Opening an unresponsive child’s airway requires precise attention, as their anatomy differs significantly from an adult’s. When a child is found unconscious or in severe respiratory distress, contact emergency medical services immediately before or while attempting any airway maneuvers. These techniques are designed to reposition the tongue, which is the most common cause of airway obstruction in an unconscious person.
Understanding Pediatric Airway Anatomy
A child’s airway is more susceptible to obstruction than an adult’s. A young child’s tongue is proportionally larger relative to the oral cavity, easily blocking the throat when muscle tone is lost. The larynx is also situated higher and more anteriorly in the neck.
The trachea is narrower and shorter, and the softer cartilage supporting the airway is more prone to collapse if the neck is improperly positioned. Infants and young children also have a proportionally larger head and occiput, which naturally causes the neck to flex when they lie flat. This flexion can inadvertently close off the airway, necessitating a specific positioning strategy.
The Standard Airway Opening Technique
When an unresponsive child has no signs of trauma, the standard approach is the Head-Tilt/Chin-Lift maneuver. This technique repositions the tongue by achieving the “sniffing position” for older children, aligning the ear canal with the shoulder. This is done by performing a gentle backward tilt of the head while lifting the chin forward.
This slight extension opens the airway without overextending the softer trachea, which could cause it to collapse. The chin lift is performed by placing fingers under the bony part of the chin and gently lifting. Be careful not to press on the soft tissues under the jaw, as this can push the tongue back and worsen the obstruction.
For infants (under one year old), the technique is modified to a neutral head position, where the head is not tilted backward. Due to their large occiput, laying an infant flat often achieves natural flexion, so a neutral position prevents overextension. If the airway remains blocked after the initial attempt, the rescuer should gently reposition the head and try again.
Airway Opening When Spinal Injury Is Suspected
If a head, neck, or spinal injury is suspected, the Head-Tilt/Chin-Lift maneuver is avoided because tilting the head can move the cervical spine and cause further harm. The alternative is the Jaw Thrust maneuver, which opens the airway while minimizing neck movement.
To perform the Jaw Thrust, the rescuer places two or three fingers under the angle of the child’s jaw on both sides. The jaw is then gently lifted upward and forward, pulling the tongue and soft tissues away from the airway entrance. This maneuver is more challenging to perform effectively than the standard technique, especially on a small child.
The rescuer must focus on moving only the jaw forward without tilting or extending the head and neck. If the Jaw Thrust is unsuccessful, the standard Head-Tilt/Chin-Lift should be performed, as maintaining an open airway takes precedence over the theoretical risk of a spinal injury.
Techniques for Clearing an Obstructed Airway
Clearing a foreign body airway obstruction (choking) requires different management than an airway blocked by the tongue. The goal is to increase intrathoracic pressure to force the object out. Interventions are necessary only if the child’s cough is ineffective or absent.
Infants (Under One Year Old)
For a conscious infant, the procedure involves a cycle of five back blows and five chest thrusts. The infant should be held face-down, straddling the rescuer’s forearm, with the head lower than the chest to use gravity. Five sharp back blows are delivered with the heel of the hand between the shoulder blades.
If the back blows do not clear the object, the infant is turned face-up, with the head still lower than the chest, to receive five chest thrusts. These thrusts are delivered in the same location as chest compressions, using two fingers. Abdominal thrusts are avoided in infants due to the risk of injuring their liver.
Children (Over One Year Old)
For a conscious child over one year old, the recommended sequence is five back blows followed by five abdominal thrusts. The back blows are delivered with the child leaning forward to help gravity dislodge the object. Abdominal thrusts (the Heimlich maneuver) are performed by standing behind the child and placing a fist just above the navel. The rescuer grasps the fist with the other hand and gives five quick, inward and upward thrusts until the object is expelled or the child becomes unresponsive.