Overview of management of congenital laryngomalacia

GERD: gastroesophageal reflux disease; H2RA: histamine type 2 receptor antagonist; PPI: proton pump inhibitor; SpO₂: peripheral oxygen saturation.

* The urgency of referral is guided by symptom severity. Infants with severe symptoms warrant expedited referral; those who have significant respiratory distress, apnea, desaturation, and/or inability to feed generally warrant inpatient admission. For infants with mild intermittent inspiratory stridor who are otherwise feeding and growing well, nonurgent referral is appropriate.

¶ In infants with mild laryngomalacia, symptoms usually resolve by 12 to 18 months of age. These patients are managed conservatively with supportive care and observation. The initial follow-up visit should occur within a month. If the patient is stable or improving, subsequent follow-up visits can be spaced to every 3 to 6 months Parents/caregivers should receive anticipatory guidance regarding the typical course and instructions on when to seek care. Feeding modification is not necessary for all infants with mild laryngomalacia but may be warranted if there is frequent regurgitation. Simple measures that may be helpful include a trial of thickened feeds, upright positioning after feeds, and avoidance of overfeeding. Refer to UpToDate's topics on swallowing dysfunction and gastroesophageal reflux in infant for additional details.

Δ Medical therapy for moderate or severe laryngomalacia includes both:

• Acid suppression therapy with either an H2RA or PPI. The choice between an H2RA or PPI is based upon cost, availability, and preferences of the clinician and caregivers. There is no evidence to suggest that one agent is more effective or that there is additional benefit from using both medications.
• Feeding modification(s) should be tailored to the individual patient and may include measures such as texture modification (eg, thickened feeds), paced feedings, or use of various special nipples for bottle feeding to reduce flow and minimize aerophagia. Infants with poor weight gain may require high-calorie formula or breast milk supplements to promote weight gain.

◊ Supraglottoplasty is the procedure of choice for treatment of severe or persistent laryngomalacia. Supraglottoplasty removes redundant supraglottic tissue thereby reducing the severity of airway obstruction. The urgency of surgical intervention depends on the clinical circumstances. In patients with more extreme manifestations (eg, severe recurrent apneic and cyanotic spells), surgical intervention should be expedited simultaneously with implementing medical therapies. In less extreme cases, it is usually feasible to provide an initial trial of medical therapy before proceeding to surgery.