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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

1987Updated 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) 
1987Updated 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.

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