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Noisy Breathing Infant

Beth Allen, MD and Ann Dietrich, MD
00:00
13:53

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Noisy breathing is a common problem in infants.  Dr Beth reviews common normal causes of noisy breathing and how to recognize more serious etiologies and when to refer.

 

Pearls:

  • The most common cause of inspiratory stridor in the newborn period is laryngomalacia and is usually self-resolving by 12-18 months of life.

  • If a child has noisy breathing with concerning symptoms such as poor feeding, poor growth, respiratory distress, cyanosis and/or changes to cry or voice, more urgent evaluation is warranted.

  • In a child who becomes more stridulous over time, growing lesions in the airway, such as subglottic hemangiomas, cysts and/or papillomas should be considered.

 

  • What is noisy breathing and how do we distinguish nasal congestion? Any noise that the family is concerned about. To distinguish between normal nasal congestion and something more serious, use your stethoscope. If the sound is louder outside the child’s nose than when auscultating the chest, nasal congestion is likely. Nasal congestion should be intermittent. If the noise is continuous, lower tract respiratory pathology should be considered.

  • How should we characterize noisy breathing? One helpful technique is to assess whether the sounds occur during inspiration or expiration. Allen uses the word stridor to describe high-pitched inspiratory sounds and wheeze to describe expiratory sounds.  Another term is stertor which sounds more like snoring and suggests an issue with the nasopharynx.

    • Physiologically, during inhalation the pressures inside the trachea become negative so you can suck air in. Anything that is causing a problem as the trachea becomes smaller will cause a squeaking noise or stridor and suggests the pathology is extrathoracic; in the trachea, larynx or pharynx.

      • Biphasic stridor can occur and suggest a problem in the upper and/or lower part of the airway causing issues with inhalation and exhalation.

        • Biphasic stridor is concerning because it suggests there is a fixed airway and interferes with both phases of respiration.  

    • Conversely, the airways in the thorax will expand during inspiration and become smaller during exhalation and therefore, wheeze heard during exhalation suggests a thoracic pathology.

 

Case

 

4 month old healthy ex-full term infant with noisy breathing that began in the newborn period.  It is worse when the child is awake and active and at times, the child is noted to have some retractions.

  • How would you characterize the above case? Laryngomalacia. For most healthy, thriving infants who present with inspiratory noises that began in the newborn period, the diagnosis is laryngomalacia; most common cause for newborn stridor. The cause is “floppiness” to the structures in the glottic area. The stridor may not began right away and may start around 2 weeks of age as the child begins to inhale more vigorously.  These children with have a normal cry and feed well. The noise is present in the awake or agitated state and may go away while sleeping. While it will generally resolve on its own, it may  take 12-18 months to fully resolve.

    • If the family is concerned, the child is not growing well, the stridor is present during sleep than an ENT evaluation is warranted. Most times, the ENT evaluation consists of an office nasopharyngoscopy to assess the airway up to the glottis. If the symptoms are very severe, ENT may recommend a rigid bronchoscopy in the OR.    

  • What is tracheomalacia? This is a condition in which the trachea is floppy, usually all the way down into the thoracic portion.  Given this, the noisy breathing is usually present on exhalation and sounds like a wheeze or rattling sound during exhalation.  This can be very severe in which children may become cyanotic when trying to exhale; these children should be assessed emergently.

    • Usually, tracheomalacia is suspected in children who have congenital anomalies of the chest, such as tracheoesophageal fistulas. It should be considered, however, in a child with constant wheezing, recurrent bronchiolitis and/or chronic brassy cough who is not responsive to standard therapies. In these children, a pulmonary referral is warranted.  

 

Case

4 month old with worsening stridor that began at 1 month of age. It was intermittent at first, but now is near constant. There are some moderate retractions noted during agitation and stridor is present when the child is asleep.

 

  • What does this case highlight? Red flags in the above case are: constant noisy breathing that is often biphasic and the moderate retractions. One concerning symptoms include feeding difficulty, poor growth, and/or change in voice/crying.  None of these symptoms are standard with normal laryngomalacia and should be further evaluated.  

    • The differential of a child with “normal breathing” that gets more stridulous with time includes:

      • Subglottic hemangioma - a collection of vascularized tissue that may expand overtime and become critical as it blocks off the airway.

      • Subglottic cysts, laryngeal cysts, papillomas - these may also grow overtime and cause obstruction.

    • If a child develops noisy breathing that is constant but not necessarily worsening over time, you should consider glottic webs or subglottic stenosis, that is either congenital or posttraumatic.  

Dania L., MD -

Hi! In the part about laryngomalacia, the presenter states that it is more prominent when the baby is awake and taking deeper breaths. I have consulted multiple other sources about laryngomalacia, and they uniformly state that it is more prominent when a child is feeding , sleeping, and relaxed, and not when they are crying. Can you please clarify this?

Solomon B., MD -

Hi Dania- thanks for the comment. We asked Dr Allen about your question- here was her response:

"“Characterized by a harsh, high-pitched sound, stridor as it presents in laryngomalacia often worsens while the infant is supine, feeding, or crying.”(From “Laryngomalacia” in Pediatric Clinics of North America, 2013;60(4):893-902.) In congenital laryngomalacia, the noise occurs because the abnormally shaped epiglottis (tightly curled, omega-shaped, with short aryepiglottic folds and redundant, prolapsing arytenoid mucosa and cartilage) is actually sucked down over the glottis during inhalation. Air must “squeak” through the remaining small airway opening – leading to stridor. As the child exhales, the structures are actually blown out of the way – and the child is NOT noisy.
If the infant is lying on its back (supine) the symptoms can be more noticeable because gravity is also helping to pull the epiglottis down over the upper airway opening. If (as is recommended) a child is placed on their back to sleep you therefore might hear some stridor. SUCTION, however, is what best completes the narrowing – and the more vigorously the infant is breathing (as with crying or during feeding) the noisier they become. Often, actually, the presence of laryngomalacia doesn’t appear in the newborn nursery – but first becomes apparent after 2-4 weeks, when the child is spending more time awake, agitated, and active (and therefore breathing more vigorously – and more noisily.)
CHOP’s website for parents states as a description of the sounds of laryngomalacia: “An audible wheeze when your baby inhales (breathes in). It is often worse when the baby is agitated, feeding, crying or sleeping on his back.” "

Send us what you were looking at so we can come to some conclusion! :) Cheers!

Sol

Dania L., MD -

Hi Sol,
Thanks for the reply! I just saw this! I had been reading in UpToDate.com:

Clinical features — Laryngomalacia manifests with intermittent low-pitched "wet" inspiratory stridor, usually in the neonatal period [7,8,11,12]. In most children with laryngomalacia, stridor is loudest at four to eight months of age and resolves by 12 to 18 months. Stridor is more intense during upper respiratory tract infections. The stridor is often worse in the supine position and may improve when prone [7]. In infants with mild to moderate laryngomalacia, the stridor is usually loudest when feeding or sleeping and may disappear completely when crying (although this may be difficult to detect due to the noise of the cry). Patients with severe laryngomalacia, conversely, may have the loudest stridor during crying [7]. In some infants, the stridor may be present only during sleep or relaxation (state-dependent laryngomalacia) [11,12].

This seems to suggest that the degree of laryngomalacia determines when symptoms are worst...

Love the program!

Solomon B., MD -

Dania- I can't intuitively understand why (and haven't anecdotally experienced it clinically) LM related stridor would go away with crying...have you ever seen that happen in your practice? Anyone else have that experience?

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