Neuromuscular block in paediatric patients undergoing airway management: a narrative review

Airway management in paediatric patients carries a high risk of respiratory complications, particularly in neonates and infants. The role of neuromuscular blocking agents (NMBAs) has evolved substantially, with increasing evidence supporting their use to optimise facemask ventilation and tracheal intubation when spontaneous breathing is not required. This review is timely as new pharmacological options and monitoring strategies have emerged to improve safety in this vulnerable population.

Evidence from randomised trials, observational studies, and international guidelines suggests that NMBAs improve first-attempt intubation success, suppress airway reactivity, and reduce perioperative respiratory adverse events. In neonates and infants, rocuronium improves intubation conditions, and the recent approval by the Food and Drug Administration of sugammadex for use in children below two years of age expands reversal options and enhances patient safety. Despite this, residual neuromuscular block remains common, especially in the absence of objective monitoring. Quantitative neuromuscular monitoring provides superior detection of incomplete recovery compared with clinical or qualitative methods.

NMBAs are a key component of paediatric airway management when spontaneous ventilation is unnecessary. Routine integration of quantitative monitoring and appropriate pharmacological reversal is essential to reduce residual block and improve patient safety.