In a 7‑day‑old male infant who had brief positive‑pressure ventilation at birth and now has inspiratory clavicular retractions and stridor without fever or apnea, what is the most likely diagnosis and how should it be acutely managed?

Laryngomalacia: Most Likely Diagnosis and Acute Management

This 7-day-old infant with inspiratory stridor, supraclavicular retractions, and noisy breathing without fever or apnea most likely has laryngomalacia, which should be managed with close observation, positioning, and supplemental oxygen if saturations fall below 92%. 1

Clinical Reasoning

The presentation is classic for laryngomalacia—the most common cause of stridor in newborns:

• Inspiratory stridor with supraclavicular retractions indicates upper airway obstruction at the laryngeal level 1
• Noisy breathing without apnea or fever rules out infectious causes and serious cardiopulmonary compromise 1
• Good feeding and alertness suggest mild-to-moderate disease without significant airway compromise 1
• Brief PPV at birth is unlikely related, as the infant recovered quickly and remained well for 7 days 2, 3

The history of PPV for 7 minutes at birth that "quickly resolved" suggests transient respiratory depression or delayed transition, not an ongoing structural problem from birth trauma. 2, 3 Most newborns requiring brief PPV have excellent outcomes without sequelae. 3

Immediate Assessment and Triage

Hospitalization is required if oxygen saturation falls below 92% at sea level. 1 The American Academy of Pediatrics recommends hospitalizing infants with moderate to severe respiratory distress characterized by retractions, nasal flaring, or grunting. 1

Key assessment parameters:

• Continuous pulse oximetry monitoring to detect desaturation episodes 1
• Respiratory rate and work of breathing assessment every 4 hours 1
• Feeding tolerance and hydration status—inability to maintain adequate oral intake mandates hospitalization 1
• Activity level and alertness—lethargy or decreased responsiveness warrants admission 1

Acute Management

Oxygen Therapy

Start supplemental oxygen immediately if SpO₂ drops below 92% to prevent hypoxemia-related complications. 1 The American Thoracic Society recommends maintaining saturations >92% in children with dyspnea. 1

Positioning

Elevate the head of bed 30-45 degrees to improve respiratory mechanics and reduce airway collapse. 1 Prone positioning during supervised awake periods may also reduce stridor severity, though this must be balanced against SIDS risk.

Supportive Care

• Ensure adequate hydration—if oral intake is compromised, provide IV fluids at 80% of maintenance with daily electrolyte monitoring 1
• Avoid agitation—crying worsens laryngeal collapse and increases work of breathing
• Monitor for feeding difficulties—aspiration risk increases with severe laryngomalacia

Diagnostic Workup

Flexible laryngoscopy is the gold standard for confirming laryngomalacia and assessing severity, though it is not emergently required in a stable infant. This can be arranged as an outpatient procedure if the infant remains stable.

Chest radiograph (PA and lateral) should be obtained if there is concern for pneumonia, aspiration, or other parenchymal disease. 1 However, in an afebrile infant with isolated stridor and no lower respiratory signs, imaging may be deferred.

Rule out other causes of stridor:

• Vocal cord paralysis (especially if history of difficult delivery or neck trauma)
• Subglottic stenosis (less likely without prior intubation beyond the brief PPV)
• Vascular ring or sling (would typically present with biphasic stridor and feeding difficulties)
• Tracheomalacia (usually expiratory stridor)

Critical Pitfalls to Avoid

Do not assume the brief PPV at birth caused structural airway damage unless there is clear evidence of trauma. 2, 3 Most infants requiring brief resuscitation have normal airways.

Do not delay oxygen supplementation if saturations fall below 92%, as hypoxemia in neonates can rapidly lead to bradycardia and cardiovascular collapse. 1, 3

Do not miss feeding difficulties or aspiration—laryngomalacia can be associated with gastroesophageal reflux and aspiration, which worsen respiratory status. 2 The American Heart Association recommends evaluating for chronic reflux and aspiration in infants with persistent respiratory symptoms. 2

Do not discharge without clear return precautions—parents should be instructed to return immediately for cyanosis, apnea, severe retractions, or inability to feed. 1

Disposition

Discharge is appropriate if:

• SpO₂ remains >92% on room air consistently 1
• Respiratory rate normalizes with decreased work of breathing 1
• Infant tolerates adequate oral intake and maintains hydration 1
• Parents demonstrate understanding of warning signs 1

Outpatient follow-up with pediatric ENT should be arranged within 1-2 weeks for flexible laryngoscopy to confirm the diagnosis and assess severity. Most cases of laryngomalacia are mild and resolve spontaneously by 12-18 months of age. Severe cases requiring supraglottoplasty are uncommon but should be identified early.