When Should a Parent Be Concerned With a Baby’s Noisy Breathing?

Parents like watching their babies sleep. They find joy in seeing their adorable little ones rest so peacefully. But sometimes babies breathe noisily, making sounds that can cause parents to wonder if something is wrong.

One of the main causes of noisy breathing, or stridor, is called laryngomalacia—a long name for a condition that usually is harmless and resolves on its own. Laryngomalacia is caused by floppy tissue falling over the larynx (voice box) and partially blocking the airway when a child breathes in.

The sound from laryngomalacia is often a high-pitched squeak that often worsens when the baby is agitated, feeding, crying, or sleeping on his or her back. Symptoms usually start within a few weeks or months of birth.

While laryngomalacia is the most common cause of noisy breathing in babies and toddlers, it requires intervention in only a small number of children, according to Jocelyn Kohn, MD, an ear, nose, and throat (ENT) specialist with Stanford Medicine Children’s Health Specialty Services in Walnut Creek. Dr. Kohn also sees patients in the East Bay as part of our partnership with John Muir Health. 

“This condition is referred to by some as a birth defect, but I prefer to think of it as an immaturity of the voice box that 90% of children grow out of,” said Dr. Kohn.

In most cases, children will outgrow laryngomalacia by the time they’re 2 and the larynx develops, she added. “As children get bigger and stronger, their larynx gets stronger too,” she said. But a small number of cases will require surgery, which is safe and effective.

Parents may notice these symptoms in their child:

• Noisy breathing (stridor) 
• Difficulty feeding
• Not gaining weight
• Gastro reflux (spitting, vomiting, and regurgitation)
• Choking while feeding
• Apnea (stopping breathing during sleep)
• An indentation in the neck and chest with each breath

Severity can vary. “Some babies I see have mild cases, just making a squeaking noise, while others can be more severe. Pediatricians always advise parents to ask their doctor about anything that concerns them,” she said. “This is good advice. But in the case of laryngomalacia, it’s usually nothing that requires treatment.”

In the worst cases, when babies are not sleeping restfully, have difficulty eating, and aren’t gaining weight, it’s best to talk with the doctor. “These may be signs that an intervention by an otolaryngologist is needed,” Dr. Kohn said.

When children with laryngomalacia fail to gain weight, it’s usually because they’re using so much energy just to breathe that they’re exhausted, she said. Breathing difficulties are often seen as an indentation in a child’s chest and neck, indicating that he or she is having trouble getting enough air.

In these cases, specialists take a closer look by inserting a camera down the throat to see what’s happening in the larynx. “Seeing something ourselves can help reassure parents or guide further treatment,” said Dr. Kohn.

If laryngomalacia is worsened by reflux, Dr. Kohn will treat it with medications. Babies can also be positioned to lessen the breathing problem. Most noisy breathing happens when babies are lying flat on their back, which is the correct position for sleeping. Babies who are awake and being watched can be placed on their stomach to help alleviate the problem.

“We tell parents to put gravity on their side. Keeping a baby upright when feeding, frequent tummy time, and positioning them on their stomach while awake all help,” advised Dr. Kohn. 

Very severe cases, and those that last past two years, may require surgery, which is effective in most children, according to Dr. Kohn. She performs a supraglottoplasty, which adjusts the supraglottis, the tissue above the vocal cords. Although the surgery requires general anesthesia, it’s minimally invasive, using endoscopes and microscopes inserted down the throat. Excess tissue is removed, and tight areas are released.

“Babies usually spend one night in the hospital and recover well, with most experiencing mild discomfort that resolves quickly. Most babies can start feeding again right after surgery,” Dr. Kohn said.

There are many reasons for noisy breathing, including cysts, hemangiomas, and inhaled objects, in addition to laryngomalacia. In case of anything with a sudden onset, or if a child put something in his or her mouth and can’t breathe, seek emergency care immediately.

Learn more about laryngomalacia in a HealthTalks podcast from Stanford Medicine Children’s Health.