Pediatric Anesthesia Digital Handbook
Department of Anesthesiology
Division of Pediatric Anesthesia
Tufts Medical Center
Boston, Massachusetts
United States of America

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Positioning Infants and Children for Airway Management

In supine position, the relatively large size of an infant’s head results in natural neck flexion compressing the soft upper airway passages. Under conditions of low airway tone like during general anesthesia, the relatively large tongue falls back against the posterior pharyngeal wall and contributes to airway turbulence and upper airway obstruction.
The classic sniffing position is an established standard across anesthesia practice. Simple extension of the neck can
bring an infant into optimal sniffing position. More often than not, a combination of a shoulder roll and head rest is required as shown in the graphics below. Notice, how the Glabella - Chin Plane is near horizontal to the ceiling, and the neck is wide open. The External Auditory Meatus (EAM) is also observed to be in horizontal alignment with the Suprasternal notch (SN). These 3 visual markers can facilitate us to position children in the sniffing position. Neck over-extension must be avoided as it can make laryngeal exposure difficult.

When positioning older children, a head rest is generally sufficient to bring patients in optimal sniffing position. The principles governing obese children are similar to that of adults. 


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NEONATES, INFANTS AND TODDLERS
STEP 1: SIMPLE EXTENSION
(No Shoulder Roll or Headrest)

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CLINICAL PEARL: SIMPLE HEAD EXTENSION MAY BRING SOME INFANTS IN THE SNIFFING POSITION.

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NEONATES, INFANTS AND TODDLERS
STEP 2: PLACE A SHOULDER ROLL

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NEONATES, INFANTS AND TODDLERS
STEP 3: ADD A HEADREST
(Shoulder Roll adjustment may be required)

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OLDER CHILDREN
STEP 1: ADD A HEADREST
(Shoulder Roll Combo may be required in Obese Children)


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Copyright © 2014. Aman Kalra, MD. Clinical Associate Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine (Author, Illustrator and Web Designer)
800 Washington Street, Box 298, Tufts Medical Center, Boston, MA 02111. USA
LAST UPDATED February 26th, 2022