Introduction

Laryngomalacia is a disorder which can occur in newborn babies when the soft tissue of the larynx, located above the vocal cords, partially covers the airway during breathing. The floppy tissue causes a partial blockage of the airway, which can often cause a whistling sound (stridor) as the baby breathes. 

Laryngomalacia typically resolves on its own as the baby grows and the tissues strengthen and mature. For newborns, however, breathing difficulties can also lead to feeding difficulties.¹

Understanding the anatomy involved with laryngomalacia and how feeding works can help you better support and care for your baby.

Understanding your baby’s throat and airway

Laryngomalacia is a common congenital condition, and it affects 45-75% of babies with stridor present at birth. Symptoms are usually mild and generally present from the moment of birth until the first four weeks of life. In most cases, laryngomalacia resolves by 12 to 24 months of age.²

Laryngomalacia translates to “soft larynx”, which reflects what causes the condition. 

In newborn babies, the soft tissue around the throat is more relaxed and less developed than in adults. When a baby breathes, the inward airflow creates negative pressure, and the soft, floppy tissue can partially cover and narrow the airway. This causes reduced airflow to the lungs, resulting in noisy breathing. 

A comparison between the anatomy of a baby with laryngomalacia and a baby without the condition is shown in the image below. 

Apart from stridor, other common symptoms of laryngomalacia include:

• Food travels from the stomach back to the oesophagus and mouth
• Vomiting
• Coughing
• Choking 
• Lack of coordination of the suck-swallow-breath (SSB) reflex
• Weigh loss
• Fast, uncontrolled breathing
• Respiratory distress
• Cyanosis (turning blue)³

It is important for healthcare providers to carefully assess a baby’s health condition and rule out other possible causes for abnormal breathing to give appropriate advice tailored to laryngomalacia.

Why feeding can be difficult

Laryngomalacia makes breathing challenging, especially when eating. 

During a feed, a baby needs to suck, swallow, and breathe all at the same time. 

In babies with laryngomalacia, this coordination becomes difficult due to the following reasons:

Breathing, especially while feeding, requires a lot of effort

The partially blocked airway limits airflow. It is therefore harder to obtain the amount of air they need. Babies with laryngomalacia work harder to breathe, especially when lying flat during a feed. The extra effort required to breathe can make them tired quickly and even pause feeding. 

Both air and food pass through the throat, but each one follows a different route in the body. Air passes through the trachea to end up in the lungs, while food passes through the oesophagus to end up in the stomach. In babies with laryngomalacia, when food is in the shared area, it can accidentally end up in the airway.⁴

In the case of milk accidentally entering the trachea, this can lead to coughing, choking, cyanosis, and milk coming out of the nose. 

Unsynchronised suck, swallow and breathe (SBB) feeding sequence 

As part of both breastfeeding and bottle-feeding, babies need to suck, swallow and breathe in a coordinated manner for effective and safe feeding. In babies without laryngomalacia, the feeding pattern looks like this:

• Suck: The baby creates suction using their lips, cheeks, and tongue to draw milk into their mouth
• Swallow: Once milk is in the mouth, swallowing moves the milk from the mouth to the throat, then to the oesophagus, and finally to the stomach
• Breathe: After swallowing, the baby takes a breath before resuming sucking again. Breathing happens through the nose, and it is fast, in order not to disrupt the feeding rhythm

For a baby with laryngomalacia, coordinating these 3 steps can be challenging, and therefore, feeding can lead to choking, coughing, or gagging.⁵

Acid reflux

It is common for some babies with laryngomalacia to suffer from acid reflux, which can cause discomfort and irritation to the oesophagus and throat, especially while feeding. This can lead to a baby refusing to eat, poor weight gain and even weight loss over time.

Symptoms to be aware of 

The following symptoms are indicators of a baby struggling with laryngomalacia, or signs in diagnosed babies that feeding is becoming challenging:

Increased feeding time

Feeding times vary from baby to baby, but if you notice that your baby is taking too long to feel satisfied, it may be a sign that the baby struggles to feed. 

Refusal to feed

A baby may refuse to feed for various reasons, including tongue-tie, infections, sensory overload, and even teething later on. Medical complications such as laryngomalacia and other breathing difficulties can also make feeding uncomfortable. A baby can perceive feeding as a negative experience and therefore, have a fear or aversion towards eating.³

Arching back

When a baby changes body posture to one that seems unusual or tense, it may be a sign of discomfort. If you have tried soothing rocking, patting, burping and changing the baby’s position and the discomfort seems to remain, it could be a sign of an underlying medical issue that needs further investigation.

Reflux-like symptoms

Milk constantly leaking from the mouth and nose can be a sign of spit-up or acid reflux. This can be attributed to the feeding position of the baby or medical conditions such as laryngomalacia. 

Constantly hungry but does not seem to feed well

If a baby seems constantly hungry but doesn't feed well, it may be a sign that they're not getting enough milk due to issues like a poor latch, weak sucking, or difficulty coordinating breathing and swallowing. The latter is a sign of laryngomalacia and should be investigated further with a paediatrician.

When to seek help

The way in which a newborn baby feeds is unique to the baby. At some point, all babies may experience loud breathing, weak sucking and discomfort. Generally, this is normal if this occurs occasionally. It is the repetitive and intense issues that you need to investigate further. If you notice any of the following signs, it is best to consult a paediatrician:

• Poor weight gain
• Trouble breathing while feeding
• Frequent choking and/or coughing while feeding⁶

What you can do to help your baby feed better

The position of the baby during a feed can make a big difference in their overall feeding experience. An upright or semi-upright position helps gravity assist swallowing, making feeding easier. The feeding and post-feeding posture can also reduce symptoms of acid reflux.

Every baby and carer is different, so it’s important to try out a few feeding positions and find what feels most comfortable for both of you.

In case of bottle-feeding, use a slow-flow bottle nipple to allow small sips. Coordinating SSB will be more manageable for the baby. 

If you notice signs of discomfort, back arching, or frequent choking, consult your paediatrician. They might encourage you to work with a feeding specialist who can assess your individual case and give personalised guidance on how to make feeding safer and more effective for your baby. 

Diagnosis

When you seek consultation, a paediatrician will take important information about your baby’s medical history, feeding habits, and symptoms. They might observe a feeding session to assess if the SBB feeding sequence is coordinated. 

To diagnose any feeding problems, certain exams might be requested, such as a swallowing test or an airway evaluation test.

What to keep in mind

As a parent, it is normal to worry about your baby’s feeding, growth and comfort. In case of a laryngomalacia diagnosis, it is important to remind yourself that it is a temporary condition, and most babies overcome it as they grow older. 

Until then, with the right support from medical providers and adjustments to the feeding positions, it is likely your baby will start to have a positive feeding experience.

FAQs

How is laryngomalacia associated with feeding?

When babies are born, their soft tissues are still developing. Soft tissue in the throat, above the vocal cords, can become floppy, leading to a partial inward collapse during breathing. This can narrow the airway and affect feeding, as the SSB feeding sequence may be uncoordinated.

How should I feed a baby with laryngomalacia?

An upright position during and after feeds is considered the optimal feeding position. This way, gravity assists with swallowing and reduces symptoms of acid reflux symptoms. Lying down should be avoided. 

Should I be worried if my baby is diagnosed with laryngomalacia?

The short answer is no. The majority of newborn babies overcome laryngomalacia within the first two years of their lives. If you are worried, seek guidance from your paediatrician, who can offer helpful advice on how to make feeding easier and more enjoyable for your baby. 

Summary

Laryngomalacia is a condition that affects newborn babies. It occurs when the soft tissue above the larynx is floppy and collapses over the trachea, narrowing the airway. This can lead to noisy breathing (stridor) and problems when feeding. The biggest challenge for babies with laryngomalacia is to coordinate the SBB reflex.

Commonly, feeding (whether breastfeeding or bottle-feeding) can become challenging, as coordinating feeding and breathing requires more effort. Most babies overcome laryngomalacia by the time they become toddlers. Until then, consult your paediatrician to better understand your baby’s challenges, gain advice on how to make feeding a more effective and enjoyable experience for your baby.