Laryngomalacia in Babies: Noisy Breathing and When to Worry

Laryngomalacia is the most common cause of stridor in babies: noisy, high-pitched breathing, like a whistle or a snore, when your baby breathes in. In most cases, this harmless condition goes away on its own before age 2. But hard breathing, pauses in breathing, or very difficult feedings mean you should see a doctor soon.

Here is what it is, how the pediatric ENT (ear, nose and throat doctor) makes the diagnosis, the signs to watch for, and what a breathing monitor can or cannot tell you at night.

What is laryngomalacia?

Laryngomalacia is a birth defect of the larynx. The tissues above the vocal cords are too soft, and they collapse with each breath in, causing stridor. This congenital condition, also called congenital stridor, affects the voice box: the organ at the top of the windpipe that holds the vocal cords. The larynx is still immature, so it is not yet firm, as explained by the website tete-cou.fr.

By collapsing toward the airway, these tissues partly block the upper airway. Air still gets through, but with noise.

It affects about 1 in every 2,000 to 3,000 births, according to Elsan. Babies are the most at risk, since their cartilage is still immature. It accounts for 60 to 70% of congenital larynx abnormalities, according to Santé sur le Net. It is a common reason for a pediatric visit, because the noise worries parents.

Baby stridor: what does the noise sound like?

Stridor is a high-pitched, vibrating sound heard while breathing, mostly when breathing in. Parents describe it as a whistle, a snore, or a small squeak. It comes from the airway being blocked by these soft tissues.

The noise gets louder when your baby cries, gets agitated, feeds, or lies on their back. According to the CHUV de Lausanne, excess tissue falls back into the airway when your baby lies on their back. Elsan notes that the loudness of the noise does not tell you whether a case is severe: a very noisy baby can be doing fine.

If your baby mostly breathes fast and hard, without a high-pitched sound when breathing in, our article on fast breathing in babies during sleep answers that other question.

What causes laryngomalacia?

Its cause is not fully understood. The main theory is a delay in the neuromuscular maturation of the upper airway. Another theory points to abnormally soft cartilage in the larynx. Genetic factors are suspected, though no gene has been clearly identified (Elsan). These theories still cannot explain why one particular baby is affected.

What are the symptoms of laryngomalacia?

The main symptom is that noise when breathing in. The first symptoms usually appear in the first 10 days of life, then often increase during the first few months, peaking between 6 and 8 months (Santé sur le Net). In affected babies, these are the most common signs:

• louder stridor when crying, during exertion, and during feedings;
• slow feedings;
• spitting up or vomiting;
• a cough without an infection.

How is laryngomalacia diagnosed?

Diagnosis starts with a clinical exam: the doctor listens to the noise and watches your baby breathe. To confirm it, the ENT orders further tests, starting with a nasofibroscopy. A small flexible camera, threaded gently through the nose, looks at the whole upper airway while your baby breathes on their own, without anesthesia (Elsan, CHUV).

This endoscopy shows how the laryngeal structures collapse on breathing in. The epiglottis often has a typical omega shape. The exam also rules out other conditions, such as vocal cord paralysis or subglottic stenosis.

Is laryngomalacia dangerous?

Usually not: the condition is mild to moderate in 80 to 90% of cases, and a minority, 10 to 20%, is severe (Santé sur le Net, Elsan). Laryngomalacia comes in different types. The sources mainly focus on these two forms:

• mild to moderate form (80 to 90% of cases): regular medical monitoring is enough;
• severe form (10 to 20% of cases): it can cause a troublesome airway blockage and feeding difficulties that may require surgery.

Elsan lists the signs of a severe form: poor growth, labored breathing, respiratory distress, and serious trouble feeding. In the severe cases described by the CHUV, the epiglottis tips backward, blocking the airway significantly. Only a doctor can tell which form your baby has.

Laryngomalacia and acid reflux: is there a link?

Reflux is very common in these babies: it affects 70 to 80% of children with laryngomalacia, according to Santé sur le Net, and it can make symptoms worse (Elsan). Feeding measures, such as thickened milk, and any anti-reflux medication are decided with your doctor. For nighttime help, read our article on acid reflux (GERD) and baby sleep explaining what helps.

Laryngomalacia and feeding: what to watch for

Feeding time is often the hardest part, so feeding is the first thing to watch. During feeds, crying or agitation makes the suction effort pull these airway tissues inward: they block the airway just when your baby needs to suck (CHUV). The CHUV advises feeding your baby gently, with frequent pauses.

Feeding warning signs: feeds lasting more than 45 minutes to an hour (Elsan), choking episodes, a sign of swallowing problems (tete-cou.fr), and a baby not gaining enough weight.

When should you see a doctor for laryngomalacia?

See a doctor soon, and go to the emergency room right away if your baby is struggling to breathe. Get help right away if you notice:

• breathing difficulties, or pauses in breathing during sleep;
• blue lips or fingers and toes (cyanosis);
• very long feeds, choking episodes, or repeated vomiting;
• not gaining enough weight;
• very loud, prolonged stridor, especially at night;
• a fainting spell.

Elsan, the CHUV and tete-cou.fr all list these signs. According to Elsan, complications, which can affect breathing and sometimes the heart, occur in 10 to 20% of the stridor cases concerned. If laryngomalacia is known or suspected, these signs call for a medical opinion. Only your doctor can tell what is going on.

How is laryngomalacia treated?

There are two main options: monitoring in most cases, and surgery for the severe form.

Monitoring

In mild to moderate cases, no treatment is needed: the ENT monitors progress and treats reflux if there is any.

Supraglottoplasty

For severe cases, the ENT recommends surgery. The standard surgical treatment is supraglottoplasty: under general anesthesia and through an endoscope, the surgeon removes the excess tissue above the vocal cords, sometimes with a CO2 laser, so it no longer blocks the airway (CHUV, Elsan). An epiglottopexy may also be needed in the most serious cases.

In children who have surgery, the success rate reaches up to 94% (Santé sur le Net). According to the CHUV, the operation does not affect the child's growth or voice.

When does laryngomalacia go away?

Most often before age 2, without treatment. These tissues gradually firm up as the child grows. Stridor may ease gently over the first 6 to 12 months (CHUV), and symptoms improve around 12 to 18 months (Elsan). In moderate cases, it resolves on its own between 12 and 24 months (Santé sur le Net). A minority of children keep symptoms longer.

Laryngomalacia and sleep: what changes at night

At night, the stridor can sound louder because your baby sleeps on their back. But don't change their sleep position on your own. The AAP recommends placing all babies on their back, flat, on a firm mattress (AAP, safe sleep guide). If any adjustment would help, your doctor is the one to say so.

Very loud stridor throughout the night, or pauses in breathing during sleep, are reasons to see a doctor.

What a breathing monitor shows, and what it doesn't

A contactless breathing sensor placed under the sheet tracks your baby's breathing rate and movements night after night. Compared with your baby's own 7-day baseline, these readings show trends: a restless night, or faster breathing than usual. For babies with laryngomalacia, these trends can be useful to share with your pediatrician or ENT.

But a sensor like this can't hear stridor. It doesn't diagnose anything, can't see the trouble during feeds, and doesn't replace a doctor visit. To decide whether a monitor makes sense for your family, read what pediatricians say about baby breathing monitors.

Laryngomalacia: the essentials

Keep these points in mind if your baby makes this noise when breathing:

• Laryngomalacia is usually harmless and the leading cause of stridor in babies: the voice box tissues are still too soft.
• The noise starts in the first days of life and gets louder when crying, feeding, or lying on the back.
• In 80 to 90% of cases, monitoring is enough, and symptoms usually disappear before age 2.
• See a doctor right away for hard breathing, pauses in breathing, cyanosis, very long feeds, or poor weight gain.
• Your baby sleeps on their back, flat, unless your doctor advises otherwise.