Laryngomalacia: Symptoms, Causes and Treatment in Babies

Quick answer

Noisy breathing in newborns that usually peaks at 4–8 months and resolves by 1–2 years; severe cases need surgery

In laryngomalacia, the tissues of the supraglottis, the part of the voice box above the vocal cords, are soft and collapse into the airway during breathing in. The typical sign is a squeaky or high-pitched noise on breathing in, starting within the first weeks of life, often louder when feeding, crying, lying on the back or during excitement. The noise often gets louder for several months before improving and usually disappears by 12 to 24 months. Most cases are mild and need only monitoring. Some babies have feeding difficulties, reflux, poor weight gain or breathing pauses, and a smaller group with severe disease need a surgical procedure called supraglottoplasty. International consensus recommendations guide assessment, including feeding and swallowing evaluation.

Important. Seek urgent medical help if your baby has pauses in breathing, turns blue or grey around the lips, has deep chest or neck retractions, struggles to breathe, cannot feed, or is not gaining weight. Call emergency services if your baby is having severe difficulty breathing.

What is laryngomalacia?

The larynx, or voice box, sits at the top of the windpipe. In laryngomalacia, the tissues above the vocal cords, including the epiglottis and the folds on either side, are unusually soft or shaped in a way that lets them flop inward with each breath in. This partly blocks the airway and makes a noise. The exact cause is not fully understood; theories include immaturity of the cartilage and differences in the nerve control and muscle tone of the larynx. It is considered a congenital condition, present from birth.

Symptoms

Noisy, high-pitched breathing (stridor) when breathing in.
Noise starting within the first days or weeks after birth.
Louder when feeding, crying, lying on the back or when excited.
Quieter when calm, asleep on the side or tummy, or lying with the neck slightly extended.
Most babies breathe and feed well and are otherwise healthy.
Some have coughing or choking with feeds, or spitting up.

Typical course

Noise often starts by around two weeks of age.
It may become louder over the first few months as the baby breathes more strongly.
It usually peaks at around four to eight months.
Most babies improve gradually, with symptoms gone by 12 to 24 months.
Colds and chest infections can temporarily make the noise worse.

Mild, moderate and severe

Mild: noisy breathing only; feeding, growth and breathing otherwise normal. This is the majority.
Moderate: noisy breathing with feeding problems such as coughing, choking or reflux, but adequate weight gain.
Severe: poor weight gain, breathing pauses (apnoea), blue spells, significant chest retractions, or heart and lung strain.
Severity guides whether monitoring or treatment is needed.

How it is diagnosed

Diagnosis is usually made by an ear, nose and throat specialist using flexible laryngoscopy, in which a thin camera is passed through the nose while the baby is awake, to watch the larynx move during breathing. It is quick and does not need anaesthetic. The International Pediatric ORL Group consensus recommendations advise considering feeding and swallowing assessment, and further airway evaluation if symptoms are severe or atypical, because some babies have additional airway problems lower down.

Feeding and reflux

Breathing and swallowing are closely linked, so babies with laryngomalacia may tire during feeds, cough, choke or bring milk back. Gastro-oesophageal reflux is common in these babies and may worsen swelling of the laryngeal tissues. Feeding in a more upright position, smaller and more frequent feeds, burping during feeds and pacing feeds can help. Doctors may recommend reflux treatment in some cases. A speech and language therapist or feeding specialist may help if feeding is difficult.

Treatment

Most babies need only reassurance and monitoring of feeding, weight gain and breathing. For severe laryngomalacia, the usual surgery is supraglottoplasty, in which the surgeon trims or releases the floppy tissues using fine instruments or a laser, under general anaesthetic. A review of the condition describes high success rates for supraglottoplasty in appropriately selected infants. Babies with other conditions, such as neurological or genetic disorders, may need more individual management.

Caring for a baby with laryngomalacia at home

Watch how your baby feeds and gains weight, and keep regular weight checks.
Feed in an upright position and take breaks.
Follow safe sleep advice: babies should sleep on their back unless a doctor advises otherwise.
Know the warning signs of breathing difficulty.
Treat colds with saline drops and keep the nose clear; see newborn nasal congestion.
Avoid smoke exposure.

Other causes of noisy breathing in babies

Nasal congestion, causing snuffly breathing.
Vocal cord problems.
Narrowing below the vocal cords (subglottic stenosis).
Softness of the windpipe (tracheomalacia), with noise on breathing out.
Infections such as croup, with a barking cough.
Noise that is present on breathing out, or both in and out, needs specialist assessment.

Three common situations

Six-week-old with squeaky breathing when feeding, gaining weight well: likely mild laryngomalacia; monitoring is usually enough.
Three-month-old with noisy breathing, coughing during feeds and slow weight gain: needs specialist review of feeding and reflux.
Baby with pauses in breathing or blue spells: seek urgent care.

Questions to ask your baby’s doctor

How severe is my baby’s laryngomalacia?
How often should my baby’s weight and feeding be checked?
Which signs mean I should seek urgent help?
Does my baby need reflux treatment or a feeding assessment?
Are any further airway tests needed?
Would my baby benefit from supraglottoplasty, and what are the risks and recovery?

Key points to remember

Laryngomalacia is the most common cause of stridor in babies.
Most cases are mild and resolve by one to two years.
Feeding, weight gain and breathing are key to monitor.
Severe cases are treated with supraglottoplasty.

Questions about laryngomalacia

These answers are general information and do not replace an examination or individual medical advice.

Is laryngomalacia dangerous?

Usually not. Most babies have mild symptoms that resolve on their own. Severe cases need treatment.

When does laryngomalacia go away?

Most babies improve by 12 to 24 months of age.

Can laryngomalacia affect sleep?

Noisy breathing may be louder during sleep in some babies. Breathing pauses need medical assessment.

Is laryngomalacia caused by something I did?

No. It is a congenital condition related to how the larynx developed.

Can adults have laryngomalacia?

Rarely, a form can occur in adults or older children, often during exercise, but it is mainly a condition of infants.

Sources

This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.