Laryngomalacia in Infants: Causes, Symptoms, and Treatment Options

Introduction

Laryngomalacia is a common congenital condition that affects the larynx (voice box) in infants, causing it to collapse inward during breathing. This leads to noisy breathing, or stridor, especially when the infant is feeding, crying, or lying on their back. First described in the 19th century, laryngomalacia is generally benign but can cause concern for parents due to the unusual breathing sounds. Most cases resolve naturally as the child grows, though some may require medical intervention.

This article provides a comprehensive overview of laryngomalacia, including its definition, risk factors, symptoms, diagnostic tests, treatment options, and home care strategies. By understanding the condition, parents and caregivers can better manage their child’s symptoms and seek appropriate care when needed.

What is Laryngomalacia?

Laryngomalacia occurs when the soft tissues of the larynx collapse inward during inhalation, leading to noisy breathing. This article will cover risk factors, symptoms, diagnostic tests, medications, procedures, and home care strategies for managing laryngomalacia.

Description of Laryngomalacia

Laryngomalacia is a congenital condition, meaning it is present at birth. It occurs when the tissues of the larynx are softer than usual, causing them to collapse inward during breathing. This collapse produces a high-pitched sound called stridor, which is most noticeable when the infant is feeding, crying, or lying on their back. The condition is typically diagnosed within the first few weeks of life.

In most cases, laryngomalacia is mild and resolves by the time the child reaches 18 to 24 months. However, severe cases can cause feeding difficulties, poor weight gain, or breathing problems that may require medical intervention.

Medical studies show that laryngomalacia is the most common cause of stridor in infants, accounting for 60-70% of cases. It affects approximately 1 in 2,600 to 3,000 live births. While generally benign, about 10-20% of infants with laryngomalacia may need surgical intervention.

Risk Factors for Developing Laryngomalacia

Lifestyle Risk Factors

Laryngomalacia is congenital, but certain lifestyle factors during pregnancy may increase the likelihood of a child being born with this condition. For example, maternal smoking during pregnancy is linked to a higher risk of respiratory issues in newborns, including laryngomalacia. Additionally, maternal malnutrition or inadequate prenatal care may contribute to congenital abnormalities, including those affecting the larynx.

Expectant mothers should maintain a healthy lifestyle during pregnancy, avoiding smoking, alcohol, and other harmful substances. Proper prenatal care, including regular check-ups and a balanced diet, can help reduce the risk of congenital conditions like laryngomalacia.

Medical Risk Factors

Premature infants are at higher risk of developing laryngomalacia. Premature birth can affect the development of the respiratory system, including the larynx, leading to softer tissues prone to collapse. Additionally, infants with gastroesophageal reflux disease (GERD) are more likely to experience laryngomalacia, as acid reflux can irritate and weaken the laryngeal tissues.

Other medical conditions that may increase the risk include neuromuscular disorders, which affect the muscles supporting the larynx, and congenital syndromes like Down syndrome, which may be associated with structural airway abnormalities.

Genetic and Age-Related Risk Factors

Laryngomalacia is most commonly seen in infants, with symptoms typically appearing within the first few weeks of life. It is rarely diagnosed in older children or adults, as it usually resolves as the child grows. However, in rare cases, it can persist into childhood or adulthood, especially if associated with other medical conditions.

There is some evidence suggesting that genetic factors may play a role in laryngomalacia development. While not typically inherited, certain genetic syndromes affecting airway development, such as Pierre Robin sequence or DiGeorge syndrome, may increase the likelihood of laryngomalacia.

Clinical Manifestations of Laryngomalacia

Stridor (100%)

Stridor is the hallmark symptom of laryngomalacia, occurring in all cases. It is a high-pitched, wheezing sound when the child breathes in, caused by the floppy laryngeal tissues collapsing inward and partially blocking the airway. Stridor is most noticeable when the baby is lying on their back, feeding, or crying. It often worsens during the first few months of life and typically improves as the child grows and the laryngeal tissues strengthen, usually resolving by 18 to 24 months.

Noisy Breathing (100%)

Noisy breathing, or stertor, is another common symptom of laryngomalacia. It occurs in all patients and is often described as a rattling or snoring sound. This noise is produced by turbulent airflow through the narrowed airway caused by the floppy laryngeal tissues. Noisy breathing is usually more pronounced during sleep or when the baby is relaxed. Like stridor, it tends to improve as the child grows and the airway stabilizes.

Difficulty Feeding (45-75%)

Difficulty feeding is reported in 45-75% of infants with laryngomalacia. The floppy laryngeal tissues can interfere with the coordination of swallowing and breathing, making it difficult for infants to feed efficiently. Babies may choke, gag, or cough during feedings, and some may refuse to eat due to discomfort. This can lead to prolonged feeding times and frustration for both the baby and the caregiver. In severe cases, feeding difficulties may contribute to poor weight gain.

Cyanosis (10-20%)

Cyanosis, or a bluish discoloration of the skin, occurs in 10-20% of infants with laryngomalacia. It indicates that the baby is not getting enough oxygen due to airway obstruction. Cyanosis may be intermittent and is often triggered by feeding, crying, or other activities that increase the baby’s respiratory effort. Frequent or severe cyanosis may require further evaluation and possible intervention to ensure the baby is receiving adequate oxygen.

Apnea (10-20%)

Apnea, or pauses in breathing, is seen in 10-20% of infants with laryngomalacia. These pauses can last a few seconds and are often associated with episodes of stridor or noisy breathing. Apnea may occur during sleep or feeding. In some cases, it can be concerning if it leads to significant drops in oxygen levels or occurs frequently. If apnea is suspected, a sleep study or further evaluation may be necessary to assess severity and determine appropriate management.

Poor Weight Gain (10-20%)

Poor weight gain, or failure to thrive, is reported in 10-20% of infants with laryngomalacia. This can result from feeding difficulties, as babies may struggle to consume enough calories due to the effort required to breathe and eat simultaneously. In some cases, the increased work of breathing can burn more calories, further contributing to poor weight gain. Monitoring growth and nutritional intake is crucial in managing infants with laryngomalacia to ensure they meet developmental milestones.

Recurrent Respiratory Infections (10-20%)

Recurrent respiratory infections occur in 10-20% of infants with laryngomalacia. The abnormal airway anatomy can make it easier for bacteria and viruses to enter the lower respiratory tract, leading to infections like bronchitis or pneumonia. These infections can worsen breathing difficulties and may require medical treatment. Preventing and managing respiratory infections is an important aspect of care for infants with laryngomalacia.

Irritability (10-20%)

Irritability is seen in 10-20% of infants with laryngomalacia. Babies may become fussy or agitated due to the discomfort associated with breathing difficulties, feeding challenges, or frequent respiratory infections. Irritability can also be a sign of fatigue, as infants with laryngomalacia may expend more energy trying to breathe. Addressing underlying symptoms, such as improving feeding or managing respiratory infections, can help reduce irritability.

Cough (10-20%)

Coughing occurs in 10-20% of infants with laryngomalacia. It may be triggered by feeding, crying, or other activities that increase respiratory effort. The cough is often a result of airway obstruction caused by the floppy laryngeal tissues. In some cases, coughing may also be related to gastroesophageal reflux, which is common in infants with laryngomalacia. Managing reflux and addressing airway obstruction can help reduce coughing episodes.

Wheezing (10-20%)

Wheezing, a whistling sound during breathing, occurs in 10-20% of infants with laryngomalacia. It is caused by the narrowing of the airway due to the collapse of the laryngeal tissues. Wheezing may be more noticeable during episodes of increased respiratory effort, such as when the baby is feeding, crying, or lying down. In some cases, wheezing may be mistaken for asthma, but it is important to differentiate between the two conditions to ensure appropriate treatment.

Diagnostic Evaluation of Laryngomalacia

The diagnosis of laryngomalacia is typically based on a combination of clinical history, physical examination, and diagnostic tests. The hallmark symptom is stridor, usually present from birth or shortly after. A healthcare provider will ask about the baby’s symptoms, including when they occur and whether they worsen with feeding, crying, or lying down. In addition to a thorough physical examination, diagnostic tests may be used to confirm the diagnosis and assess the severity of the condition. These tests help rule out other potential causes of airway obstruction and guide treatment decisions.

Laryngoscopy

Laryngoscopy is the most common diagnostic test for confirming laryngomalacia. It involves using a small, flexible tube with a camera (laryngoscope) to visualize the larynx and vocal cords. The procedure is typically performed in an outpatient setting and may be done while the baby is awake or under mild sedation. The laryngoscope is inserted through the nose or mouth, allowing the healthcare provider to see the laryngeal structures in real-time. This test provides a direct view of the floppy tissues causing airway obstruction in laryngomalacia.

Bronchoscopy

Bronchoscopy is another diagnostic test that may be used to evaluate the airway in infants with suspected laryngomalacia. This procedure involves inserting a thin, flexible tube with a camera (bronchoscope) into the airway to examine the trachea and bronchi (the large airways leading to the lungs). Bronchoscopy is typically performed under sedation or general anesthesia in a hospital setting. It allows the healthcare provider to assess the entire airway, including the larynx, trachea, and bronchi, to rule out other causes of airway obstruction. This test is particularly useful if there is concern about additional airway abnormalities.

Chest X-ray

A chest X-ray is a simple imaging test that uses a small amount of radiation to create pictures of the lungs and chest structures. While it is not used to directly diagnose laryngomalacia, it can help rule out other conditions that may cause similar symptoms, such as pneumonia, lung abnormalities, or heart problems. The test is quick and painless, and it is often performed in an outpatient setting. The baby will be positioned in front of the X-ray machine, and images will be taken from different angles to provide a clear view of the chest.

CT Scan

A CT scan (computed tomography) is a more detailed imaging test that uses X-rays to create cross-sectional images of the body. In the case of laryngomalacia, a CT scan may be used to evaluate the airway and surrounding structures in more detail. The test is typically performed in a hospital or imaging center, and the baby may need to be sedated to remain still during the procedure. A CT scan can provide valuable information about the anatomy of the airway and help rule out other causes of airway obstruction, such as masses or structural abnormalities.

What if all Tests are Negative but Symptoms Persist?

If all diagnostic tests come back negative but your baby continues to have symptoms such as stridor, noisy breathing, or feeding difficulties, it is important to follow up with your healthcare provider. They may recommend additional testing or refer you to a specialist, such as a pediatric pulmonologist or otolaryngologist (ENT). In some cases, symptoms may be due to other conditions, such as gastroesophageal reflux or a neurological disorder, which require different management strategies. Your healthcare provider will work with you to determine the best course of action to address your baby’s symptoms and ensure their well-being.

Treatment Options for Laryngomalacia

Medications for Laryngomalacia

Omeprazole

Omeprazole, a proton pump inhibitor (PPI), works by reducing the production of stomach acid. It is often prescribed to manage acid reflux, which can worsen laryngomalacia symptoms such as noisy breathing and feeding difficulties.

Omeprazole is typically recommended when acid reflux is suspected to be irritating the larynx. It is a first-line treatment for mild to moderate reflux and is taken orally, usually once a day, for both infants and adults.

Patients may notice a reduction in reflux symptoms within a few days to a week, leading to decreased airway irritation and improvements in breathing and feeding.

Ranitidine

Ranitidine, an H2 blocker, also reduces stomach acid production. It is used to treat conditions like gastroesophageal reflux disease (GERD), which can exacerbate laryngomalacia symptoms, including stridor in infants.

Ranitidine is often prescribed for mild to moderate reflux that contributes to airway irritation. It is taken orally, usually twice daily. While less potent than PPIs like omeprazole, it can still effectively manage reflux-related symptoms.

Symptom relief may occur within a few days, with gradual improvements in breathing and feeding as airway inflammation subsides.

Sucralfate

Sucralfate works by coating the lining of the stomach and esophagus, protecting it from acid damage. It is commonly used to treat ulcers and other conditions where the stomach lining is irritated.

Sucralfate is often used alongside medications like omeprazole or ranitidine to provide additional protection against acid reflux. It is taken orally, usually before meals and at bedtime.

Patients may experience reduced reflux-related irritation within a few days to a week, helping to alleviate laryngomalacia symptoms.

Montelukast

Montelukast, a leukotriene receptor antagonist, helps reduce airway inflammation. It is commonly used to treat asthma and allergic rhinitis, which can sometimes be associated with laryngomalacia.

Montelukast may be prescribed when laryngomalacia is linked to airway inflammation or allergies. It is taken orally, usually once a day, and is often combined with other treatments.

Patients may notice improvements in breathing and reduced airway inflammation within a few weeks of starting the medication.

Diphenhydramine

Diphenhydramine, an antihistamine, is used to treat allergic reactions and symptoms such as itching, sneezing, and a runny nose. It also has a sedative effect.

Diphenhydramine may be prescribed when allergies contribute to airway irritation in laryngomalacia patients. It is typically taken orally, either as needed or on a regular schedule, depending on the severity of symptoms.

Patients can expect relief from allergic symptoms within an hour, which may help reduce airway irritation and improve breathing.

Prednisone

Prednisone, a corticosteroid, reduces inflammation throughout the body. It is used to treat conditions like severe allergic reactions and asthma, which can worsen laryngomalacia symptoms.

Prednisone may be prescribed in severe cases of laryngomalacia where significant inflammation contributes to airway obstruction. It is usually taken orally for a short period to reduce inflammation quickly.

Patients can expect noticeable improvements in breathing and reduced inflammation within a few days of starting prednisone.

Albuterol

Albuterol, a bronchodilator, helps open the airways, making breathing easier. It is commonly used to treat asthma and other conditions that cause airway constriction, including severe laryngomalacia.

Albuterol may be prescribed for patients with laryngomalacia who experience wheezing or difficulty breathing. It is typically administered through an inhaler or nebulizer and used as needed for symptom relief.

Patients can expect rapid relief from breathing difficulties within minutes of using albuterol, though the effects are temporary and may require repeated doses.

Theophylline

Theophylline, another bronchodilator, relaxes the muscles in the airways, making breathing easier. It is used to treat conditions like asthma and chronic obstructive pulmonary disease (COPD) and may be considered in severe cases of laryngomalacia.

Theophylline may be prescribed for patients with severe laryngomalacia who experience significant airway obstruction. It is taken orally, usually once or twice a day, and is often combined with other treatments.

Patients can expect gradual improvements in breathing over several days to weeks as the medication takes effect.

Dexamethasone

Dexamethasone, a corticosteroid, reduces inflammation in the body. It is used to treat conditions like severe allergic reactions and airway inflammation, which can worsen laryngomalacia symptoms.

Dexamethasone may be prescribed in severe cases of laryngomalacia where significant inflammation contributes to airway obstruction. It is usually taken orally or administered via injection for a short period.

Patients can expect noticeable improvements in breathing and reduced inflammation within a few days of starting dexamethasone.

Procedures for Laryngomalacia Treatment

Supraglottoplasty

Supraglottoplasty is a surgical procedure that trims or reshapes tissues around the larynx to reduce airway obstruction. It is the most common surgical treatment for severe laryngomalacia, especially in infants with significant breathing problems.

This procedure is typically recommended for infants and children with severe laryngomalacia who experience breathing difficulties, feeding problems, or failure to thrive. It is performed under general anesthesia and usually requires a short hospital stay.

Most patients experience significant improvements in breathing and feeding within a few days to weeks after the procedure, with long-term relief from symptoms.

Tracheostomy

A tracheostomy is a surgical procedure where a tube is inserted into the windpipe (trachea) to bypass the upper airway. It is used in cases of severe airway obstruction, often seen in the most severe cases of laryngomalacia.

Tracheostomy is typically reserved for the most severe cases of laryngomalacia, where other treatments have failed, and the patient is at risk of life-threatening airway obstruction. It is a more invasive procedure and requires long-term care and monitoring.

Patients who undergo a tracheostomy can expect immediate relief from airway obstruction. However, the procedure requires ongoing care and may be temporary or permanent, depending on the severity of the condition.

Improving Laryngomalacia Symptoms and Seeking Medical Help

While medical treatments are essential for managing laryngomalacia, several home remedies can help improve symptoms and support overall health:

1. Elevating the head during sleep can reduce airway obstruction and improve breathing.
2. Avoiding allergens and maintaining a smoke-free environment can reduce airway irritation.
3. Using a humidifier helps keep airways moist and reduces irritation.
4. Ensuring proper feeding positions and avoiding overfeeding can reduce reflux and improve feeding.
5. Monitoring weight gain and using smaller, more frequent feedings can ensure proper nutrition and reduce feeding difficulties.
6. Keeping the baby calm during feeding can prevent airway obstruction and improve feeding efficiency.

If your child experiences laryngomalacia symptoms like noisy breathing, feeding difficulties, or poor weight gain, seek medical help. Telemedicine offers a convenient way to consult healthcare providers from home. Our primary care telemedicine practice can assess your child’s symptoms, recommend treatments, and provide ongoing support.

Living with Laryngomalacia: Tips for Better Quality of Life

Living with laryngomalacia can be challenging, but there are steps you can take to improve your child’s quality of life:

1. Follow your healthcare provider’s recommendations for medications and treatments to manage symptoms effectively.
2. Track your child’s symptoms and progress, and report any changes to your healthcare provider.
3. Ensure your child receives proper nutrition by monitoring feeding and weight gain.
4. Use home remedies, such as elevating the head during sleep and using a humidifier, to reduce symptoms.
5. Stay informed about your child’s condition and seek support from healthcare providers and support groups.

Conclusion

Laryngomalacia is a common condition affecting the airway, causing noisy breathing and feeding difficulties. While most cases are mild and resolve on their own, some children may require medical treatment or surgery to manage symptoms.

Early diagnosis and treatment are essential for ensuring the best possible outcomes. If you suspect your child may have laryngomalacia, our primary care telemedicine practice is here to help. We offer convenient, compassionate care from the comfort of your home, providing the support and guidance you need to manage your child’s condition effectively.

James Kingsley

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