Introduction

Breathing difficulties in newborns can be alarming, especially for first-time parents. One common cause is underdeveloped soft tissue in the airways, which often leads to a condition called laryngomalacia, otherwise known as floppy airways. This occurs when the soft tissue in the larynx (voice box) collapses during inhalation. It blocks the airflow slightly, causing breathing difficulties.¹ 

Soft airways in newborns can collapse when they inhale due to the lack of structural support and soft tissue. This obstruction can cause high-pitched whistling sounds when breathing, and can result in laboured breathing, feeding difficulties, and poor oxygen levels.¹ 

If you would like to understand how to treat these issues and when to take caution, read on for a more in-depth look at the causes, symptoms, and what you should know as a parent of a baby with this condition. 

What is soft airway tissue in newborns?

The airway is composed of several structures, including the nose, throat, larynx, trachea, and bronchi, all of which work together to facilitate breathing. In newborns, they are more susceptible to obstruction and are smaller than an adult.^1,2

These structures are normally supported by firm cartilage, which keeps the airways open during both inhaling and exhaling. However, in some infants, this structure is not fully developed, remaining soft and flexible. This softness, specifically in the larynx, means that tissue can collapse inward when the baby breathes, partially obstructing airflow. This is known as laryngomalacia and leads to noisy breathing in newborns as a result of the structural deficiency of the upper airway.^1,2

This condition is typically seen in the first few weeks of living with you’re newborn and is pronounced when the baby is feeding, crying, or lying on their back. Although this condition is harmless, it can interfere with feeding, lead to poor weight gain, and contribute to breathing difficulties that may require medical attention.^1,2 

Symptoms of breathing difficulties caused by soft tissue

Newborns with soft tissue abnormalities, particularly laryngomalacia, often exhibit a range of respiratory and feeding symptoms. Most commonly, a noticeable sign is stridor, a high-pitched wheezing or squeaky sound that occurs during inhalation. Many of the affected infants also exhibit signs of poor feeding and gastroesophageal reflux, due to the energy used for breathing, which interferes with effective swallowing and suckling.^3,4 

In more severe cases, the obstruction can lead to cyanosis, characterised by a bluish tint surrounding the lips or face due to a lack of oxygen, causing sleep apnoea where the baby temporarily stops breathing. Additionally, breathing difficulties can disrupt regular sleeping patterns, which results in sleep disturbance and increased fatigue in newborns. These symptoms can vary in severity and should be closely monitored to determine if further medical intervention is necessary.^3,4

Diagnosis and medical intervention

Diagnosing breathing difficulties caused by soft airway tissue starts with a thorough physical examination followed by clinical observation. Your general practitioner and other healthcare providers will typically listen for any abnormal breathing patterns and sounds, like stridor, and assess the baby’s feeding, weight gain, and overall respiratory effort. 

To confirm a diagnosis, a flexible laryngoscopy is performed. This procedure involves passing a thin, flexible tube with a camera attached through the baby’s nose to directly visualise the larynx and observe the airway tissues move during breathing. This helps determine whether the airway is collapsing, which can lead to further evaluations to rule out other airway disorders like vocal cord paralysis or subglottic stenosis, ensuring an accurate diagnosis and appropriate treatment plans.⁵

Treatments available 

The treatment of soft airway tissue problems such as laryngomalacia depends on the severity of the symptoms. In mild cases, the condition often resolves on its own as the baby grows and the airway structure becomes stronger, requiring only watchful waiting and regular monitoring by healthcare providers.⁶ 

When symptoms are more worrisome, specifically during feeding and reflux are present, therefore, medical interventions such as anti-reflux medication can be recommended to reduce inflammation and improve breathing and feeding comfort.⁶ 

In severe cases where the airway obstruction is significantly impacting breathing or feeding, a surgical procedure known as supraglottoplasty can be preformed. This surgery involves rimming or tightening, which removes or reshapes excess tissue in the upper larynx to relieve airway obstruction this treatment is common for children in stridor and helps with the alleviating sleep aponea.^6,7

Differential diagnosis, prognosis, and long-term outlook

When evaluating noisy breathing and respiratory distress in newborns, healthcare professionals need to consider other conditions that can mimic or coexist with soft airway tissue complications. A couple of examples being:^8,9,10

• Tracheomalacia, where the cartilage of the trachea is weak and collapses during exhalation, can also lead to breathing difficulties, but presents with different breathing patterns
• Subglottic stenosis, a narrowing of the airway below the vocal cords that causes persistent stridor requiring imaging or endoscopy for confirmation
• Vocal chord paralysis, where one or both vocal cords are not moving properly, which potentially leads to weak crying, difficulty breathing, or aspiration during feeding

Being able to differentiate among these conditions is crucial for ensuring correct diagnosis and treatment. 

Most infants with laryngomalacia or other soft airway tissue conditions experience a natural resolution of symptoms over time. As the baby grows, the cartilage in the airway gradually becomes stiff, typically leading to complete improvement by 18 to 34 months of age.⁴ 

Parents should be aware of signs that require urgent attention, such as persistent cyanosis (blue hands and feet), aponea (cessation of breathing), or severe feeding difficulties.⁴ If such cases persist, you should seek medical advice or even emergency care. 

For neonates that have undergone surgery, the outcome after supraglottoplasty is generally well received, with most showing rapid improvement in breathing and feeding. Long-term complications are rare, but ongoing follow-up with a paediatric otolaryngologist is carried out to ensure continued progress and safety. 

FAQs

Will my baby outgrow soft airway tissue problems?

Yes. In most cases, the conditions usually improve as the baby’s airway structure becomes firmer, around 18 to 24 months. 

When should I be concerned about my baby’s breathing?

If your baby has persistent noisy breathing, feeding issues, poor weight gain, or any signs of respiratory distress like cyanosis, seek medical guidance promptly. 

Summary 

Soft airway tissue in newborns can cause difficulty when breathing, particularly in a condition known as laryngomalacia. This occurs when the baby’s soft tissue in the throat has not yet developed firm cartilage, causing the throat to collapse temporarily. This results in a partial airway obstruction and symptoms during inhalation, commonly stridor, a high-pitched breathing sound, poor feeding, gastro-oesophageal reflux, and, in more severe cases, cyanosis and apnoea. 

Diagnosing these conditions can sometimes lead to misdiagnosis, as they can be mistaken for other diseases with similar symptoms. Typically, when diagnosing newborns, physical examination and clinical observations are confined by flexible laryngoscopy, which helps to visualise airway movement and rule out other conditions like tracheomalacia, subglottic stenosis, and vocal cord paralysis.

Treatment varies depending on the severity of symptoms; mild cases often go away as the baby develops, but if symptoms persist, anti-reflux medication is provided to ease breathing and feeding issues, or surgical intervention, like supraglottoplasty, can be performed. Overall, understanding the signs, diagnosis, and treatment options can empower you as a parent to manage this.