American Academy of Pediatrics

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APPENDIX 7

Comparison of 1987 Pediatric Brain Death Guidelines and the Updated Guideline for Determination of Brain Death in Infants and Children

	1987	Updated Guidelines
Waiting period before initial brain death examination	Not specified	24 hours following cardiopulmonary resuscitation or severe acute brain injury is suggested if there are concerns about the neurologic examination or if dictated by clinical judgment
Clinical examination	Required	Required
Core body temperature	Not specified	> 35°C (95°F)
Number of examinations	Two exams	Two exams, irrespective of ancillary study results
	2nd examination not necessary in 2 months–1 year age group if initial examination, EEG and concomitant CBF consistent with brain death	(if ancillary testing is being done in lieu of initial examination elements that cannot be safely performed, the components of the second examination that can be done must be completed)
Number of examiners	Not specified	Two (Different attending physicians must perform the first and second exam)
Observation interval between neurologic examinations	Age dependent	Age Dependent
	days–2 months: 48 hours 2 months–1 year: 24 hours >1 year: 12 hours (24 hrs if HIE)	Term newborn (37 weeks gestation) to 30 days of age: 24 hours 31 days–18 years: 12 hours
Reduction of observation period between exams	Permitted only for > 1 year age group if EEG or CBF consistent with brain death	Permitted for both age groups if EEG or CBF consistent with brain death
Apnea testing	Required, number of tests ambiguous	Two apnea tests required unless clinically contraindicated
Final Pco₂ threshold for apnea testing	Not specified	≥60 mm Hg and ≥20 mm Hg above the baseline Paco₂
Ancillary study recommended	Age dependent 7 days–2 months: 2 EEGs separated by 48 hrs 2 months–1 year: 2 EEG's separated by 24 hours. CBF can replace the need for 2nd EEG >1 year: No testing required	Not required except in cases where the clinical examination and apnea test cannot be completed Term newborn (37 weeks gestation) to 30 days of age: EEG or CBF are less sensitive in this age group. CBF may be preferred. >30 days–18 years: EEG and CBF have equal sensitivity
Time of death	Not specified	Time of the second examination and apnea test (or completion of ancillary study and the components of the second examination that can be safely completed)

	1987	Updated Guidelines
Waiting period before initial brain death examination	Not specified	24 hours following cardiopulmonary resuscitation or severe acute brain injury is suggested if there are concerns about the neurologic examination or if dictated by clinical judgment
Clinical examination	Required	Required
Core body temperature	Not specified	> 35°C (95°F)
Number of examinations	Two exams	Two exams, irrespective of ancillary study results
	2nd examination not necessary in 2 months–1 year age group if initial examination, EEG and concomitant CBF consistent with brain death	(if ancillary testing is being done in lieu of initial examination elements that cannot be safely performed, the components of the second examination that can be done must be completed)
Number of examiners	Not specified	Two (Different attending physicians must perform the first and second exam)
Observation interval between neurologic examinations	Age dependent	Age Dependent
	days–2 months: 48 hours 2 months–1 year: 24 hours >1 year: 12 hours (24 hrs if HIE)	Term newborn (37 weeks gestation) to 30 days of age: 24 hours 31 days–18 years: 12 hours
Reduction of observation period between exams	Permitted only for > 1 year age group if EEG or CBF consistent with brain death	Permitted for both age groups if EEG or CBF consistent with brain death
Apnea testing	Required, number of tests ambiguous	Two apnea tests required unless clinically contraindicated
Final Pco₂ threshold for apnea testing	Not specified	≥60 mm Hg and ≥20 mm Hg above the baseline Paco₂
Ancillary study recommended	Age dependent 7 days–2 months: 2 EEGs separated by 48 hrs 2 months–1 year: 2 EEG's separated by 24 hours. CBF can replace the need for 2nd EEG >1 year: No testing required	Not required except in cases where the clinical examination and apnea test cannot be completed Term newborn (37 weeks gestation) to 30 days of age: EEG or CBF are less sensitive in this age group. CBF may be preferred. >30 days–18 years: EEG and CBF have equal sensitivity
Time of death	Not specified	Time of the second examination and apnea test (or completion of ancillary study and the components of the second examination that can be safely completed)

EEG Electroencephalogram.

CBF Cerebral blood flow.

HIE Hypoxic ischemic encephalopathy.