Variation in neurological criteria protocols for pediatric brain death in the United States

Protocols for death by neurological criteria (DNC) differ between pediatric facilities in the United States. A cross-sectional study of these protocols found that aligning institutional practices with national guidelines would improve consistency and accuracy, according to results published in Neurology.

In 2018, the study researchers invited institutions of the Children’s Hospital Association (n = 242) to submit protocols anonymously. Each protocol was independently checked by 2 investigators and compared with the current national guidelines.

A total of 118 hospitals provided sufficient information to participate in this analysis. Most (86%) related to the 2011 guidelines and 9% were formulated prior to the publication of the current guidelines.

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Of the protocols published after 2011, 77% complied with the guidelines that only treating physicians can carry out the DNC evaluation, 85% agreed that only patients with a gestational age of at least 37 weeks should be evaluated, 64% stated that the examination 24 Hours after the brain injury, and 75% defined time of death as the time at which the last neurological examination or apnea test was completed.

Common exam requirements included identification of a mechanism of catastrophic brain injury (97%), a minimum core body temperature (97%), and a blood pressure target (66%).

The components of the neurological examination included the absence of pupillary, corneal, eye and cough reflexes (≥90% of the protocols). Less common components were oculocephalic (65%), digging and sucking reflexes (52%).

Most of the protocols met the requirement for apnea testing (98%), but only a few met the requirement for additional testing (15%).

For protocols published prior to 2011, at least 75% met the age criteria and 100% met the observation periods between exams from the 1987 guidelines. All protocols required neurological and apnea tests and 50% required additional testing.

This study was limited as it only covered protocol contents and not doctors’ DNC practices. In addition, it did not assess why different institutions promoted different protocols that violate current national guidelines for DNC assessments.

The study authors concluded that DNC ​​protocols in children’s hospitals vary significantly between facilities. It is likely that new strategies will be needed to ensure that institutions adopt current guidelines so that consistent and accurate DNC results can be maintained across locations.


Francoeur C., Weiss MJ, Macdonald JM, et al. Variability in Pediatric Protocols for Determining Brain Death in the United States. Neurology. 2021; 10.1212 / WNL.000000000012225. doi: 10.1212 / WNL.0000000000012225

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