October 4, 2022

UK could revise standards for infant brain death after Baby A experience

Never simple, brain death in UK babies is being reviewed after a 3-month-old baby was declared “brain dead” due to “irreversible cessation of brain stem functioning” – yet started to breathe independently.

According to Clare Dyer in the BMJ, Joe Brierley, a paediatrician at Great Ormond Street Hospital, was appointed to study the startling incident.

Mr Brierley observed that in most cases like this, babies who “recovered” had not been examined properly. However, this was not the case with Baby A. The child had been examined thoroughly, several times, and according to best practice.

Perhaps something different is going on, as Mr Brierley explained in his report:

… the brain stem [is] less likely than the more complex parts of the brain to be damaged by lack of oxygen and blood flow to the brain. He wrote, “In the most severe brain injuries caused by lack of oxygen and blood flow to the brain, the outside structures are most severely affected, whilst sometimes the brain stem is not badly affected and continues working usually.   

“The mechanism of action by which children become ‘brain dead’ is not usually due to direct damage to the brain stem but due to severe swelling of the brain above it.” However, he noted that, “in infants such as A, the skull bones are not fused, so some of the swelling can be dealt with by the bones spreading apart and the skull expanding.” 

In an explanation that he described as just a hypothesis he added, “The extent to which parts of the brain stem have become irreversibly damaged and which parts temporarily impaired due to swelling, which eventually allows function to return, only becomes apparent over time. As with any child who survives the initial phase of a severe brain injury, the full extent of the damage can only be assessed after the initial swelling and inflammation have passed.”

As for Baby A, although he had begun to breathe independently, his condition continued to deteriorate. The Judge recommended that ventilation be withdrawn.

The Academy of Medical Royal Colleges is studying the case and is working on new guidelines for confirmation and diagnosis of the death of newborns.