title: Special Comments - Neonatal Intensive Care Drug Manual
text: Evidence summary
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  Efficacy
  Muscle relaxation
  The routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended. However, for ventilated preterm infants with evidence of asynchronous respiratory effort, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular haemorrhage [RR (95% CI) 0.55 (0.34, 0.89)] and possibly on pneumothorax. However, uncertainty remains regarding the long-term pulmonary and neurological effects and the safety of prolonged use of pancuronium in ventilated newborn infants.2 (LOEI, GOR B)
  Intubation
  Thirty infants with birth weights from 580 to 3450 g (25 to 40 weeks gestation) were prospectively studied during nasotracheal intubation. The infants were randomised to receive atropine 0.01 mg/kg, atropine 0.01 mg/kg plus pancuronium 0.1 mg/kg or no medication (controls) prior to intubation. Pancuronium plus atropine was associated with lesser increases in intracranial pressure and with the least changes in heart rate in response to intubation.1 (LOEII, GOR C)
  The dose used in RCTs for neonatal neuromuscular block in mechanically ventilated neonates is 0.03 mg/kg to 0.1 mg/kg.2
  There is one study reporting on use of pancuronium infusion for muscle relaxation in ventilated newborn infants with dose range 0.03–0.07 mg/kg/hour.8 (LOE IV GOR C)
  Drug holidays (i.e. stopping neuromuscular blocking agents until forced to restart based on the patient’s condition) may decrease the incidence of post-paralytic quadriparesis.7,18 (LOE IV GOR D)
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