Laryngomalacia

What is laryngomalacia?

Laryngomalacia (lah-ring-oh-ma-LAY-shia) is a larynx (voice box) abnormality that can happen in newborn babies. It occurs when weak, floppy tissues above the voice box temporarily fall back over the airway. It’s the most common cause of noisy breathing in babies.

Laryngomalacia sounds like a high-pitched squeak (stridor) when your baby breathes in. It usually isn’t serious. But in severe cases, it can cause breathing and feeding issues, among other complications.

How common is laryngomalacia?

Congenital laryngomalacia (meaning you’re born with it) is common in infants. Over half of all newborn babies have it during the first week of life, and even more develop it when they’re 2 to 4 weeks old.

Laryngomalacia can also occur in adults, but it’s rare. (Healthcare providers refer to this as acquired laryngomalacia.)

What are the symptoms of laryngomalacia?

Laryngomalacia symptoms can range from mild to severe. Loud, noisy or squeaky breathing is the main thing to watch for. This often worsens over the first several months but resolves within a year or two.

Most babies with laryngomalacia have no trouble breathing or feeding, even when their breathing sounds concerning. Breathing usually gets louder when lying down, sleeping, crying or feeding.

Babies with severe laryngomalacia may have these symptoms:

• Apnea (long pauses in breathing).
• Aspiration (pulling food into the lungs).
• Cyanosis (a condition that causes the skin to develop a bluish hue).
• Difficulty swallowing (dysphagia).
• Inability to gain weight.
• “Tugging” or “pulling in” at the neck or chest when breathing.

If your baby shows any of the symptoms listed above, call their pediatrician right away.

What causes laryngomalacia?

Experts aren’t exactly sure why some babies develop laryngomalacia and others don’t. But they have a few theories about why it happens, in general:

• Structural abnormalities: The cartilage or muscles around the voice box form atypically (differently) during fetal development.
• Neuromuscular disorders: These include disorders that affect the vocal cord nerves and muscles.
• GERD: If acid reflux reaches the voice box, it can cause swelling in the area. This can worsen any structural abnormalities causing laryngomalacia.

Types of laryngomalacia

Healthcare providers categorize laryngomalacia into three types according to cause:

1. Type 1: The mucous membranes of the voice box are too tight or too short.
2. Type 2: The upper part of the voice box has excess soft tissue.
3. Type 3: An underlying disorder (like GERD or neuromuscular disorder) causes laryngomalacia.

How is laryngomalacia diagnosed?

Nasopharyngolaryngoscopy (NPL) is the main test healthcare providers use to diagnose laryngomalacia. An otolaryngologist (ENT) uses a scope with a tiny camera (endoscopy) to view your baby’s voice box. They’ll gently guide the scope into your baby’s nostril and down their throat. Providers can do this routine test in about two to five minutes.

Other laryngomalacia tests

If your baby has laryngomalacia, their provider may need to run other tests to determine the extent of the condition. These tests may include:

• Airway fluoroscopy: This procedure combines X-rays and a contrast agent (like dye) that illuminates affected areas within your baby’s body. Your provider may do this as a swallow study to see how laryngomalacia affects your baby’s swallowing function.
• Impedance probe: A healthcare provider inserts a small tube through your baby’s nose and into their esophagus. Then, they use a measuring device to see how much stomach acid reaches your baby’s voice box. Babies who have this procedure usually stay for at least one night in the hospital.
• Microlaryngoscopy and bronchoscopy (ML&B): A healthcare provider uses a lighted scope to examine your baby’s trachea (windpipe) and voice box to see what’s causing loud breathing. They’ll do this procedure under general anesthesia.
• Neck or chest X-rays: These imaging tests can tell your healthcare provider if your baby has any structural abnormalities that may cause noisy breathing.

How is laryngomalacia treated?

Most of the time, laryngomalacia goes away on its own within a year or two and the noisy breathing improves over time. In mild cases, you can manage your baby’s symptoms at home. But if your baby has severe laryngomalacia, they might need medication or surgery.

Treatment at home

If your baby has mild symptoms, you can usually keep an eye on things at home. Laryngomalacia management depends on your baby’s unique situation:

• If your baby has trouble with feeding, you may need to feed them more often to make up for lost calories and nutrition. You can also try thickening their formula. (You can do this with infant cereal or over-the-counter thickeners.) This increases the “stickiness” of their food so it’s less likely to come back up into their esophagus.
• If your baby has breathing difficulties, your provider might recommend elevating the head of their mattress. This may help open their airway.

Ask your provider about specific ways to manage your baby’s laryngomalacia symptoms.

Medication

When GERD occurs with laryngomalacia, your baby’s provider may prescribe an anti-reflux medication like a proton pump inhibitor (PPI) or H2 blocker. GERD can worsen swelling associated with laryngomalacia, so it’s important to keep reflux in check if it’s a contributing factor.

Surgery

Laryngomalacia surgery involves trimming the weak, floppy tissue above your baby’s voice box. This procedure is a supraglottoplasty. An ENT surgeon will do a supraglottoplasty in an operating room while your child is under general anesthesia. Your baby will typically stay overnight in the hospital for observation.

How long will it take for my baby to feel better after treatment?

Anti-reflux medication usually improves symptoms within two weeks. But your baby will probably need to stay on the medication for several weeks or months.

If your baby had laryngomalacia surgery, their breathing may sound worse for a few days. This is normal. It’s due to post-op inflammation (swelling) around their vocal cords. The noisy breathing should gradually improve, with full recovery taking about two weeks.

Can laryngomalacia be prevented?

You can’t prevent laryngomalacia. But you can manage your baby’s symptoms with treatment.

As a parent, you want to shield your baby from all harm. But laryngomalacia is just something that happens. It doesn’t mean you’ve done something wrong. Although the sounds your child makes may be scary at first, treatment may not be necessary.

Should I be worried about laryngomalacia?

Despite the noisy breathing, laryngomalacia is usually not dangerous. While most babies outgrow laryngomalacia, a few will need surgery to correct the issue, especially if they’re having trouble gaining weight or are having severe breathing difficulties. Your healthcare provider can tell you what to expect if your baby receives a diagnosis.

How long the condition lasts

Laryngomalacia usually goes away on its own by age 1 or 2. But you should keep an eye out for severe symptoms like apnea and a bluish color around their lips. These things can cause serious complications.

When should I call my baby’s healthcare provider?

If your baby shows symptoms of laryngomalacia, like noisy breathing, consider scheduling an appointment with your healthcare provider. They can examine your baby and make recommendations for referral to ENT, home care and management.

Call your provider right away if your baby develops sudden symptoms, or if they have GERD.

When should I go to the ER?

Head to the nearest emergency room if your baby:

• Stops breathing for more than 10 seconds at a time.
• Has a “tugging” or “pulling in” at the chest or neck when breathing.
• Turns blue around the lips.

Laryngomalacia vs. tracheomalacia: What’s the difference?

Both laryngomalacia and tracheomalacia are conditions affecting the airway. While laryngomalacia refers to floppy tissues above the voice box, the characteristics of tracheomalacia include floppy or weak cartilage of the windpipe, which is below the voice box. Tracheomalacia is far less common — and usually more serious — than laryngomalacia.

Can laryngomalacia cause weight gain?

Not usually. In fact, babies with severe laryngomalacia may struggle to gain weight.

What worsens laryngomalacia?

Lying on their back could make your baby’s laryngomalacia symptoms worse. If you notice that your baby is having difficulty breathing when sleeping on their back, please see your healthcare provider.

Additionally, GERD — which is common in babies with laryngomalacia — may make their symptoms worse.