Laryngomalacia is a common condition present at birth that involves the laryngeal tissue being unusually soft and floppy. This structural abnormality, often referred to as a floppy voice box, allows the tissue above the vocal cords to fall into the airway during inhalation, partially blocking the flow of air. It is recognized as the most frequent cause of noisy breathing, known as stridor, in infants. While the condition often resolves spontaneously as the baby grows and the laryngeal cartilage matures, a clear understanding of its varying severity is important for parents.
The Typical Course of Laryngomalacia
The hallmark sign of this condition is inspiratory stridor, a high-pitched squeaking sound heard when the baby breathes in. This noise is the result of air passing through the partially obstructed, narrowed airway. The stridor is usually not present at birth but develops within the first few weeks of life, generally becoming noticeable by two to four weeks of age.
The noisy breathing is often positional, becoming louder when the baby is agitated, crying, feeding, or lying flat. Conversely, the sound frequently improves when the infant is calm, quiet, or placed on their stomach. This variation is characteristic of mild to moderate laryngomalacia, which accounts for the majority of cases.
Symptoms frequently worsen over the first months of life, peaking around four to eight months of age as the baby generates more vigorous airflow. For most infants, the condition is self-limiting, meaning the laryngeal tissues naturally stiffen and mature over time. Resolution typically occurs without medical intervention by 12 to 18 months old.
Immediate Warning Signs Requiring Emergency Care
Although laryngomalacia is commonly benign, severe obstruction can lead to respiratory distress requiring immediate emergency intervention. One alarming sign is severe retractions, visible signs of the child fighting to pull air into their lungs. This involves the skin sharply pulling in between the ribs (subcostal), beneath the sternum (substernal), or above the collarbone (suprasternal) with every breath.
A change in the baby’s color, known as cyanosis, signals dangerously low oxygen levels. This is most often noticeable as a blue or gray tint around the lips, in the mouth, or on the fingertips. Any episode of color change not immediately relieved by repositioning or calming the baby warrants an emergency call.
A life-threatening symptom is apnea, defined as prolonged pauses in breathing lasting more than 10 seconds. The sudden cessation of breathing indicates the airway is critically compromised. Parents should also watch for a significant change in the infant’s level of consciousness, such as extreme lethargy, floppiness, or unresponsiveness.
If the stridor becomes constant and does not improve regardless of the baby’s position or state, it may signal an acute crisis. This constant noise, especially when accompanied by panic, choking, or difficulty coordinating breathing with swallowing during feeding, signals that the partial obstruction has become a severe restriction. These acute signs mean the baby is struggling to get enough oxygen and requires immediate medical attention.
Chronic Complications and Monitoring Growth
Beyond acute breathing crises, laryngomalacia can lead to chronic issues requiring ongoing medical management, particularly when the obstruction is moderate to severe. Persistent airway resistance increases the energy expenditure required for breathing, diverting calories away from growth. This chronic struggle can result in Failure to Thrive (FTT), marked by poor or plateaued weight gain.
Feeding difficulties are frequently associated with more severe cases, as the infant struggles to coordinate the suck-swallow-breathe sequence. This often manifests as prolonged feeding times, excessive back arching, gagging, or frequent vomiting. Gastroesophageal reflux disease (GERD) is a common comorbidity, as the negative pressure from struggling to breathe can worsen acid reflux, which further irritates and swells the floppy laryngeal tissue.
When conservative measures like elevated feeding positions and anti-reflux medications fail to support adequate weight gain, further testing is indicated. Chronic airway obstruction and poor growth are the primary indicators signaling the need for surgical intervention. The procedure of choice is supraglottoplasty, which involves trimming the excess floppy tissue to relieve the obstruction and ensure the child can thrive.