An infant presents with a barky cough, inspiratory stridor that worsens when supine, and intermittent cyanosis and dyspnea. What is the appropriate acute management?

Management of Laryngomalacia in an Infant

This infant has laryngomalacia, and the appropriate management is reassurance with close monitoring, as most cases resolve spontaneously by age 2 years. 1, 2, 3, 4

Clinical Reasoning

The presentation is classic for laryngomalacia, not acute croup:

• Chronic inspiratory stridor (not acute onset) that worsens when supine is pathognomonic for laryngomalacia 1, 2, 4
• Barky cough can occur with laryngomalacia, though it's also seen in croup and tracheomalacia 1, 5
• Intermittent cyanosis and dyspnea suggest episodes of airway obstruction consistent with dynamic supraglottic collapse 1, 2
• Laryngomalacia accounts for the overwhelming majority of chronic stridor cases in infants and is the most common congenital laryngeal anomaly 2

The key distinguishing feature is chronicity and positional worsening—croup presents with sudden onset of symptoms, while laryngomalacia presents as chronic stridor from early infancy 1, 2

Management Algorithm

Most Cases: Conservative Management

• Reassurance is appropriate for the majority of infants with laryngomalacia, as symptoms typically resolve by 2 years of age as the airway enlarges 1, 3, 4
• Monitor for adequate weight gain and feeding tolerance 1, 2
• Optimize positioning during feeding and sleep 1, 4
• Treat gastroesophageal reflux if present, as it can worsen symptoms 1, 4

Indications for ENT Referral and Flexible Bronchoscopy

Refer immediately to pediatric otolaryngology if any of the following are present:

• Severe or persistent symptoms including feeding difficulty, failure to thrive, oxygen desaturation, or apnea 1, 2
• Hoarseness accompanying stridor (suggests vocal cord pathology) 1, 2
• Inadequate weight gain despite optimized feeding 1, 2
• Clinical suspicion of synchronous airway lesion 1, 2

Critical point: Up to 68% of infants with stridor have concomitant lower airway abnormalities, making complete airway evaluation essential in severe or persistent cases 1, 2, 5

When Supraglottoplasty Is Indicated

• Supraglottoplasty is the treatment of choice for severe laryngomalacia that does not improve with conservative management 1, 3, 4
• The majority of patients will have resolution of stridor postoperatively 3
• This is reserved for children who do not improve or have severe disease with failure to thrive, significant feeding difficulties, or life-threatening events 1, 3, 4

Tracheostomy Is NOT Indicated

• Tracheostomy is not first-line management for laryngomalacia 1, 3, 4
• It would only be considered in extremely rare cases of severe airway obstruction unresponsive to supraglottoplasty or in the presence of multiple complex airway lesions 1

Common Pitfalls to Avoid

• Do not confuse chronic positional stridor (laryngomalacia) with acute croup, which presents with sudden onset, barking cough, and hoarse voice without positional variation 1, 2, 4
• Do not assume isolated laryngomalacia—remember that 68% of infants with stridor have additional airway abnormalities below the epiglottis 1, 2, 5
• Do not delay referral if red flags are present (feeding problems, desaturation, apnea, failure to thrive) 1, 2
• Flexible bronchoscopy is superior to rigid bronchoscopy for assessing airway dynamics because less positive pressure is applied 5