2017 Sec 1 Green Book

J. Carter et al./International Journal of Pediatric Otorhinolaryngology 86 (2016) 256–261

Laryngomalacia

Mild laryngomalacia : Inspiratory stridor with no other symptoms or radiographic findings suggesting secondary airway lesion

Moderate laryngomalacia : Cough, choking, regurgitation, feeding difficulty

Severe Laryngomalacia : Apnea, cyanosis, failure to thrive, pulmonary hypertension, cor-pulmonale

Start acid supression therapy and consider feeding therapy/swallow evaluation *see section 4

1 month symptom check, if stable or improving can extend to 3-6 month symptom check

Start acid suppresion therapy and consider feeding therapy/swallow evaluation *see section 4

Consider co-morbidities that place infant at high risk to do poorly: 1. Cardiac disease 2. Neurologic disease 3. Respiratory disease 4. Craniofacial dysmorphism

1. Laryngoscopy/bronchoscopy 2. Supraglottoplasty

*See section 5 for after care

Fig. 2. Comprehensive care algorithm.

6.5. Section 5 : post-surgical treatment algorithm and persistent laryngomalacia

be made worse by surgery. Variation in practice among the current group members remains, and the purpose of this section is to provide a list of reasonable options based on expert opinion.

The algorithm displayed in Fig. 4 is intended to guide manage- ment in infants who have undergone supraglottoplasty and is targeted toward those who have persistent laryngomalacia despite surgery. Time course for follow-up is variable among providers and is dictated by the severity of persistent symptoms in the patient. Persistent laryngopharyngeal reflux or undiagnosed eosinophilic esophagitis may drive persistent laryngeal edema leading to con- tinued laryngomalacia. Confirming the presence or absence of obstructive sleep apnea may drive decision making toward surgi- cal management vs. observation. Identifying and optimizing cardiac, neurologic, and pulmonary co-morbidities is paramount in man- aging the infant with persistent symptoms after supraglottoplasty, especially before considering revision surgery. Patients with mul- tiple severe comorbidities or multilevel airway obstruction are less likely to succeed with supraglottoplasty alone and may require tra- cheostomy. Again, variation in practice among the current group members remains, and the purpose of this section is to provide a list of reasonable options based on expert opinion.

6.4. Section 4 : management of the difficult to feed infant with laryngomalacia

This algorithm in Fig. 3 outlines a guide for managing infants who have been diagnosed with laryngomalacia and are having difficulty with effectively and/or safely feeding. The algorithm may be best performed in conjunction with feeding or speech therapy services when available to guide feeding recommenda- tions and therapy (texture modification, bottle pacing, augmenting feeding schedule, etc.). Chest x-ray may be indicated in the infant if there are signs of respiratory compromise. Aspiration, pooling of secretions, and decreased supraglottic sensation may be seen during endoscopy in the setting of uncontrolled laryngopharyn- geal reflux or neurologic disease. Persistence of symptoms despite maximal reflux suppression, especially in infants with hypotonia, should prompt work-up for neurologic causes prior or concurrent to surgical management. Neurologic disease is not a contraindica- tion to supraglottoplasty, but the benefit of improving airway obstruction must be weighed with the risk of worsening aspira- tion in this scenario. Variation in practice among the current group members remains, and the purpose of this section is to provide a list of reasonable options based on expert opinion.

6.6. Section 6 : recommendations for acid suppression therapy

Fig. 5 provides a “step-up” vs. a “step-down” regimen for man- aging acid suppression therapy. In a “step down” regimen, therapy

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