Criteria for Diagnosing Death in Infants Less Than 2 Months of Age

July 2017

Emergency Care

Country of origin: UK

Royal College of Paediatrics and Child Health sets out recommendations to diagnose death by neurological criteria in young infants.

Guidance on the diagnosis of death by neurological criteria (DNC) in infants less than two months oldin the UK has been published today by the Royal College of Paediatrics and Child Health (RCPCH).

Previous UK guidelines relating to the diagnosis of death by neurological criteria have excluded this age group. 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 gestation and 2 months old.[1] Therefore doctors in the UK do not diagnose death in young unresponsive infants until their heart ceases to beat, whereas this diagnosis is made in other countries where criteria exist.

The updated RCPCH guidance has reviewed the scientific literature up to 2014 to assess whether evidence now exists to allow this diagnosis to be made with security in this age group. The guidance recommends that the same neurological clinical examination for children younger than 2 months is appropriate as for older children and adults and that there should be an observation period of at least 24 hours where the clinical state of complete unresponsiveness should be present. This means:

The patient is comatose and has to be ventilated because they cannot breathe
Structural brain damage has been established, or the cause of irreversible coma is known
The clinical diagnosis of 'death by neurological criteria' should be made using the following criteria:

Absence of basic brain reflexes such as the pupil reactions
Absence of any movement in response to painful stimuli
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.

Professor Neil McIntosh, Chair of the working group who developed the guidance, explains:

“This guidance is about diagnosing death in unresponsive young infants aged 37 weeks – 2 months using the absence of neurological criteria which are necessary for life. It does not cover broader issues around withdrawal or withholding medical treatment in children, or issues surrounding organ donation and transplantation.

“The reason that the neurological criteria for diagnosing death have been extended to include younger infants is because there are now sufficient reported instances of the clinical outcome in these very young infants. In all these reports, fulfilment of the neurological criteria for the diagnosis of death has been followed by the heart beat stopping without recovery of consciousness or of the ability to breathe. 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.

“It is the case that 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. This would usually be considered at the request of the parents and always requires close consultation with them.”

Prior to this guidance, 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. Instead, doctors had to wait until after the child's heart had stopped. This usually makes donation of any organs, other than heart valves and corneas impossible because organs deteriorate when their blood supply is cut off.

The consequences of this change in practice will be monitored carefully both for its effect on parents with infants in the group concerned and also for the staff managing such infants.

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