Considerations Regarding Children

It is generally assumed that the brain of an infant or child is more resistant to injury leading to death, although

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The need for facilitation of end-of-life decision and organ procurement in infants and children has increased. In 1987, the Task Force for the Determination of Brain Death in Children endorsed the Determination of Death Act and offered the Guidelines for the Determination of Brain Death in Children^[88] ( Table 79-2 ). The distinctions from the criteria for adults are three separate, longer observation periods, depending on the child's age, and the necessity for two corroborating EEGs or one EEG with corroborating radionuclide angiography. It is generally agreed that, except in very immature, preterm newborns, the same criteria of brain death can apply to term newborns,

TABLE 79-2 -- Brain death guidelines for children

A. History: Determine the cause of coma to eliminate remediable or reversible conditions

B. Physical examination criteria

1. Coma and apnea

2. Absence of brainstem function

a. Midposition or fully dilated pupils

b. Absence of spontaneous oculocephalic ("doll's-eye") and caloric-induced eye movements

c. Absence of movement of bulbar musculature and corneal, gag, cough, sucking, and rooting reflexes

d. Absence of respiratory effort with standardized testing for apnea

3. Patient must not be hypothermic or hypotensive.

4. Flaccid tone and absence of spontaneous or induced movements excluding activity mediated at spinal cord level

5. Examination should remain consistent for brain death throughout the predetermined period of observation.

C. Observation period according to age

1. Seven days to 2 months: two examinations and electroencephalograms (EEGs) 48 hours apart

2. Two months to 1 year: two examinations and EEGs 24 hours apart and/or one examination and an initial EEG showing electrocerebral silence combined with a radionuclide angiogram showing no cerebral blood flow

3. Over 1 year: two examinations 12 to 24 hours apart. EEG and isotope angiography are optional.

Data from Task Force for the Determination of Brain Death in Children: Guidelines for the determination of brain death in children. Neurology 37:1077, 1987, and from Ashwal S: Brain death in early infancy. J Heart Lung Transplant 12(Pt 2): S176, 1993.

infants older than 7 days, children, and adults^[89] if an observation period is prolonged for smaller children, although there have been several reports arguing against this notion. Ashwal^{[90] [91]} stressed that brain death could be diagnosed in the term newborn, even when younger than 7 days old, if the observation period to confirm the diagnosis was prolonged to 48 hours, and if the EEG was isoelectric or a cerebral blood flow study showed no flow, the observation period could be shortened to 24 hours. However, the Special Task Force excluded infants younger than 7 days from its guideline.^[88] There are several concerns about the diagnosis of brain death in newborns:

1. If the injury occurred in utero, the duration of the insult and severity may be difficult to establish.
2. Normal systemic arterial pressure of newborn is not determined.
3. The EEG and transcranial Doppler (TCD) sonography may not be 100% reliable.
4. The clinical examinations cannot be reliable because of immaturity.^[92]

It was reported that a premature infant sustained an intraventricular hemorrhage on day 2 of life and showed the absence of brainstem reflexes, apnea, and flaccidity but was never clinically brain dead,^[93] and that 15 of 20 neonates who had isoelectric EEGs preserved partial clinical brain function.^[94] Mejia and colleagues^[95] investigated variability in the practices of determining brain death and organ procurement in pediatric intensive care units. Contrary to their expectations, there was much variability. Although apnea testing has been considered the most important criterion for brain death,^[96] apnea testing was not carried out for 23 (25%) of 93 brain-dead patients, and the methods of apnea testing were not consistent with the Guideline for Determination of Brain Death in Children for 20 patients (22%). Four of 30 patients younger than 1 year did not have a confirmatory test. They concluded that the variability in brain death determination practices might reflect differences in documentation, lack of knowledge of the guidelines, or disagreement with the guidelines.