Laryngomalacia (LM) is a common congenital condition affecting the larynx (voice box) and is the most frequent cause of noisy breathing in infants. This condition involves a structural weakness where tissues above the vocal cords are softer than usual, causing them to partially collapse into the airway during inhalation. The resulting sound is a high-pitched squeak known as stridor. LM is usually self-limiting, resolving as the laryngeal cartilage matures. Managing symptoms, especially inspiratory stridor during sleep, is a primary concern for caregivers.
How Laryngomalacia Impacts Breathing During Sleep
Breathing is often more labored and noisy during sleep compared to when the infant is awake and upright. This worsening occurs due to two primary factors: muscle relaxation and body positioning. When an infant enters deeper sleep stages, particularly Rapid Eye Movement (REM) sleep, muscle tone in the upper airway naturally decreases. This reduction allows the floppy laryngeal tissues, such as the epiglottis and arytenoids, to fall more readily into the airway opening.
The horizontal position assumed during sleep further exacerbates the obstruction through gravitational forces. When an infant lies flat on their back, gravity pulls the floppy laryngeal structures backward, increasing the degree of collapse upon inhalation. This intensifies the inspiratory stridor and increases the effort required for breathing. This position-dependent obstruction can lead to sleep-related breathing disorders, such as obstructive sleep apnea, in severe cases.
Effective Sleep Positioning Strategies
The standard recommendation for infant sleep is the supine (back) position, strongly advocated to reduce the risk of Sudden Infant Death Syndrome (SIDS). For infants with mild laryngomalacia, however, back sleeping often maximizes stridor and breathing effort, as gravity pulls the laryngeal tissue into the airway. Caregivers must prioritize SIDS prevention guidelines, and the back position remains the safest option unless a specialist advises otherwise.
Elevating the Sleep Surface
One beneficial modification is elevating the entire sleep surface. Utilizing gravity to pull the laryngeal tissues forward and away from the airway opening can reduce the degree of collapse. This elevation should be achieved by safely raising the head of the crib or bassinet mattress, often by six to nine inches, to create a gentle incline. Ensure the elevation is firm and uniform, using blocks or risers under the crib feet. Avoid using soft wedges or pillows inside the crib, which pose a suffocation risk.
Non-Supine Positions
If breathing is severely compromised in the back position, a pediatric Ear, Nose, and Throat (ENT) specialist may recommend positioning the infant on their side or tummy (prone). Side sleeping can significantly reduce obstructive events and lessen breathing effort compared to the supine position. The prone position also alleviates stridor by shifting the tissues forward. These non-supine positions fundamentally contradict safe sleep guidelines and must only be implemented under explicit medical direction, often requiring specialized monitoring.
When to Seek Advanced Medical Assessment
Most cases of laryngomalacia are mild and self-resolve, but caregivers must monitor for signs indicating a severe condition requiring intervention beyond positioning adjustments.
Signs of Acute Distress
Respiratory distress is a clear warning sign, often presenting as retractions. Retractions are the visible sinking-in of the skin at the neck, between the ribs, or under the rib cage during inhalation, indicating the infant is using excessive effort to pull air past the obstruction.
Cyanosis, a bluish discoloration around the lips or face, signals low oxygen levels in the blood. Caregivers should also monitor for episodes of apnea, or long pauses in breathing, which suggest the airway has failed to remain open. These acute symptoms warrant immediate medical attention.
Chronic Concerns and Intervention
A chronic indicator of severe LM is failure to gain weight or poor feeding, often termed “failure to thrive.” The increased energy expended on breathing interferes with caloric intake, making feeding exhaustive. If these severe symptoms are present, positioning alone is insufficient, and consultation with a pediatric ENT specialist is necessary. The specialist may recommend a diagnostic procedure, such as flexible laryngoscopy, or discuss surgical intervention like supraglottoplasty to trim the floppy laryngeal tissues and open the airway.