The upper part of the larynx, or voice box, closes to keep food and
liquids from entering the lungs when we swallow and opens to let air
into our windpipe.  It also helps us to make noise and talk.  If the
upper part is floppy/weak, it will collapse and make noise when we take
a breath in.  This is called stridor.  Laryngomalacia is the most common
cause of stridor in newborns.  It is usually worse when lying on their
back, eating, crying or when upset.  If babies are unable to protect
their airway due to this weak tissue, they can aspirate into their
lungs.  Yes, the majority 'grow out of it' by one to two years but for
the baby that has severe symptoms causing inadequate oral intake for
growth, increased fatigue, increased work of breathing that may lead to
a significant increase in calorie expenditure also being at risk fot
failure to thrive, coughing/choking/sweating are signs of aspiration.
For the most severe cases only, a supraglottoplasty may be performed to
tighten that tissue.  For mild cases, you may have mild stridor which
may be helped with position changes during feedings or sleep - usually
more upright or forwarkd leaning.  Parents will need to discuss sleep
time position with the PCP since the usual back to sleep position may
not be the best for this patient.  Since laryngomalacia most often poses
difficulties with protecting their airway, slowing the suck swallow
breathe cycle may be needed.  A videofluoroscopic swallow study may be
done to view the suck swallow process laterally and can document whether
that particular feeding allowed partial or full entry into the airway of
barium mixed fluid.  As the infant feeds, especially when they have
increased work of breathing with laryngomalacia, they fatigue and
increase their respiratory rate, so it becomes more difficult to protect
the airway as the feeding continues.  By slowing the suck swallow
breathe cycle, the infant is given more time to clear the airway before
the next bolus of liquid is swallowed.  Most often, this along with
positioning, is the treatment.  Studies also show that reflux in most
cases will be present with Laryngomalacia so most ENT docs will also
treat for reflux since may be asymptomatic but present none the
less.Unfortunately, this cannot be done while feeding at the breast.
Thickening in this treatment is not for the reflux but primarily for the
pacing of the suck swallow breathe and to prevent penetration and
aspiration of fluid into the lungs.  Infant rice cereal is usually the
first choice of thickening since is less allergy causing that other
cereals.  Also, adult type thickeners like 'thick-It' do not have many
calories, and since thickening will slightly decrease breast milk, the
calories from the cereal will be needed.  The other difficulty with
thickening expressed breast milk is that it breaks down the infant
cereal.  So, if parents are understanding of keeping the texture at a
certain level, they can add more cereal as it thins.  This is very
important, since aspirating can be a life threatening episode.  So, if
the symptoms are mild, the baby may be able to gain weight and feed well
at the breast with position changes and not have concerns or symptoms of
aspiration.  I recently evaluated a mom and baby pair that were not
diagnosed prior to my eval but the symptoms were clear to me and I sent
them to our  ENT Aerodigestive Clinic who did diagnose as
laryngomalacia.  I was so happy with how the mother used her instincts
to manage breastfeeding.  She fed him very frequently, he was in an
upright vertical position leaning forward as mom leaned backward.  They
were all measure that I would recommend.
Currently, our Aerodigestive clinic physicians are able to do a nasal
pharyngeal scope in the office while mom feeds at breast to view the
vocal cords and diagnosis a floppy airway.  
Our Radiology department is only able to do the fluoro swallow studies
using a bottle due to the level of radiation exposure.  We do not use
ultrasound, at least at this point but I have brought up the idea to the
Speech Pathologists who are involved in the procedure, as I have seen
CGW show in her presentation.
I think you get the idea, that laryngomalacia is far too frequently seen
that I would have the reason to have this much experience with it.  I
work not only with breastfeeding infants but work in a team approach
with Speech Pathologists, Occupational Therapists and Registered
Dietitians.  In many facilities, this may only be handled by the ENT,
OT, or Speech department.

Angie Kirkwood RN, BSN, IBCLC

Nurse Feeding Specialist and Certified Lactation Consultant
Children's Hospital of Pittsburgh

Office  412-692-5036


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