What is airway floppiness?

The medical term for Airway Floppiness is known as laryngomalacia in infants, and it can contribute to obstructive sleep apnea (OSA). Obstructive sleep apnea is a commonly spotted sleep disorder. Obstructive sleep apnea can be seen in both babies and adults. Here we are more focused on babies. The obstructive airway can result in life-threatening problems. If infants and babies are having stridors and noisy breathing during feeding, crying, or when lying on their backs, this may indicate laryngomalacia or other respiratory issues. 

The reasons causing airway problems can be broadly classified into the following: 

1. Reasons that lead to obstruction 
2. Reasons that involve abnormal communication within the airway

Usually, if the conditions are due to abnormal congenital communication, they can be spotted and diagnosed more quickly than those that are non-congenital. Congenital examples include laryngotracheal cleft and facial or skeletal abnormalities. Also, inflammation in the airway can occur as a result of infection. Infection can cause serious inflammation in the airway. The mechanism behind this is that swollen mucosa could block or reduce the airway, leading to difficult breathing. 

In terms of occurring ages, some reports suggest that there is less significance between age and happening timing, while some suggest 12 to 18 months. For the majority of cases, the following management can ease conditions. 

• Feeding upright
• Antireflux therapy 
• Observation of respiratory symptoms.

Surgical treatment may be needed for severe cases.

• Supraglottoplasty – some research reported 95% success rates. However, when the first operation is performed in infants younger than 2 months of age, the likelihood of requiring revision surgery increases, especially in those with neurologic or cardiac comorbidities

Why is feeding so difficult for babies with airway floppiness?

It is a very challenging and distressing situation for parents to feed babies with airway floppiness. 

Feeding difficulties are a common and often distressing problem for parents of babies with airway floppiness, a condition often referred to as laryngomalacia or tracheomalacia. While the exact presentation can vary, the underlying issue is a lack of structural rigidity in the airway, which leads to it partially collapsing during breathing. This collapse becomes particularly problematic during feeding due to the intricate coordination required between breathing, sucking, and swallowing.

There are a number of key reasons why feeding is so challenging for these infants. During feeding, normal presentation of laryngomalacia means that negative pressure develops in the baby’s oral cavity. This negative pressure could also exacerbate the collapse of floppy airway tissues. This increased obstruction makes it harder to breathe. The narrow and collapsed airway disrupts the rhythm of sucking-swallow-breathing, as babies would be forced to be fed and to breathe at the same time. The liquid would be more likely to go down to the airway and lung rather than the stomach due to a higher risk of aspiration. Therefore, both parents and babies face a constant struggle, fraught with discomfort and frustration. Although you might think the risk of gastroesophageal reflux would also be exacerbated, there is currently no conclusive evidence to support this.

When you feed your baby, it is important to observe your infant's reactions and the colour of their face. Are they coughing or gagging? Is there any milk or juice dribbling out? Alternatively,  is your baby losing weight and struggling to eat? Is their face turning blue or purple? In any of these circumstances, you should seek the advice of your local GP.

What are the best feeding positions?

The following are some useful positions for babies with airway problems. 

Upright/Semi-upright position

• The mechanism allows floppy tissue to move forward naturally by gravity, allowing the airway to remain open. This reduces airway obstruction, making it easier for the baby to breathe while sucking and swallowing
• Practical Tips:
  • Bottle Feeding: Hold the baby in a position where their head is above their chest and hips. This could be in your arm, or in a more seated, upright position if they have good head control. Avoid letting the baby lie completely flat on their back

Side-lying position

• When a baby feeds on their side, gravity can gently draw the floppy tissues to the side, away from the central airway. Additionally, this position allows for better control of milk flow from the bottle or breast; any excess milk can more easily dribble out the side of the mouth instead of being forced into the airway
• Practical Tips:
  • Bottle Feeding: Lay the baby on their side, perhaps supported by a cushion or pillow, with their body snug against yours. Encourage the baby to control the flow by holding the bottle horizontally. 
  • Breastfeeding: The traditional side-lying breastfeeding position can be very effective, as it allows the baby to control the latch and the rate of milk flow

Semi-prone position (with "laid-back" breastfeeding mother

• Rationale: The "laid-back" position for the mother, combined with the infant being semi-prone and tummy-to-tummy with the mother, leverages gravity in a unique way. The baby is "draped" over the mother's body, which helps to keep the airway more open by allowing the soft tissues to fall forward onto the chest wall. The baby also has more control over the latch and milk flow
• Practical Tips:
  • The mother reclines slightly
  • The infant is brought into a side-lying position, then gently manoeuvred into a semi-prone (partially on their tummy) position, with their abdomen in close contact with the mother

Variations

• Most commonly, the infant's body axis is horizontal across the mother's reclined body
• For some infants, a diagonal positioning (feet lower than the head, maintaining semi-prone) can be even more beneficial, providing a slightly more upright angle
• In some cases, the infant might be almost fully prone on the mother's chest if the mother is lying almost flat. This position encourages a more instinctive latch and allows the baby to dictate the pace of feeding, often leading to less forceful milk flow

General important considerations for feeding positions

• Pacing the Feed: Regardless of the position, it's crucial to allow the baby frequent breaks to breathe and rest. Look for cues like coughing, choking, gagging, arching, or changes in skin colour, and pause the feed if these occur
• Smaller, More Frequent Feeds: Offering smaller amounts of milk more often can reduce the burden on the baby's respiratory and digestive systems
• Elevated Head After Feeds: Keeping the baby's head elevated for at least 30-90 minutes after feeding can help reduce gastroesophageal reflux, which is often associated with airway floppiness and can worsen feeding difficulties
• Observation and Individualisation: Every baby is unique. Observe your baby's cues closely and note which positions seem to facilitate easier breathing and more comfortable feeding for them
• Professional Guidance: Always consult with a pediatric feeding specialist, such as a Speech-Language Pathologist (SLP) or feeding therapist, along with your paediatrician or ENT. These professionals can conduct a thorough assessment, recommend the most appropriate positions and feeding techniques for your specific baby's needs, and determine if other interventions (like thickened feeds) are necessary. They can also use tools like FEES to directly visualise the airway and swallowing during feeding to guide recommendations

By carefully applying these positional strategies and working closely with healthcare professionals, parents can significantly improve the safety and comfort of feeding for their baby with airway floppiness.

Last but not least, it is always better to consult with professionals, such as a paediatrician or an ear, nose, and throat specialist. Speech therapists or feeding therapists are also experts in infant feeding and swallowing. A multidisciplinary approach would be helpful and supportive. 

Summary

Feeding a baby with airway floppiness can certainly feel challenging, but it's important to remember that you're not helpless. With the right strategies and support, you can make mealtimes safer and more comfortable for your little one.

The right feeding position is crucial. Whether you opt for an upright, semi-upright, or side-lying approach, the goal is to support your baby's airway, reduce their distress, and make feeding more productive. These positions help gravity work in your favor, keeping floppy tissues from obstructing the airway and allowing your baby to breathe more easily while they eat.  

Beyond positioning, recognising signs of feeding trouble. Knowing when to pause the feed, offer smaller, more frequent meals, and keep your baby elevated after feeding can significantly improve their experience. Don't hesitate to reach out to healthcare professionals, such as paediatricians, ENTs, and feeding therapists, who can offer tailored guidance and ensure your baby gets the best possible support.