From the Guidelines
Infantile laryngomalacia typically presents with inspiratory stridor, suprasternal retractions, and feeding difficulties, and is often diagnosed with flexible endoscopy, as seen in studies such as 1. The condition usually begins within the first few weeks of life, worsens over the first few months, and resolves by 12-24 months of age. The stridor is characteristically high-pitched, worse during feeding, crying, and supine positioning, and improves when the infant is prone or with neck extension. Clinical findings include:
- Suprasternal retractions
- Feeding difficulties with poor weight gain
- Regurgitation
- In severe cases, cyanotic episodes or apnea The condition results from immature laryngeal cartilage causing collapse of supraglottic structures during inspiration. Most cases (60-80%) are mild and self-limiting, requiring only observation and reassurance. Moderate cases may benefit from treatment of associated gastroesophageal reflux with medications like omeprazole (0.7-3.3 mg/kg/day divided twice daily) or lansoprazole (0.5-1.5 mg/kg/day), as suggested by recent studies such as 1 and 1. Severe cases (10-20%) presenting with failure to thrive, significant respiratory distress, or cor pulmonale require surgical intervention, typically supraglottoplasty to trim redundant supraglottic tissue, as recommended by the most recent study 1. Parents should be educated about positioning the infant prone or with the head elevated during sleep (under supervision), thickening feeds if aspiration is a concern, and recognizing signs of worsening respiratory distress that warrant immediate medical attention. It is essential to note that sleep-dependent laryngomalacia is increasingly recognized as a cause of persistent obstructive sleep apnea (OSA) and is preferentially diagnosed by drug-induced sleep endoscopy (DISE), as stated in 1. Supraglottoplasty is a common surgical intervention for children with persistent OSA, and its outcomes show clinically meaningful improvements in polysomnography (PSG) parameters, as seen in 1.
From the Research
Presentation of Infantile Laryngomalacia
- Laryngomalacia typically presents with stridor, a high-pitched, musical, vibrating, multiphase inspiratory noise appearing within the first 10 days of life 2
- Stridor is the most common symptom, affecting 45-75% of all infants with congenital stridor 3
- Atypical presentations include snoring and/or sleep-disordered breathing (S-SDB) or swallowing dysfunction (SwD) 4
- Signs of severity include poor weight gain, dyspnoea with permanent and severe intercostal or xyphoid retraction, episodes of respiratory distress, obstructive sleep apnoea, and/or episodes of suffocation while feeding or feeding difficulties 2
Clinical Findings
- Laryngomalacia is defined as collapse of supraglottic structures during inspiration 2
- The diagnosis is based on systematic office flexible laryngoscopy to confirm laryngomalacia and exclude other causes of supraglottic obstruction 2
- Rigid endoscopy under general anaesthesia is only performed in specific cases, such as absence of laryngomalacia on flexible laryngoscopy or presence of laryngomalacia with signs of severity 2
- Patient factors that influence disease severity include APGAR scores, resting SAO2 level at time of presentation, and the presence of a secondary airway lesion 5
- Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) contribute to feeding symptoms and disease severity 5, 3