Hours In Infants Research Articles

Skin-to-skin contact and its effect on mothers’ postpartum psychological distress and their full-term neonate in Egypt

A randomized controlled study was conducted on 400 mothers, who were divided into two groups: 200 mothers who applied skin-to-skin infant care (SSC) for at least 1 h daily for 12 weeks and 200 mothers who performed the usual mother-infant care. The mothers were recruited from the Obstetric Department of Al-Zahraa University Hospital in Cairo, Egypt. The enrolled mothers' infants were assessed for body weight. Sleep hours and frequency of breast milk feeding were evaluated by the mother during the day. All of the mothers who took part in the study were assessed for postoperative pain, wound healing, postpartum depression, anxiety, sleep quality and newborn maternal bonding. There was a significant increase in frequencies of breastfeeding and the body weight at 12 weeks' postnatal age and also an increase in sleep hours in the infants who had SSC. The mothers who performed SSC had good sleep quality in comparison with those who performed the usual infant care; in addition, they had less postoperative pain intensity and proper wound healing apart from better maternal-infant bond, decreased anxiety and decreased depression frequency. SSC was associated with better infant breastfeeding, increased sleep hours in infants and less postpartum psychological burden in mothers.

Clinical Pharmacology of Antituberculosis Drugs in Infants and Children

The antituberculosis drugs used in paediatric patients are: rifampicin, isoniazid, and pyrazinamide. The treatment of infections with rifampicin, isoniazid, and pyrazinamide has been reviewed. The efficacy and safety of rifampicin have been reported in children. The pharmacokinetics of rifampicin have been studied in infants and rifampicin median elimination half-life is 7.1 hours in infants with a postnatal age < 14 days and 3.5 hours in infants with a postnatal age ≥ 14 days. The treatment of children with rifampicin has been described. Rifampicin penetrates into the cerebrospinal fluid and treats the tuberculous meningitis and tuberculous meningo-encephalitis. Rifampicin is poorly transferred across the human placenta and poorly migrates into the breast-milk. The pharmacokinetics of isoniazid have been studied in children and the median elimination half-life of isoniazid is 3.22 hours. The treatment of children with isoniazid has been described and isoniazid poorly migrates into the breast-milk. The pharmacokinetics of pyrazinamide have been studied in children and the median elimination half-life of pyrazinamide is 3.47 hours and pyrazinamide poorly migrates into the breast-milk. The aim of this study is to review the treatment with rifampicin, isoniazid, and pyrazinamide. Rifampicin efficacy and safety, pharmacokinetics, treatment, penetration into the cerebrospinal fluid, treatments of meningitis, transfer across the human placenta, and migration into the breast milk have been reviewed. The efficacy and safety of isoniazid, the pharmacokinetics of isoniazid, and the migration of isoniazid into the breast-milk have been reviewed. The pharmacokinetics of pyrazinamide and the migration of pyrazinamide into the breast-milk have been reviewed.

Clinical pharmacology of salbutamol in infants and children

Inhaled β2 agonists are the bronchodilator treatment of choice in asthma because they are the most effective bronchodilators. β2 agonists may cause bronchodilation by inhibiting the release of bronchoconstrictor neurotransmitters from airway nerves. Inhaled short-acting β2 agonists are the most widely used and effective bronchodilators for the treatment of asthma due to their functional antagonisms of bronchoconstriction. Salbutamol is a short-acting β-adrenergic agonist widely used by asthmatics for its bronchodilator activity. Salbutamol is a racemic mixture of active R-salbutamoland inactive S-salbutamol. In infants, salbutamol is administered by nebulizer solution at a dose of 2.5 mg trice-daily to treat chronic lung disease. In children, salbutamol may be administered intravenously, by inhalational, nebulisation, or orally and salbutamol dose varies with the child's age. The efficacy and safety of salbutamol have been extensively studied in infants and children and salbutamol is sulphatedin-vivo in patients and in-vitro in human lung, liver, and duodenum and the sulfation-rate remarkably varies among patients and among lung, liver, and duodenum specimens. The pharmacokinetics of salbutamol have been studied in infants and children and the elimination half-life of salbutamol is 2.2 hours in infants and about 6 years in children. The treatment of infants and children with salbutamol has been extensively studied and salbutamol poorly crosses the human placenta. The aim of this study is to review the salbutamol dosing, efficacy and safety, pharmacokinetics, and treatment in infants and children and salbutamol metabolism and transfer across the human placenta.

Clinical Pharmacology of Levetiracetam in Infants and Children

Levetiracetam inhibits focal and secondary generalized tonic-clonic seizures. The mechanism of levetiracetam action is not fully understood, however the correlation between binding affinity of levetiracetam and its analogues and their potency toward audiogenic seizures suggest that the synaptic vesicle glycoprotein 2A mediates the anticonvulsant effects of levetiracetam. The neural function of the synaptic vesicle 2A protein is not fully understood, but binding of levetiracetam to synaptic vesicle glycoprotein 2A might affect neuronal excitability by modifying the release of glutamate GABA through an action on vesicular function. Synaptic vesicle glycoprotein 2A may plain a role in vesicle recycling following exocytosis of neurotransmitter. In addition, levetiracetam inhibits N-type Ca2+ channels and Ca2+ release from intracellular stores. Levetiracetam may be administered intravenously or orally to infants and children and in children the levetiracetam dose varies according to the child age and body-weight. Levetiracetam is almost completed absorbed after oral administration and levetiracetam is found efficacy and safe in infants and children but it may induce adverse-effects. The levetiracetam elimination half-life is about 6 hours in infants and children, and in children the renal clearance is similar to the non-renal clearance. The prophylaxis, treatment, and trials with levetiracetam have been extensively studied in infants and children. Levetiracetam freely crosses the human placenta and freely migrates into the breast-milk. The aim of this study is to review the levetiracetam dosing, efficacy, safety, adverse-effects, pharmacokinetics, prophylaxis, treatment, and trials and transfer of levetiracetam across the human placenta and levetiracetam migration into the breast-milk.

Association of Antenatal Terbutaline and Respiratory Support Requirements in Preterm Neonates.

Before the advent of antenatal steroids, early non-invasive respiratory support (NIV), and intratracheal surfactant, antenatal terbutaline was also used to improve lung compliance and reduce the incidence of respiratory distress syndrome (RDS). The objective of this paper was to study the association between antenatal terbutaline and endotracheal intubation (ET) within the first 24 hours of life, RDS, bronchopulmonary dysplasia (BPD), and intraventricular hemorrhage (IVH) in infants with the gestational age (GA) of <32 weeks, and to study the association between antenatal terbutaline, and ET or NIV within the first 24 hours of life, and RDS in infants with the GA of 32 to 36 weeks. This was a retrospective medical record review of preterm infants delivered at a single tertiary care center from October 2016 to December 2020. Multivariable logistic regression was used to explore the association between antenatal terbutaline and neonatal respiratory support. 1,794 infants were included, 234 (13.0%) had the GA of <32 weeks and 1,560 (86.9%) had the GA of 32 to 36 weeks. Antenatal terbutaline, corticosteroid, or both agents were administered in 561 (31.3%), 1,461 (81.4%), and 555 (30.9%), respectively. Antenatal terbutaline was significantly associated with a reduction in ET (adjusted odds ratio [aOR] = 0.40, 95% confident interval [CI] 0.19-0.82, p = 0.012) in infants with the GA of <32 weeks, but not in infants with the GA of 32-36 weeks. Antenatal terbutaline was not associated with RDS or BPD but was significantly associated with a reduction in grade III-IV IVH (aOR 0.11, CI 0.01-0.98; p = 0.048), in infants with the GA of <32 weeks. In a state-of-the-art neonatal care setting, antenatal terbutaline was associated with a reduction in ET during the first 24 hours in infants with the GA of <32 weeks. The use of antenatal terbutaline to improve acute neonatal respiratory outcomes merits reconsideration. · The neonatal respiratory benefits of antenatal terbutaline in the era of antenatal corticosteroids were uncertain.. · Terbutaline is associated with a reduction in endotracheal intubation in a modern care setting.. · The role of terbutaline, and potentially other betamimetics, to improve neonatal respiratory outcomes merits reconsideration..

Clinical pharmacology of teicoplanin in infants and children

Teicoplanin is a glycopeptide and is a mixture of related glycopeptides. Teicoplanin inhibits the synthesis of the cell wall in sensitive bacteria by binding with high affinity to the D-alanyl-D-alanine terminus of cell wall precursor units. Because of its large molecular size, teicoplanin is unable to penetrate the outer membrane of gram-negative bacteria. The intravenous dosage of teicoplanin consists in a loading dose of 16 mg/kg followed by a maintenance dose of 8 mg/kg once-daily to infants aged &lt; one month and in older infants the dosage of teicoplanin consists in a loading dose of 12 mg/kg twice-daily followed by a maintenance dose of 10 mg/kg once daily. In children, the oral dose is 100 to 200 mg twice-daily and the intravenous dosage consists in 12 mg/kg twice-daily followed by 12 mg/kg once-daily. Teicoplanin has been found efficacy and safe in infants and children. The elimination half-life of teicoplanin is 73.9 hours in infants and children and teicoplanin is cleared from the body by renal and extra-renal routes. The total body clearance of teicoplanin is 0.09 L/h in children aged &lt; 12 months and 0.29 L/h in older children. The treatment and the prophylaxis with teicoplanin have been described in infants and children. Teicoplanin administered intravenously and/or intraventricularly treats the cerebral infections caused by staphylococci and enterococci. The aim of this study is to review the published data on teicoplanin dosing, efficacy and safety, pharmacokinetics, drug-interactions, treatment, prophylaxis, and penetrates into the cerebrospinal fluid in infants and children.

Ensuring administration of first dose of antibiotics within the golden hour of management in neonates with sepsis

Administration of first dose of antibiotics within the golden hour in infants with sepsis is critical. Delays can increase mortality. During our observations as part of antibiotic stewardship programme in...

Oseltamivir treatment of influenza A and B infections in infants.

BackgroundOseltamivir treatment is currently the only way of managing influenza in young infants for whom influenza vaccines are not licensed, but little data exist on the effectiveness of the treatment in this age group.MethodsIn a prospective study, we enrolled 431 newborn infants and followed them up for 10 months during their first respiratory season (September 2017‐June 2018). During each respiratory illness, we examined the infants and obtained nasopharyngeal specimens for determination of the viral etiology. Infants with influenza were re‐examined at short intervals, and additional nasopharyngeal specimens were obtained at each visit for measuring the viral load. All infants with symptoms <48 hours received oseltamivir treatment. The parents filled out daily symptom diaries.ResultsAmong 23 infants with influenza A, the mean total duration of illness in oseltamivir recipients was 82.1 hours, compared with 253.5 hours in infants without treatment (P = .0003). For infants with influenza B, the corresponding durations were 110.0 and 173.9 hours, respectively (P = .03). In infants with influenza A, total symptom scores were significantly lower in oseltamivir‐treated infants at all time points between days 3 and 11 after the onset of therapy. In most children with either influenza A or B, viral antigen concentrations declined rapidly within 1‐2 days after the initiation of oseltamivir treatment.ConclusionsOseltamivir treatment of infants with influenza rapidly decreased the viral load in nasopharyngeal secretions and shortened the duration and severity of symptoms. The clinical effectiveness of oseltamivir appeared to be greater against influenza A than against influenza B infections.

Improving Timeliness of Hepatitis B Vaccine Birth Dose Administration.

When given within 24 hours of birth, the hepatitis B vaccine is up to 90% effective in preventing perinatal infection. The American Academy of Pediatrics now recommends administration within 24 hours for infants with a birth weight >2 kg, but a national benchmark for compliance with this time frame has not been established. We aimed to increase the monthly average of eligible newborns receiving the vaccine on time from 40% to 80% over a 9-month period. A series of plan-do-study-act cycles were conducted to improve timeliness of hepatitis B vaccine birth dose administration among newborns in the level 1 nursery at our academic community hospital. Interventions included staff education, nurse-driven consent and vaccine ordering, and earlier initial newborn assessments performed by nursing staff. Our primary outcome was the monthly percentage of newborns receiving the vaccine within 24 hours of birth, and our secondary outcome was the frequency of nonvaccination events. Statistical process control was used to analyze the effectiveness of interventions. Our mean monthly rate of vaccine administration within the 24-hour time frame increased from 40% to 92%. Predischarge vaccination rate improved from a mean of 13 to 61 cases between infants discharged without vaccination. Nurse-led interventions, including the ability to obtain consent and incorporation of the vaccine into our nurse-activated admission order set, were significant contributors to improvement in the timeliness of hepatitis B vaccine administration. We propose a mean of 90% compliance with the American Academy of Pediatrics recommendations as a benchmark for other institutions.

Avoiding the Overdiagnosis of Congenital Hypothyroidism in Premature Newborns.

* Abbreviations: CH — : congenital hypothyroidism NBS — : newborn screening TSH — : thyrotropin VLBW — : very low birth weight Nowadays, most programs use thyroid-stimulating hormone (TSH) as the primary analyte in newborn screening (NBS) for congenital hypothyroidism (CH); however, unlike for 17-hydroxy-progesterone levels used in NBS to diagnose 21-hydroxylase deficiency,1 gestational age-specific cutoffs have not been defined. In this issue of Pediatrics , Kaluarachchi et al2 publish TSH reference ranges at NBS for preterm infants until they reach term equivalent gestational age. This study is based on multiple dried blood-spot TSH samples, as suggested by international guidelines,3 to detect the delayed TSH rise that has been described in preterm infants. The main finding of this study is that the 99th centile of estimated serum TSH (assuming a 55% hematocrit) is ∼30.6 mU/L on the first sample collected at 24 to 96 hours in infants born at 28 to 31 weeks and 41.6 mU/L in those born at 22 to 27 weeks. To avoid any confusion, the latter figure corresponds to 18.9 mU/L when translated back to milliunits per liter of whole blood (the way … Address correspondence to Guy Van Vliet, MD, Center Hospitalier Universitaire Sainte-Justine, Room 3740, 3175 Chemin de la Cote-Ste-Catherine, Montreal, QC H3T 1C5, Canada. E-mail: guy.van.vliet{at}umontreal.ca

Effect of Delayed Cord Clamping on Systemic Blood Flow: A Randomized Controlled Trial

To determine whether delayed cord clamping improves systemic blood flow compared with immediate cord clamping in very preterm infants in the first 24 hours. Women delivering at <30 weeks' gestation at 5 tertiary centers were randomized to receive immediate cord clamping (<10 seconds) or delayed cord clamping (≥60 seconds). Echocardiography and cardiorespiratory data were collected at 3, 9, and 24 hours after birth. The primary outcome was mean lowest superior vena cava (SVC) flow. Of 266 infants enrolled, 133 were randomized to immediate cord clamping and 133 to delayed cord clamping. The 2 groups were similar at baseline, including mean gestation (immediate cord clamping 28 weeks vs delayed cord clamping 28 weeks) and birth weight (immediate cord clamping 1003 g vs delayed cord clamping 1044 g). There was no significant difference between groups in the primary outcome of mean lowest SVC flow (immediate cord clamping 71.4 mL/kg/min [SD 28.1] vs delayed cord clamping 70.2 mL/kg/min [SD 26.9]; P = .7). For secondary outcomes, hemoglobin increased by 0.9 g/dL at 6 hours in the group with delayed cord clamping (95% CI 3.9, 14.4; P = .0005, adjusted for baseline). The group with delayed cord clamping had lower right ventricular output (-21.9 mL/kg/min, 95% CI -39.0, -4.7; P = .01). Rates of treated hypotension, ductus arteriosus size and shunt direction, and treatment of the ductus arteriosus were similar. Delayed cord clamping had no effect on systemic blood flow measured as mean lowest SVC flow in the first 24 hours in infants <30 weeks' gestation. Australia New Zealand Clinical Trials Registry: ACTRN12610000633088.

Pérdida de peso en recién nacidos por cesárea: una consecuencia de los trastornos en la lactancia materna

Sr. Editor: Promover la lactancia materna exclusiva durante los primeros 6 meses es muy importante, al igual que conocer una adecuada técnica de lactancia que nos permita asegurar la alimentación efectiva del recién nacido. Durante los primeros días, el recién nacido presenta variaciones de peso que dependen de factores intrínsecos como cambios en la temperatura corporal o factores extrínsecos como la escasa ingesta de leche(1). En nuestro país, se han reportado pérdidas de peso de hasta 7,8% ± 2,8% en las primeras 72 horas en recién nacidos alimentados con leche materna exclusiva (2,3).

Clinical Pharmacology of Phenobarbital in Neonates: Effects, Metabolism and Pharmacokinetics.

Phenobarbital is an effective and safe anticonvulsant drug introduced in clinical use in 1904. Its mechanism of action is the synaptic inhibition through an action on GABAA. The loading dose of phenobarbital is 20 mg/kg intravenously and the maintenance dose is 3 to 4 mg/kg by mouth. The serum concentration of phenobarbital is up to 40 µg/ml. Nonresponders should receive additional doses of 5 to 10 mg/kg until seizures stop. Infants with refractory seizures may have a serum concentration of phenobarbital of 100 µg/ml. Phenobarbital is metabolized in the liver by CYP2C9 with minor metabolism by CYP2C19 and CYP2E1. A quarter of the dose of phenobarbital is excreted unchanged in the urine. In adults, the half-life of phenobarbital is 100 hours and in term and preterm infants is 103 and 141 hours, respectively. The half-life of phenobarbital decreases 4.6 hours per day and it is 67 hours in infants 4 week old.

National Sleep Foundation’s updated sleep duration recommendations: final report

ObjectiveTo make scientifically sound and practical recommendations for daily sleep duration across the life span. MethodsThe National Sleep Foundation convened a multidisciplinary expert panel (“Panel”) with broad representation from leading stakeholder organizations. The Panel evaluated the latest scientific evidence and participated in a formal consensus and voting process. Then, the RAND/UCLA Appropriateness Method was used to formulate sleep duration recommendations. ResultsThe Panel made sleep duration recommendations for 9 age groups. Sleep duration ranges, expressed as hours of sleep per day, were designated as recommended, may be appropriate, or not recommended. Recommended sleep durations are as follows: 14-17 hours for newborns, 12-15 hours for infants, 11-14 hours for toddlers, 10-13 hours for preschoolers, 9-11 hours for school-aged children, and 8-10 hours for teenagers. Seven to 9 hours is recommended for young adults and adults, and 7-8 hours of sleep is recommended for older adults. The self-designated basis for duration selection and critical discussions are also provided. ConclusionsConsensus for sleep duration recommendations was reached for specific age groupings. Consensus using a multidisciplinary expert Panel lends robust credibility to the results. Finally, limitations and caveats of these recommendations are discussed.

Breast Milk Iodine and Iodine Status of Breast-Fed Infants

Background: Breast milk is the only source of iodine for exclusively breast-fed infants. Iodine status of breast-fed infants depends on iodine in breast milk and also number of feeding in 24 hours. Iodine deficiency and iodine excess both have bad impact on infant’s health.Objective: To measure the iodine in breast milk and to evaluate iodine status of their breast-fed infants.Materials and method: This observational analytical study was carried out in the department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka with active cooperation of Kumudini Women’s Medical College Hospital, Mirzapur, Tangail involving fifty lactating mothers and their exclusively breast-fed infants. Early morning urine and breast milk samples were collected in dry and clean plastic container free from any chemical contamination. Urinary iodine was used as indicator for assessing iodine status. All statistical analyses were done by using SPSS (statistical programme for social science) 12 version software package for Windows.Results: The median (range) urinary iodine concentration of lactating mothers and their breast-fed infants were 225.25 ?g/L (61.50-530.00) and 225.75 ?g/L (100.50-526.00) respectively. The median (range) breast-milk iodine concentration was 157 ?g/L (54.50-431.50) which was more than three times of recommended minimum concentration (50 ?g/L). Only 2 (4%) lactating mothers had mild biochemical iodine deficiency (UIE, 50-99 ?g/L). There was no biochemical iodine deficiency of breast-fed infants. Iodine in breast milk of lactating mothers was positively correlated with their urinary iodine excretion (p&lt;0.01). Infant’s urinary iodine was positively correlated with iodine concentration in breast milk (p&lt;0.01) and with urinary iodine of lactating mothers (p&lt;0.01).Conclusion: Lactating mothers and their breast-fed infants in this study were iodine sufficient. If iodine content of breast-milk is within normal range, 10-12 numbers of feeding in 24 hours for infants is enough to get sufficient iodine from their mother’s milk.Delta Med Col J. Jul 2015; 3(2): 74-77

Pediatric brain death determination.

Clinical guidelines for the determination of brain death in children were first published in 1987. These guidelines were revised in 2011 under the auspices of the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society, and provide the minimum standards that must be satisfied before brain death can be declared in infants and children. After achieving physiologic stability and exclusion of confounders, two examinations including apnea testing separated by an observation period (24 hours for term newborns up to 30 days of age, and 12 hours for infants and children from 31 days up to 18 years) are required to establish brain death. Apnea testing should demonstrate a final arterial PaCO2 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. The committee concluded that ancillary studies may be used (1) when components of the examination or apnea testing cannot be completed, (2) if uncertainty about components of the neurologic examination exists, (3) if a medication effect may be present, or (4) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should still be performed and components that can be completed must remain consistent with brain death.

Clinical pharmacology of ibuprofen in preterm infants: A meta-analysis of published data

OBJECTIVES: Ibuprofen is a non-selective anti-inflammatory cyclooxygenase inhibitor drug of the propionic acid class of non-steroidal agents, available without prescription in the USA. In preterm infants, ibuprofen is used to close the Patent Ductus Arteriosus and it was found to be more effective than indomethacin. This metaanalysis determined whether differences exist in the closure rate of Patent Ductus Arteriosus following the oral vs. intravenous ibuprofen administration to preterm infants; it examines metabolism, pharmacokinetics and adverse renal effects of ibuprofen. METHOD: The bibliographic search was performed using PubMed and EMBASE databases as search engines. In addition, the books ‘‘Neofax: a Manual of Drugs Used in the Neonatal Care’’ by Young and Mangum and the ‘‘Neonatal Formulary’’ were consulted. RESULTS: Patent Ductus Arteriosus closure was 89% with oral ibuprofen (9 reports) vs. 75% with intravenous ibuprofen (13 reports); p = 0.011. The half-life (t1/2) of ibuprofen is 43.1 and 26.8 hours in infants on the 3 rd and 5 th day of life, respectively. In adults, the half-life of ibuprofen is 2 hours. The rapid shortening of ibuprofen t1/2 is due to the rapid increase of cytochromes CYP2C9 and CYP2C8 activities, which metabolize ibuprofen and which surge in the liver during the first weeks of life. Ibuprofen reduces the renal glomerular filtration and the sodium tubular transport rates. CONCLUSION: Oral ibuprofen is more effective than intravenous ibuprofen to close patent ductus arteriosus. Ibuprofen has fewer renal adverse effects than intravenous ibuprofen and has the most favourable risk/benefit ratio.

1326 Comparison of Intensive Light-Emitting Diode and Intensive Compact Fluorescent Phototherapy in Non-Hemolytic Jaundice

In severe and rapidly increasing jaundice, the use of high-intensity phototherapy provides greater effectiveness and a faster decrement in bilirubin levels. The aim of this study is compare the effectiveness...

Index of Suspicion

Index of Suspicion

Guidelines for the determination of brain death in infants and children: An Update of the 1987 Task Force Recommendations—Executive Summary

To review and revise the 1987 pediatric brain death guidelines. Relevant literature was reviewed. Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. (1) Determination of brain death in term newborns, infants, and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants <37 weeks gestational age are not included in these guidelines. (2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected, and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. (3) Two examinations including apnea testing with each examination separated by an observation period are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age and 12 hours for infants and children (>30 days to 18 years) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination. (4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial PaCO(2) 20mmHg above the baseline and ≥60mmHg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. (5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death (a) when components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (b) if there is uncertainty about the results of the neurologic examination; (c) if a medication effect may be present; or (d) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed, and components that can be completed must remain consistent with brain death. In this instance, the observation interval may be shortened, and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. (6) Death is declared when these above criteria are fulfilled.