Signs of an airway problem and when to seek help

As a parent or caregiver, it can be very concerning when your child struggles to breathe.

Many things can affect how well a child can breathe and while some of them are temporary, others may require long-term care.

Cynthia Wang, M.D., Pediatric Otolaryngologist (ENT) at Children's Health℠ and Assistant Professor at UT Southwestern, and Aimee Robinson, M.D., Pediatric Pulmonologist at Children’s Health and Assistant Professor at UT Southwestern, explain common airway issues in children and what symptoms may mean it’s time to see a specialist.

What is an airway issue in children?

An airway disorder is any condition that partially blocks or narrows a child's airway – making it difficult for them to move air in and out.

Airway disorders can cause noisy breathing, chronic cough, feeding problems, sleep problems or trouble getting enough air.

Some newborns have airway problems that they grow out of. Other children have airway problems due to infections, injuries or certain medical conditions.

Common airway problems

Not all breathing problems are caused by asthma, allergies or other sinus issues.

Some airway conditions, such as vocal cord dysfunction or exercise-induced laryngeal obstruction (EILO), can cause similar symptoms but require different treatment.

Other common airway problems in kids include:

• Laryngomalacia. This is the most common type in newborns, caused by a floppiness of the cartilage in the voice box. Kids who have this condition usually have squeaky breathing that gets worse when they feed, cry or lie on their back.

• Croup. Croup is caused by a common virus that narrows a child’s airway. Some kids who get recurrent croup may need to go to the ER or ICU for breathing support.

• Obstructive sleep apnea (OSA). OSA in children is typically caused by enlarged tonsils and adenoids. Kids with OSA snore at night and may have pauses in their breathing or turbulent, "Darth Vader"-style breathing.

• Chronic cough. Chronic coughing can affect breathing. Coughs in kids that last longer than a month may be related to asthma, protracted bacterial bronchitis, allergies, pneumonia, reflux or cystic fibrosis.

“More than anything I see kids with chronic coughs whose parents just can’t figure out why their child’s cough won’t go away,” says Dr. Robinson.

Who is at higher risk for airway problems?

Some children are more likely to experience airway problems. Risk factors can include:

• Being born prematurely

• Having been intubated as a newborn

• Having a neurologic condition that causes lower-than-normal muscle tone (hypotonia) and weakness of the respiratory muscles

• Certain congenital conditions, including Down syndrome, craniofacial differences and cystic fibrosis

• Having obesity

Signs of an airway problem in children

A child may have symptoms of an airway problem if they have:

• Recurrent respiratory infections like pneumonia.

• A chronic cough, especially a wet cough (can be a sign of a swallowing problem).

• Wheezing, stridor or a barky cough.

• Asthma medications they take (like inhaled steroids or albuterol) that don’t seem to be working.

• Chronic shortness of breath.

• Poor weight gain.

• Night snoring, breathing pauses at night, frequent wakings at night or recurrent bedwetting.

• Excessive tiredness during the day that may cause behavioral problems (including attention issues or hyperactivity).

• Morning headaches.

Tracking symptoms of an airway problem

If you’re concerned about your child’s breathing, paying attention to when symptoms happen can provide helpful information for your child’s pediatrician or specialist

You might:

• Take a video recording of breathing or snoring episodes.

• Note when noisy breathing is worse (for example: during feeding, when they’re agitated or when lying on their back).

• Note when breathing improves (for example: when sitting upright or after certain medications).

• Track frequency of breathing difficulties.

• Note if coughing/choking occurs at the beginning or end of a feeding.

“I love when a parent brings in a video of their child snoring,” says Dr. Wang. “It can be hard for parents to try to mimic their child snoring and to know if a child’s snoring is really bad or not.”

The relationship between feeding problems and airway problems

Airway problems and digestive and feeding problems can be closely related.

A child’s larynx and trachea (their airway) and their esophagus (the tube food travels down) are next to each other. So when a child has a condition that can cause food to back up into their esophagus, it can also irritate their airway. Or when a child has a food or seasonal allergy, it may cause inflammation of both the esophagus and the airway.

The proximity of the esophagus and the airway can also cause problems in newborns who aren’t yet eating solid foods. When a newborn breastfeeds or bottle feeds, they essentially eat by chugging, where they take big, fast gulps without stopping to breathe.

“Airway issues affect the suck, swallow, breathe cycle of newborns – which leads to choking, prolonged feedings and failure to thrive,” says Dr. Wang. “The good news is that most babies with breathing issues due to laryngomalacia will outgrow it without surgery.”

Who evaluates children with airway concerns?

Several specialists may be involved in evaluating and treating airway problems in children.

These specialists include:

• Ear, nose and throat (ENT) doctors who evaluate the mouth, throat and airway for structural conditions that may contribute to airway and breathing problems.

• Pulmonologists who treat problems that affect the lungs can evaluate if your child has trouble getting air in or air out. Treatment includes doing a detailed history, physical exam and possible blood tests and tests for asthma. We can also do a lower airway evaluation for direct visualization of the airway and obtain samples from the lungs.

• Gastroenterologists (GI) who diagnose and treat digestive conditions that may inflame the airway and affect breathing, including EOE (eosinophilic esophagitis) and reflux.

• Other specialists including feeding specialists, physical therapists and occupational therapists, depending on the specific type of problem a child may have.

When should I contact my child’s doctor?

Contact your child’s health care provider if your child:

• Is losing weight or not gaining weight appropriately.

• Has had repeated respiratory infections.

• Develops new or worsening breathing problems.

• Has persistent wheezing or is not responding to asthma medications.

• Coughs and chokes with feeding.

• Snores at night or has breathing pauses while sleeping.

Seek emergency care immediately if your child:

• Is using their accessory muscles to breathe – which caregivers will notice by seeing a child “pull in” above their breastbone or between their ribs.

• Is short of breath when laying down flat (a possible sign of pneumonia).

• Is leaning forward to breathe (tripoding).

• Turns blue or becomes unresponsive.

“When a child’s working too hard to breathe, it can cause growth problems. Airway issues can also affect a child’s ability to get adequate rest, which can lead to learning problems or exercise intolerance – all of which greatly impact long-term health and well-being,” says Dr. Robinson.

Find the right care for your child

Children's Health offers expert care for children with airway disorders through our Pediatric Ear, Nose and Throat (ENT) program and Multidisciplinary Pediatric Aerodigestive Clinic (MPAC). Our specialists work together to diagnose complex airway, feeding and swallowing conditions and create personalized treatment plans so children can breathe, eat and thrive.