What is the best course of action for a 1 year and 2 week old patient with a history of laryngeal malacia (softening of the laryngeal cartilage) and croup, presenting with cough, congestion, and recent episode of bloody nose, vomiting, and difficulty sleeping?

SOAP Note for 1-year-old with Laryngomalacia Presenting with Respiratory Symptoms

Subjective

• 1-year and 2-week-old male with history of laryngeal malacia
• Presenting with cough and congestion
• History of previous croup episodes
• Mother concerned about possible recurrence of croup
• Last night: difficulty sleeping, required nasal suctioning, Tylenol, and milk to sleep
• This morning: woke with bloody nose lasting 10 minutes
• Increased cough and vomiting since waking

Objective

Key Assessment Points:

• Vital signs with focus on respiratory rate, oxygen saturation, and temperature
• Assess for signs of respiratory distress:
  • Stridor (inspiratory vs. expiratory)
  • Retractions (intercostal, subcostal, suprasternal)
  • Nasal flaring
  • Grunting
  • Cyanosis
• Lung examination for wheezing, crackles, air entry
• Upper airway assessment for congestion, erythema
• Hydration status assessment

Assessment

This patient with laryngomalacia is experiencing an acute respiratory exacerbation, likely viral in origin, with symptoms that could represent either a simple upper respiratory infection or recurrent croup complicated by his underlying airway condition. 1

Differential diagnosis:

1. Viral upper respiratory infection with laryngomalacia exacerbation
2. Recurrent croup
3. Foreign body aspiration
4. Bacterial sinusitis/rhinitis
5. Allergic rhinitis

Plan

1. Immediate Management:

• For mild-moderate symptoms without significant respiratory distress: Conservative management with positioning therapy, nasal suctioning, and adequate hydration is recommended. 1
• For moderate-severe symptoms with respiratory distress: Consider single oral dose of dexamethasone (0.6 mg/kg) to reduce airway inflammation 2
• Avoid bronchodilators as they may worsen dynamic airway collapse in laryngomalacia 1

2. Home Management Instructions:

• Elevate head of bed/crib to reduce reflux and improve airway patency
• Continue nasal suctioning as needed for congestion
• Humidification (cool mist humidifier) to help thin secretions
• Adequate hydration with frequent small amounts of clear fluids
• Avoid irritants (smoke, strong odors)

3. Return Precautions/Follow-up:

• Return immediately for:
  • Increased work of breathing
  • Cyanosis or pallor
  • Inability to drink fluids
  • Lethargy or altered mental status
• Follow-up in 1-2 weeks to reassess symptoms

4. Additional Questions to Ask:

• Duration and progression of current symptoms?
• Any fever associated with current illness?
• Any known triggers for previous croup episodes?
• Any recent choking episodes or possible foreign body exposure? 3
• Any history of gastroesophageal reflux (can exacerbate laryngomalacia)? 1
• Any previous bronchoscopy or specific treatment for laryngomalacia?
• Current medications and response?
• Family history of allergies or asthma?

5. Education:

• Explain relationship between laryngomalacia and increased susceptibility to croup-like symptoms 4
• Discuss natural history of laryngomalacia (typically improves by age 2-3 years) 1
• Review warning signs requiring immediate medical attention

6. Considerations for Specialist Referral:

• If symptoms persist despite appropriate management
• If recurrent episodes of severe respiratory distress
• If failure to thrive or feeding difficulties develop
• Consider ENT referral for repeat evaluation of laryngomalacia severity

Important Note: Foreign body aspiration should always be considered in young children with sudden onset of respiratory symptoms, especially with a history of choking. Sudden onset of respiratory distress without fever or preceding symptoms of congestion suggests possible foreign body rather than infectious cause. 5