Pediatric Succinylcholine Dosing
For rapid sequence intubation in pediatrics, administer succinylcholine 2 mg/kg IV for infants and small children, and 1 mg/kg IV for older children and adolescents. 1
Age-Specific IV Dosing
The most recent French guidelines (2019) provide the most granular age-based dosing algorithm 2:
- Up to 1 month: 1.8 mg/kg IV
- 1 month to 1 year: 2 mg/kg IV
- 1 to 10 years: 1.2 mg/kg IV
- Over 10 years: 1 mg/kg IV
The FDA labeling corroborates this approach, noting that neonates and infants up to 6 months require 2-3 mg/kg, infants up to 2 years need 1-2 mg/kg, and older children require lower doses 1. This age-dependent variation reflects the relatively larger volume of distribution in younger pediatric patients.
Alternative Routes When IV Access Unavailable
Intramuscular dosing: 3-4 mg/kg IM (maximum 150 mg total dose), with onset in 2-3 minutes 1. The American Academy of Pediatrics recommends 4 mg/kg IM for general pediatrics, increasing to 5 mg/kg IM for infants under 6 months 3.
Intraosseous route: 1 mg/kg IO produces adequate intubating conditions within 45 seconds and is an effective alternative when IV access is not immediately available 4.
Critical Safety Considerations
Premedication with Atropine
Administer atropine 0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) before succinylcholine to prevent bradycardia or asystole 3. This is particularly important in children aged 28 days to 8 years, especially those with septic shock, hypovolemia, or when using succinylcholine 5. The French guidelines (2019) provide Grade 2+ evidence supporting this practice in these specific populations 5.
However, there is controversy here: one 2005 study argues that atropine premedication for single-dose succinylcholine in emergency settings lacks evidence and may be unnecessary 6. The weight of guideline evidence, however, supports its use, particularly given the higher incidence of bradycardia in pediatric patients after even a first dose of succinylcholine (unlike adults who typically develop bradycardia only after repeated doses) 1.
Absolute Contraindications
Do not use succinylcholine in patients with:
- History of malignant hyperthermia 3, 7
- Severe burns or crush injury
- Spinal cord injury
- Neuromuscular disease or myopathy
- Hyperkalemia 8
These conditions create life-threatening hyperkalemia risk. If cardiac arrest occurs immediately after succinylcholine administration, suspect hyperkalemia, particularly in boys under 9 years old 3. In these situations, use rocuronium (>0.9 mg/kg) as the alternative neuromuscular blocker 2.
Clinical Pearls
Onset and duration: Adequate relaxation for intubation occurs in 30-45 seconds after IV administration and 3-5 minutes after IM administration. Duration of action is 5-10 minutes 3.
Ventilatory support is mandatory: Personnel skilled in airway management must be present with age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation immediately available 3.
Succinylcholine provides no sedation, analgesia, or amnesia—always combine with appropriate induction agents 3.
For patients with increased intracranial pressure: Consider a defasciculation dose of a non-depolarizing agent (e.g., vecuronium 0.01 mg/kg) before succinylcholine 3.
Comparison to Rocuronium
While rocuronium (0.9-1.2 mg/kg) is an acceptable alternative, succinylcholine remains the preferred first-line agent for pediatric rapid sequence intubation due to its shorter duration of action 2, 9. The 2019 French guidelines provide Grade 2+ evidence supporting succinylcholine as first choice, with rocuronium reserved for contraindications 2. A 2024 multicenter US study found succinylcholine use was only 11% in pediatric RSI, suggesting practice patterns may not align with guideline recommendations 8.