Summary Recommendations for the Diagnosis of Brain Death in Neonates, Infants, and Children

RecommendationEvidence ScoreRecommendation Score
1. Determination of brain death in neonates, infants and children relies on a clinical diagnosis that is based on the absence of neurologic function with a known irreversible cause of coma. Coma and apnea must coexist to diagnose brain death. This diagnosis should be made by physicians who have evaluated the history and completed the neurologic examinations.HighStrong
2. Prerequisites for initiating a brain death evaluation
    a. Hypotension, hypothermia, and metabolic disturbances that could affect the neurological examination must be corrected prior to examination for brain death.HighStrong
    b. Sedatives, analgesics, neuromuscular blockers, and anticonvulsant agents should be discontinued for a reasonable time period based on elimination half-life of the pharmacologic agent to ensure they do not affect the neurologic examination. Knowledge of the total amount of each agent (mg/kg) administered since hospital admission may provide useful information concerning the risk of continued medication effects. Blood or plasma levels to confirm high or supratherapeutic levels of anticonvulsants with sedative effects that are not present should be obtained (if available) and repeated as needed or until the levels are in the low to mid therapeutic range.ModerateStrong
    c. The diagnosis of brain death based on neurologic examination alone should not be made if supratherapeutic or high therapeutic levels of sedative agents are present. When levels are in the low or in the mid-therapeutic range, medication effects sufficient to affect the results of the neurologic examination are unlikely. If uncertainty remains, an ancillary study should be performed.ModerateStrong
    d. Assessment of neurologic function may be unreliable immediately following cardiopulmonary resuscitation or other severe acute brain injuries and evaluation for brain death should be deferred for 24 to 48 hours or longer if there are concerns or inconsistencies in the examination.ModerateStrong
3. Number of examinations, examiners and observation periods
    a. Two examinations including apnea testing with each examination separated by an observation period are required.ModerateStrong
    b. The examinations should be performed by different attending physicians involved in the care of the child. The apnea test may be performed by the same physician, preferably the attending physician who is managing ventilator care of the child.LowStrong
    c. Recommended observation periods:
        (1) 24 hours for neonates (37 weeks gestation to term infants 30 days of age)ModerateStrong
        (2) 12 hours for infants and children (> 30 days to 18 years).
    d. The first examination determines the child has met neurologic examination criteria for brain death. The second examination, performed by a different attending physician, confirms that the child has fulfilled criteria for brain death.ModerateStrong
    e. Assessment of neurologic function may be unreliable immediately following cardiopulmonary resuscitation or other severe acute brain injuries and evaluation for brain death should be deferred for 24 to 48 hours or longer if there are concerns or inconsistencies in the examination.ModerateStrong
4. Apnea testing
    a. Apnea testing must be performed safely and requires documentation of an arterial Paco2 20 mm Hg above the baseline Paco2 and ≥ 60 mm Hg with no respiratory effort during the testing period to support the diagnosis of brain death. Some infants and children with chronic respiratory disease or insufficiency may only be responsive to supranormal Paco2 levels. In this instance, the Paco2 level should increase to ≥ 20 mm Hg above the baseline Paco2 level.ModerateStrong
    b. If the apnea test cannot be performed due to a medical contraindication or cannot be completed because of hemodynamic instability, desaturation to < 85%, or an inability to reach a Paco2 of 60 mm Hg or greater, an ancillary study should be performed.ModerateStrong
5. Ancillary studies
    a. Ancillary studies (EEG and radionuclide CBF) are not required to establish brain death unless the clinical examination or apnea test cannot be completedModerateStrong
    b. Ancillary studies are not a substitute for the neurologic examination.ModerateStrong
    c. For all age groups, ancillary studies can be used to assist the clinician in making the diagnosis of brain death to reduce the observation period or when (i) components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (ii) if there is uncertainty about the results of the neurologic examination; or (iii) if a medication effect may interfere with evaluation of the patient. If the ancillary study supports the diagnosis, the second examination and apnea testing can then be performed. When an ancillary study is used to reduce the observation period, all aspects of the examination and apnea testing should be completed and documented.ModerateStrong
    d. When an ancillary study is used because there are inherent examination limitations (ie, i to iii), then components of the examination done initially should be completed and documented.HighStrong
    e. If the ancillary study is equivocal or if there is concern about the validity of the ancillary study, the patient cannot be pronounced dead. The patient should continue to be observed until brain death can be declared on clinical examination criteria and apnea testing, or a follow-up ancillary study can be performed to assist with the determination of brain death. A waiting period of 24 hours is recommended before further clinical reevaluation or repeat ancillary study is performed. Supportive patient care should continue during this time period.ModerateStrong
6. Declaration of death
    a. Death is declared after confirmation and completion of the second clinical examination and apnea test.HighStrong
    b. When ancillary studies are used, documentation of components from the second clinical examination that can be completed must remain consistent with brain death. All aspects of the clinical examination, including the apnea test, or ancillary studies must be appropriately documented.HighStrong
    c. The clinical examination should be carried out by experienced clinicians who are familiar with infants and children, and have specific training in neurocritical care.HighStrong
  • The “evaluation score” is based on the strength of the evidence available at the time of publication.

  • The “recommendation score” is the strength of the recommendations based on available evidence at the time of publication. Scoring guidelines are listed in Table 2.