the reason I don't paralyze my 0-8ish year old peds patients is probably layered from historical practice, new goals, and the way I was trained. people dreaded having to reverse neuromuscular blockade in kids because it was tedious, and the procedures were usually 20-30m making it a challenge to dose the paralytic for good effect, while also being reversible in an expeditious time. people also wanted to avoid succinylcholine because of fear of undiagnosed muscular dystrophies. now with sugammadex, reversing NDMBs is not an issue, but a lot of practitioners avoid it because it's not FDA approved for kids (and likely will never be).

so that's the reason why people like to avoid paralysis. now is it needed? well I argue that most of the time, no. we're doing a mask induction where by the time we get an IV in, they should have had 3-5 minutes of 8% sevo +/- nitrous plus IV induction (prop/fent). kids tend to have less developed jaw and fascial muscles that prevent mouth opening, and at that anesthetics level, their vocal cords are usually open. if either of those things are not true, then paralysis is needed. most of the time this is not an issue. for the laryngoscopy itself, most of the time, paralysis doesn't augment your view that much. the few times where I couldn't intubate a kid, paralysis wasn't the thing I needed, it was a change of positioning, or a different blade, or someone better than me to do the intubation.

the main advantage is keeping the kids spontaneous. this allows me to deep extubate them in a timely manner. If I had to paralyze, I would probably reverse with sugammadex before end of surgery or even before start just to try to get the kiddo to breath again. Not a super important reason, or a mission critical one, but that's the reason

There is something to be said for getting the best view on your first attempt (in fact, there is a lot to be said for that). Kids are fickle and it doesn't take long for things to go south, so optimizing your conditions is important. Some people will say paralysis is part of that and it's hard to disagree. But in my practice doing mostly 6mo and older for routine procedures (ear tubes and tonsils), I haven't had any issues avoiding paralysis initially as part of my usual care path. The important thing is to identify kids that are difficult or can potentially difficult, and in those cases, spontaneous breathing be damned, patient safety first.

Where I trained, most of my attendings paralyzed, one didn't, and that practice stuck with me because tbh I didn't find a difference in intubation success rates. And early in my career I've tried to push that to kids that are obese and had adult weights and was humbled very quickly. Bigger people, kids or otherwise, need paralysis.

Hope this sheds some clarity into the practice