Variation in Neurologic Criteria Protocols for Pediatric Brain Death in the United States

Two days old newborn baby.
To evaluate the variability in pediatric death by neurologic criteria (DNC) protocols, study investigators assessed US pediatric institutions and compared them to the 2011 DNC guidelines.

Protocols for death by neurologic criteria (DNC) differ among pediatric institutions 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 findings published in Neurology.

Study researchers invited institutions belonging to the Children’s Hospital Association (n=242) to anonymously submit protocols in 2018. Each protocol was independently reviewed by 2 physician-investigators and compared with current national guidelines.

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

Of the protocols published after 2011, 77% were in line with guidelines that only attending physicians could perform the DNC evaluation, 85% were in agreement that only patients with a gestational age of at least 37-weeks’ should be evaluated, 64% specified that the exam should occur 24-hours after brain injury, and 75% defined time of death as the time the final neurologic examination or apnea test was completed.

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

Components of neurologic examination included absence of pupillary, corneal, oculovestibular, and cough reflexes (≥90% of protocols). Less common components were oculocephalic (65%), rooting and sucking reflexes (52%).

Most protocols were consistent with the requirement for apnea testing (98%) but few were consistent with the requirement for ancillary testing (15%).

For the protocols published before 2011, at least 75% were consistent with age criteria and 100% were consistent with the observation periods between examinations from the 1987 guidelines. All protocols required neurologic testing and apnea testing and 50% required ancillary testing.

This study was limited as it only addressed protocol content rather than physician DNC practices. Additionally, it did not assess why different institutions promoted varying protocols which violated current national guidelines on DNC evaluations.

The study authors concluded that there was considerable variability across institutions for DNC protocols among pediatric hospitals. It is likely that new strategies are needed to assure that institutions adopt current guidelines such that consistent and accurate DNC findings can be maintained across sites.


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