Development of the neuromuscular junction and neuromuscular blocking agents in neonates, infants and children

Neuromuscular blocking agents (NMBAs) are critical components in paediatric anaesthesia, facilitating intubation, surgical procedures and mechanical ventilation in neonates, infants and children. This narrative review examines the pharmacological properties, clinical applications, monitoring, reversal and safety of NMBAs across paediatric populations. Given the unique physiological characteristics of neonates and infants - including hepatic and renal maturation, and neuromuscular junction development - NMBA metabolism, efficacy and adverse effects in these age groups differ markedly from those in older children and adults. These physiological factors necessitate specific approaches to NMBA selection, dosing and monitoring to ensure effective blockade while minimising risks. Emphasis is placed on understanding how the pharmacokinetics and pharmacodynamics of commonly used NMBAs vary with age, influencing onset, duration and recovery. Additionally, practical strategies for the safe and effective monitoring of neuromuscular blockade using quantitative monitoring techniques are discussed to avoid residual neuromuscular blockade. Recent advances in the reversal of neuromuscular blockade, including the use of sugammadex, offer promising improvements in paediatric anaesthesia safety, though their application in neonatal populations requires further study. Finally, the review discusses current research trends, highlighting the need for age-specific guidelines and pharmacologic innovations that address the challenges unique to NMBA use in neonates, infants, and children.