Pediatric Anesthesia Digital Handbook

Positioning Infants and Young 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. 
NEONATES, INFANTS AND TODDLERS
STEP 1: SIMPLE EXTENSION
(No Shoulder Roll or Headrest)
CLINICAL PEARL: SIMPLE HEAD EXTENSION MAY BRING SOME INFANTS IN THE SNIFFING
POSITION.
NEONATES, INFANTS AND TODDLERS
STEP 2: PLACE A SHOULDER ROLL
NEONATES, INFANTS AND TODDLERS
STEP 3: ADD A HEADREST
(Shoulder Roll adjustment may be required)
OLDER CHILDREN
STEP 1: ADD A HEADREST
(Shoulder Roll Combo may be required in Obese
Children)
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USEFUL LINKS
Tufts Medical Center
Floating Hospital for Children
American Board of Anesthesiology (ABA)
American Society of Anesthesiologists (ASA)
Society of Pediatric Anesthesia (SPA)
Accreditation Council for Graduate Medical Education
ASA Guidelines, Statements and Practice Advisories
Malignant Hyperthermia Association of the United States
AnesthesiaHub - The Central Resource of Anesthesiology

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Tufts Medical Center Webmail
Tufts Hirsh Health Sciences Library

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 3rd, 2019

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