Feeding and swallowing function in infants with laryngomalacia: morphologic and functional predictors of airway invasion

Abstract Background Dysphagia is increasingly recognized in infants with laryngomalacia; however, the relative contribution of anatomical and functional factors to airway invasion remains unclear. Objective To investigate anatomical and functional predictors of airway invasion in infants with isolated laryngomalacia and to explore the underlying pathophysiology of dysphagia in this population. Methods Forty infants (median age: 5 months) with confirmed isolated laryngomalacia underwent clinical swallowing evaluation (CSE), structured bedside assessment using the Mansoura Early Feeding Skills Assessment (MEFSA) score, and fiberoptic endoscopic evaluation of swallowing (FEES). Univariate and multivariable logistic regression analyses were performed to identify predictors of penetration/aspiration. Results Most infants presented with stridor (77.5%), while 22.5% presented with both stridor and associated feeding difficulties. Unsafe, ineffective oral feeding with suck-swallow-breath incoordination (SSBI), as identified by MEFSA, was observed in 72.5% of infants. On FEES, penetration/aspiration was identified in 55% of infants, predominantly before or during swallowing. Premature bolus entry and/or delayed swallow initiation were observed in 47.5% of cases and emerged as the most consistent independent correlate of airway invasion in multivariable analysis. Arytenoid prolapse was associated with increased odds of penetration/aspiration (odds ratio = 7.6, p = 0.053), while shortened aryepiglottic folds showed a trend toward a protective association (odds ratio = 0.17, p = 0.059). Conclusion Airway invasion in infants with laryngomalacia appears to be primarily related to impaired swallow–breath coordination and delayed swallow timing, with supraglottic configuration potentially modulating this risk. These findings support the importance of functional swallowing assessment and suggest a tailored assessment approach based on morphology–function interaction rather than respiratory symptoms alone.