UMEM Educational Pearls

Category: Pediatrics

Title: Positioning in Pediatric Intubation

Keywords: Airway, Intubation, Pediatric, Positioning (PubMed Search)

Posted: 5/13/2011 by Adam Friedlander, MD (Updated: 8/28/2014)
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"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature.  Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.

However, the correct anatomic positioning principle applies to all ages.  Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.  

Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso.  In all ages, if you follow these positioning principles, you will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).




  • The 2011 Practical Airway Management Workshop (Drs. Richard Levitan and Ken Butler)
  • Images from and