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

This NICE accredited evidence-based clinical guideline 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. 

Key recommendations

The guideline 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.

Preconditions

  • The preconditions detailed in the 2008 AoMRC ‘A Code of Practice for the Diagnosis and Confirmation of Death 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.

You can download the full guideline below.

Background and methodology

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

The guideline provides a review of the latest scientific literature and recommendations on the diagnosis of DNC in infants. Previous guidance has 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.

This guideline is NICE accredited and was developed in accordance with the RCPCH Guideline development process manual (RCPCH Setting standards for the development of clinical guidelines in paediatrics). For full details please see the Methodology document, available to download below.

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