Diagnosis of death by neurological criteria (DNC) in infants less than two months old - clinical guideline

Our NICE accredited evidence-based clinical guideline (published 2015) provides recommendations on the diagnosis of death by neurological criteria (DNC) in infants from 37 weeks corrected gestation (post menstrual) to two months of age (post term). It is for all UK paediatric and neonatal health care practitioners and other groups involved in the regulation or practice of the health care of critically ill neonates and young infants. The 2015 guideline and methodology can be downloaded at the bottom of this page.

Planned update to the 2015 guideline

Status: Under development (changes to the remit of the work)

Estimated publication: Spring 2024

Notes: The work of the RCPCH working group revising the diagnosis of death by neurological criteria for infants, children and adolescents will now be presented in an Appendix on the updated 2024 AoMRC Code of Practice, rather than as a separate guideline. The Appendix will contain all the updated paediatric criteria and will be complemented by a RCPCH methodological report describing the evidence reviewed and the rationale for any changes to the existing paediatric criteria.

The main reason for this change is to fully integrate the paediatric criteria into the AoMRC Code rather than have two separate documents, so the paediatric criteria is accessible in one place only thus avoiding any unnecessary duplication and potential confusion to the reader.

Alert (2013)

On 16 February 2023, and following expert review of a case, we published guidance that highlights contexts in which the apnoea test and ancillary investigations are not valid.

Recommendations of the 2015 guideline

Our clinical guideline, Diagnosis of death by neurological criteria (DNC) in infants less than two months old, recommends that the diagnosis of DNC in young infants is a clinical diagnosis with certain preconditions, and that ancillary tests do not help in this diagnosis. Download the full guideline below


  • The preconditions detailed in the 2008 AoMRC A code of practice for the diagnosis and confirmation of death (PDF) should be fulfilled before diagnosing DNC.
  • An additional precautionary precondition to be taken in young infants: In post-asphyxiated infants, or those receiving intensive care after resuscitation, whether or not they have undergone therapeutic hypothermia, there should be a period of at least 24 hours of observation during which the preconditions necessary for assessment for DNC should be present before clinical testing for DNC. If there are concerns about residual drug-induced sedation, then this period of observation may need to be extended.

Clinical diagnosis of DNC

  • A stronger hypercarbic stimulus is used to establish respiratory unresponsiveness. Specifically, there should be a clear rise in PaCO2 levels of >2.7 kPa (>20 mm Hg) above a baseline of at least 5.3 kPa (40 mm Hg) to >8.0 kPa (60 mm Hg) with no respiratory response at that level.
  • The interval between tests need not be prolonged as stated in 2008 AoMRC's Code of Practice.

Ancillary tests

  • Ancillary tests are not required to make a diagnosis of DNC in infants from 37 weeks corrected gestation to two months post term.
  • In cases where a clinical diagnosis of DNC is not possible (for example because of extensive faciomaxillary injuries, or high cervical cord injury), ancillary tests are not sufficiently robust to help confidently diagnose DNC in infants.

Background and methodology of the 2015 guideline

In 2015 we, by the request of the Academy of Medical Royal Colleges (AoMRC), updated the 1991 British Paediatric Association (now RCPCH) report, Diagnosis of Brain Stem Death in Infants and Children: A Working Party report by the British Paediatric Association.

The 2015 guideline provides a review of the latest scientific literature and recommendations on the diagnosis of DNC in infants. Previous guidance had excluded infants in this age group due to a lack of evidence surrounding the presence of the required criteria in this group. However, after a review of the current evidence, the working group considered there was now sufficient evidence to extend the criteria for diagnosis to this group. Download the methodology below

The 2015 guideline is NICE accredited and was developed in accordance with the RCPCH Setting standards for the development of clinical guidelines in paediatrics.

NICE accredited

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