Pregnancy, birth, and newborn history

• Prenatal care and exposures (alcohol, smoking, anticonvulsants, corticosteroids)

• Gestational age of the newborn at birth (e.g., preterm, term, and postterm)

Family history of orofacial clefting

Additional medical problems

• Cleft palate without cleft lip: 40% incidence of syndromic presentation

Airway concerns

• Consider Pierre Robin sequence (Chapter 18) if small jaw and airway obstruction

Feeding and weight gain history

Classify the extent of cleft and structural involvement

• Complete (i.e., soft and hard palates) or incomplete (i.e., soft palate alone)

• Primary and/or secondary palate (dividing point is the incisive foramen)

• Unilateral or bilateral (vomer visible on one or both sides)

• Cleft lip involvement, if any

• Veau cleft palate classification system (Table 17.1)

Evaluate for facial dysmorphic features and other congenital anomalies

• Cleft palate alone (without cleft lip): 40% incidence of syndromic presentation

• Mandible evaluation: Pierre Robin sequence—micrognathia/retrognathia, glossoptosis, and airway difficulties (see Chapter 18)

Head-to-toe examination for other anatomic abnormalities

Evaluate other organ systems (e.g., echocardiogram, renal ultrasound, X-rays of the spine) if there is suspicion for other congenital anomalies or syndrome.

Perform genetic testing if syndrome is suspected, possible through chromosomal microarray analysis.