The expected difficult airway in children is a rare but challenging entity. Publications about pediatric airway management present global recommendations and strategies in order to improve safety and outcome. However, even when a careful plan is implemented according to these fundamental aspects, safety and efficacy may be compromised. The objective of this case report is to alert for the importance of a careful airway planning along with an exhaustive attention to details. A 6 month-year-old child with a complex polymalformative syndrome was scheduled for anti-reflux surgery due to recurrent respiratory infections. A careful plan for airway management was designed, based on airway examination and description of a previous approach with a video laryngoscope. It was decided to schedule two anesthesiologists, one of them experienced in the difficult airway approach. Airway management was planned in order to maintain spontaneous ventilation under inhalational anesthesia with sevoflurane and 100% inspired oxygen fraction. Approaches and sequential steps after failed intubation attempts are described as well as technical difficulties related to material and devices. Given the risk of losing the airway and ventilation it was decided to proceed with the final step of our plan and a surgical tracheostomy was performed. This is an example of how meticulous should be our preparation when planning the airway management in pediatric anesthesia. The presence of another anesthesiologist with expertise in pediatric difficult airway approach, exhaustive description of previous airway approaches and the meticulous revision of the available material including that for invasive procedures should always be kept in mind.