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UK doctors given guidance on diagnosing brain death in young babies

Move puts UK on par with other countries and should help boost donor organ supply

Caroline White

Monday, 27 April 2015

UK doctors will be able to diagnose death in babies under 2 months old without having to wait for the child’s heart to stop, following the publication of updated guidance* extending the neurological criteria for brain death to this age group.

The move puts the UK on a par with several other countries and is set to increase the chances of organs being saved for donation because the blood supply has been left intact.

The previous criteria stated that it was ‘rarely possible’ to confidently diagnose death by neurological criteria in a comatose and unresponsive child aged between 37 weeks and 2 months of age.

This left doctors in the UK unable to diagnose death in such patients until their heart had stopped beating, whereas this diagnosis is made in other countries where criteria exist.

The updated guidance published by the Royal College of Paediatrics and Child Health (RCPH) reviewed the scientific literature up to 2014 to assess whether there is sufficient evidence to permit a confident diagnosis to be made in this age group.

The guidance recommends that the same neurological clinical examination used for older children and adults is suitable for children younger than 2 months and that there should be an observation period of at least 24 hours where the child is in a clinical state of complete unresponsiveness.

In practice, this means the patient is comatose and requires ventilation because s/he cannot breathe on his/her own, and that structural brain damage has been established or the cause of irreversible coma is known.

The guidance recommends that a clinical diagnosis of ‘death by neurological criteria’ should be made when: basic brain reflexes, such as pupil reactions are absent; there’s no movement in response to painful stimuli; and no breathing response when carbon dioxide builds up in the blood.

These criteria are the same for older children and adults, but the guidance recommends that a stronger carbon dioxide stimulus is used before respiratory unresponsiveness is diagnosed in the younger age group.

“This guidance…does not cover broader issues around withdrawal or withholding medical treatment in children, or issues surrounding organ donation and transplantation,” explains Professor Neil McIntosh, Chair of the working group that developed the guidance.

The neurological criteria for diagnosing death had been extended to younger infants because there were now sufficient data on the clinical outcome in these very young infants, he said.

In all these cases, fulfilment of the neurological criteria for the diagnosis of death was followed by the heart beat stopping without recovery of consciousness or of the ability to breathe, he added.

“The death of the individual in that state can therefore be said to have occurred and continuation of artificial ventilation can no longer be justified as being in the best interests of the child,” he said.

“If this guidance is widely adopted, UK doctors will be able to diagnose death in babies under 2 months without waiting for the heart to stop and this will increase the chance that organs could be saved for donation,” he continued.

But he emphasised that this would usually be considered at the request of the parents and would always require close consultation with them.

In the past, it has been difficult for doctors in the UK to help parents who request that organ donation be considered after the death of their baby before the age of 2 months.

Waiting until after the child’s heart has stopped usually makes donation of any organs, other than heart valves and corneas, impossible because organs deteriorate when their blood supply is cut off.


* The diagnosis of death by neurological criteria in infants less than two months old. RCPCH, April 2015.

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