Laryngomalacia, Gastroesophageal Reflux, and Severe Bronchopneumonia in an Infant: An Aerodigestive Challenge

Abstract

Laryngomalacia is a leading cause of congenital stridor in infants; however, concomitant severe lower respiratory infection and feeding difficulties may complicate clinical assessment. This report describes the challenge of distinguishing upper-airway obstruction, bronchopneumonia, and possible aspiration in a male infant younger than two months. The infant had stridor since early life, productive cough, progressive respiratory distress, regurgitation, and choking during feeding. During acute deterioration, the respiratory rate reached 72 breaths/min, oxygen saturation was 82% on room air, and blood gas analysis showed pH 7.28, PaCO₂ 56 mmHg, and PaO₂ 48 mmHg. Chest radiography revealed bilateral infiltrates. Flexible nasopharyngolaryngoscopy demonstrated an omega-shaped epiglottis and dynamic supraglottic collapse, supporting laryngomalacia. Treatment included high-flow nasal cannula at 6 L/min with FiO₂ 40%, antibiotics, and feeding modifications. Oxygen saturation improved to 96–99%; by June 18, 2026, respiratory distress and crackles had resolved, with minimal stridor only during forceful crying. Feeding symptoms raised concern for swallowing dysfunction or aspiration, although objective swallowing assessment and pH-impedance monitoring were not performed. The case highlights that marked hypoxemia in an infant with laryngomalacia should not automatically be attributed to supraglottic obstruction, because concurrent pulmonary infection may contribute substantially. The principal learning points are the need for integrated aerodigestive assessment, careful documentation of respiratory response, and restraint in inferring a causal association between reflux, aspiration, and bronchopneumonia.