Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND: Use of neuromuscular blocking agents (NMBAs) is recommended by European Society of Anaesthesiology and Intensive Care in neonates (<1 month) and infants (<1 year) to facilitate tracheal intubation, but the use in other paediatric age groups is still debated.

OBJECTIVE: We assessed the effects of avoidance versus use of NMBA for facilitation of tracheal intubation in children and infants. The primary outcome was incidence of difficult tracheal intubation.

DESIGN: A systematic review of randomised controlled trials with meta-analyses and trial sequential analysis.

ELIGIBILITY CRITERIA: Paediatric patients undergoing tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy with or without NMBAs for any type of procedure requiring general anaesthesia.

DATA SOURCES: A systematic search up to 8 July 2025 in Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials (CENTRAL), BioSciences Information Service of Biological Abstracts (BIOSIS), International Web of Science and Advanced Google and Cumulative Index to Nursing & Allied Health Literature (CINAHL). Trial registries were explored to uncover unpublished data or supplementary trials, http://links.lww.com/EJA/B253.

RESULTS: We identified 47 randomised clinical trials (n = 2276). Three trials were categorised as 'low risk of bias'. Thirty trials reported the primary outcome. Avoidance of NMBAs was associated with increased risk of difficult tracheal intubation with a risk ratio (RR) of 3.47 [95% confidence interval (CI), 2.52 to 4.77, P < 0.001, I2 = 18%] and moderate certainty of evidence. The trial sequential analysis resulted in α-spending adjusted RR of 3.68 when avoiding NMBAs (95% CI, 2.22 to 6.11; α = 5%, β = 90%). We found no significant increased risk of serious adverse events comparing avoidance and use of NMBA (very low certainty of evidence).

CONCLUSION: Using NMBAs for facilitation of tracheal intubation reduces the incidence of difficult tracheal intubation compared to avoidance of NMBA in children and infants.