Sir.—The need to establish brain death criteria in the pediatric age group was addressed by Rowland et al1 in the AJDC. Neurologists generally agree about the pure clinical criteria in the diagnosis of brain death—deep coma with absent brain-stem reflexes, including apnea. Questions arise, both for adult and pediatric patients, concerning the "preconditions" needed before considering brain death diagnosis and the "observation period" necessary once cessation of brain functions has been established.
Rowland et al1 omitted a major precondition that represents a keystone of the more recent sets of brain death criteria—the establishment of a known cause for brain damage that is sufficient to account for the cessation of brain functions.2,3 The absence of such an adequately established diagnosis should prompt the physician to gather further clinical and laboratory data. Furthermore, to consider cases for brain death determination in which the diagnosis is even remotely in