s limitations due to the small cohort examined, researchers concluded that a lack of consistent improvement in respiratory indices or oxygenation in the nonsupine position indicates that PSG testing should be used to verify objective improvements in OSA prior to deviating from the AAP guidelines for safe sleep.

To learn more about the American Cleft Palate-Craniofacial Association and cleft and craniofacial conditions, please visit

About the American Cleft Palate-Craniofacial Association
The American Cleft Palate-Craniofacial Association (ACPA) is a nonprofit 501(c)(3) association of interested individuals and health care professionals who treat and/or perform research on oral cleft and craniofacial conditions. Since 1943, ACPA has worked to optimize outcomes for individuals with oral cleft and craniofacial conditions through education, support, research, advocacy and interdisciplinary team care. ACPA also provides information to affected individuals and families and seeks to educate the public about facial differences through its ACPA Family Services program. For more information, please visit