Is laryngospasm during sleep common in neonates?

Laryngospasm in Sleep Among Neonates

Laryngospasm during sleep is not common in neonates, but represents a potentially serious respiratory event that requires prompt recognition and management when it occurs.

Incidence and Risk Factors

Laryngospasm is relatively rare in the general population with an incidence of approximately 8.7 per 1000 patients, but is more common in children (17.4 per 1000) 1. In neonates specifically, laryngospasm is not a common occurrence during normal sleep, but may occur in certain clinical scenarios:

• Neonates with gastroesophageal reflux disease (GERD) may experience sleep-related laryngospasm 2
• Preterm infants or those with pre-existing airway infections are at higher risk 1
• Neonates with certain genetic conditions, particularly mutations in SCN4A, may experience recurrent life-threatening laryngospasm 3

Pathophysiology

Laryngospasm in neonates involves a persistent apposition of the vocal cords, which can lead to:

• Characteristic inspiratory "crowing" sound in partial obstruction
• Silent inspiration in complete obstruction
• Marked suprasternal recession ("tracheal tug")
• Use of accessory respiratory muscles
• Paradoxical movements of thorax and abdomen 1

The pathophysiology is particularly concerning in neonates due to:

1. Higher susceptibility during REM sleep when upper airway muscles (except nasal and laryngeal abductors) become atonic 1
2. Lower negative pressure required to collapse the neonatal upper airway (approximately 3 cm H₂O) 1
3. Reduced inspiratory force reserve of respiratory muscles in infants compared to adults 1

Clinical Presentation

Laryngospasm in neonates during sleep may present as:

• Sudden awakening with respiratory distress
• Stridor or characteristic "crowing" sound
• Cyanosis or color changes
• Apnea episodes (particularly in preterm infants)
• Bradycardia
• Suprasternal and subcostal retractions 1

It's important to note that in preterm infants, apnea may replace the usual sign of stridor due to easy fatigability and paradoxical response to hypoxemia 1.

Differential Diagnosis

When evaluating a neonate with suspected sleep-related laryngospasm, consider:

• Gastroesophageal reflux disease (GERD) 2
• Congenital subglottic stenosis
• Laryngomalacia
• Vocal cord paralysis
• Genetic conditions (e.g., SCN4A mutations) 3
• Sudden unexpected postnatal collapse (SUPC) 1

Management Approach

Acute Management

For acute laryngospasm in neonates:

1. Position the airway optimally
2. Apply continuous positive airway pressure with 100% oxygen
3. Consider Larson's maneuver (pressure at the "laryngospasm notch" between posterior border of mandible and mastoid process)
4. In severe cases requiring medical intervention, consult anesthesiology or critical care 1

Prevention and Long-term Management

For neonates with recurrent laryngospasm during sleep:

1. Evaluate for GERD - Consider pH monitoring during sleep if GERD is suspected 2
2. Safe sleep practices - Always place infants on their back for sleep to reduce SIDS risk 1, 4
3. Avoid overfeeding - Particularly before sleep periods 4
4. Consider genetic testing - For recurrent life-threatening episodes, especially if there are other neuromuscular symptoms 3
5. Medication management - For confirmed cases related to specific conditions:
   • Carbamazepine has shown efficacy in SCN4A-related laryngospasm 3
   • Appropriate GERD management for reflux-related cases 4

Monitoring and Follow-up

For neonates with a history of laryngospasm during sleep:

• Consider cardiorespiratory monitoring for high-risk infants
• Educate parents/caregivers on recognition of warning signs
• Ensure close follow-up with appropriate specialists (pulmonology, ENT, gastroenterology)
• Monitor for post-obstructive pulmonary edema, which can develop following severe laryngospasm 1

Important Considerations

• Do not confuse with normal infant noises - Newborn gurgling is often normal, but becomes concerning when associated with respiratory distress, cyanosis, feeding difficulties, or projectile vomiting 4

• Avoid inappropriate positioning - While positioning strategies may help with GERD symptoms when the infant is awake, always place infants on their back for sleep, regardless of reflux concerns 1, 4

• Recognize the potential severity - If unrelieved, laryngospasm can lead to post-obstructive pulmonary edema and progress to hypoxic cardiac arrest and death 1