How do you position the head in neonatal intubation?

Head Positioning for Neonatal Intubation

Position the neonate's head in the "sniffing" position—a combination of neck flexion and head extension—which is the standard recommended positioning for neonatal intubation. 1, 2

Specific Positioning Technique

Age-Based Positioning Strategy

For neonates and infants under 2 years:

• Place a roll or small pad under the shoulders to achieve neck flexion 1
• This creates the appropriate "sniffing" alignment for optimal airway visualization 1

For children over 2 years:

• Use a neutral head position without shoulder elevation 1
• The anatomical differences in older children make neutral positioning more effective

The "Sniffing" Position Components

The American Academy of Pediatrics defines this position as having two key elements 1, 2:

• Neck flexion: Achieved by elevating the occiput or placing padding under the shoulders in neonates
• Head extension: The atlanto-occipital joint is extended to align the oral, pharyngeal, and laryngeal axes

Practical Implementation

Initial Setup Steps

• Place the infant under a radiant heat source for warmth 1, 2
• Position the head in the sniffing position to open the airway 1, 2
• Ensure proper alignment before the first intubation attempt, as optimal positioning is essential 1

Verification of Correct Position

The goal is to align anatomical structures to optimize laryngoscopic view 3. In adults and older patients, this involves aligning the external auditory meatus with the suprasternal notch (the "ramped" position), though this specific landmark is less commonly referenced in neonatal guidelines 1.

Common Pitfalls and How to Avoid Them

Avoid hyperextension of the neck:

• Excessive extension can actually worsen the laryngoscopic view and compress airway structures 1
• The position should be "sniffing," not "star-gazing"

Avoid inadequate shoulder elevation in neonates:

• Neonates have proportionally larger occiputs that cause neck flexion when lying flat 1
• Without a shoulder roll, the head naturally falls into a flexed position that obstructs the airway

Check for interfering factors:

• Certain hairstyles (elaborate braids) can affect neck extension and may require removal before intubation 1
• Large breasts in obstetric patients can interfere with laryngoscope insertion, requiring head-up positioning 1

Special Considerations for Difficult Airways

If the initial sniffing position does not provide adequate visualization 4:

• Reassess and optimize head position before subsequent attempts 1
• Consider using a videolaryngoscope with age-adapted standard blade as first choice 4
• Limit intubation attempts to 2-3 before considering alternative airway strategies 1

The "Golden Minute" principle applies: Complete initial positioning, assessment, and begin ventilation within approximately 60 seconds if spontaneous breathing is inadequate 2.

Equipment Considerations

Using specialized positioning aids can improve success 3:

• Triangular-shaped pillows that create a slope for the head have been shown to improve laryngoscopic view grades compared to regular pillows in research settings
• The slope naturally positions the head in extension while the shoulders remain elevated

Critical monitoring during positioning: Simultaneously evaluate heart rate, respirations, and oxygen saturation via pulse oximetry once positioning is established and intubation begins 1, 2.