Frequently asked Questions about Laryngomalacia
Q. Why does my baby make a wheezing or squeaking sound in her neck when she breathes?A. Noisy breathing coming from the voice box in the neck is called “stridor” (STRY-DER). The voice box is also called the “larynx” (LAIR-INKS). The most common cause of newborn stridor is laryngomalacia (LAH-RING-O-MAH-LAY-SHA), which means “floppy voice box”.
Q. What actually causes the noise coming from my baby’s throat?
A. The upper part of the larynx, above the vocal cords, contains supporting cartilages. When a baby takes a breath, these structures are supposed to open wide, to allow air to go into the windpipe. However, in some babies these cartilages are so weak and floppy that during a deep breath, these cartilages become sucked inward, collapsing over the vocal cords, leading to a squeaking or “wheezing” sound.
Q. Can certain things make the noise worse?
A. The noisy breathing heard with laryngomalacia is typically worse during feeding, crying, and excitement (due to increased airflow from deeper breaths), and can be worse when the baby is lying flat on her back (due to the tongue falling back and pressing against the cartilages of the larynx).
Q. How can you confirm the diagnosis?
A. the diagnosis of the laryngomalacia is confirmed by examining the larynx, which is commonly done in the office by placing a small, flexible endoscope into the child’s nose and advancing it down to the larynx.
Q. What can I do to treat this problem?
A. Laryngomalacia is expected in most cases to resolve by itself, usually by 18 to 24 months of age or earlier. Therefore, the treatment in many cases is simply observation, often with the empiric trial of reflux medication (see below). If the symptoms are worse when the baby is lying flat on their back, they can be placed in more of an upright position while sleeping, if that helps. Treatment of gastroesophageal reflux, as well as surgery (for the most severe cases), can also help.
Q. What is the relationship between laryngomalacia and gastroesophageal reflux disease?
A. Research studies using pH probes have shown that gastroesophageal reflux is nearly always present in cases of laryngomalacia, even when there are no obvious symptoms such as vomiting or regurgitation. Sometimes this type of reflux is called “laryngopharyngeal reflux” (reflux from the stomach up into the larynx and throat), which may explain the laryngeal (voice box) symptoms, even in the absence of obvious gastric (stomach) symptoms. Of course, when a child with laryngomalacia is also having frank vomiting, the diagnosis of reflux becomes even more obvious.
Medicine for reflux can often help with noisy breathing associated with laryngomalacia, and therefore is a popular treatment option to try. Many parents have noticed a decrease in stridor when reflux is treated. Other things that sometimes help the symptoms include thickening the formula or breast milk with cereal (approximately 1 tsp. per oz.), switching from a milk-based to a soy-based formula (in case there is an underlying milk allergy) and giving more frequent feeds or smaller volumes.
Q. Does laryngomalacia cause gastroesophageal reflux?
A. Maybe. One theory suggests that when stomach acid comes up into the throat, it irritates the larynx, exacerbating the stridor heard with laryngomalacia either by causing swelling of the already-floppy lining of the larynx, or by causing more rapid breathing. The acid exposure can also cause the vocal cords to spasm shut. This closing of the vocal cords helps to keep stomach acid and formula from going down the windpipe, but also causes breath-holding and apnea and makes it difficult to breathe.
Q. Can laryngomalacia be associated with swallowing problems?
A. In some cases, yes. Swallowing can be impaired in babies with laryngomalacia, due to a variety of reasons. The presence of gastroesophageal reflux is one possible reason. Also, in children with more severe laryngomalacia, the larynx can have decreased sensation and reaction in response to being stimulated, making it easier for formula or milk to be aspirated (“goes down the wrong pipe”). Also, newborns need to coordinate breathing, sucking, and swallowing and if breathing is already difficult because of the laryngomalacia, the delicate coordination between swallowing and the breathing cycle can be disrupted, making a feeding more of a challenge.
Q. Are some cases of layngomalacia worse than others?
A. Yes in most severe cases of laryngomalacia, the baby can have difficulty eating and growing (they do not keep up on their growth charts and have “failure to thrive”). In the most severe cases of laryngomalacia, infants may also have spells where they stop breathing and turn blue. For this small subset of patients, surgery can be performed to trim the floppy voice box tissues in order to relieve symptoms. The procedure is called “supraglottoplasty”. This surgery is generally brief, safe, and successful. However, since laryngomalacia is eventually expected to improve on its own, the surgery is typically reserved for only the most severe cases.
Q. Is all noisy breathing in babies caused by laryngomalacia?
A. No. it must be remembered that not all noisy breathing in newborns and infants is due to laryngomalacia, and even when laryngomalacia is present, there is a chance that there may be more than one problem with the air passages. The most definitive way to assess the child’s air passages is to perform formal endoscopy in the operating room, and the decision to do so is made on a case-by-case basis, depending on the type and severity of the symptoms, the presence of any other significant medical problems or syndromes, and the overall clinical picture.