If examined just prior to a scheduled feeding, a normal arousal response in a neonate more than 34 weeks gestational age is usually triggered by gently shaking the thorax, and the arousal is sustained for at least 5 to 10 minutes. Normal neonates born between 28 and 33 weeks gestation require more vigorous stimulation and are seldom able to sustain an arousal for longer than 5 minutes. Neonates from 25 to 27 weeks gestation require vigorous and frequent stimulation to arouse and the arousal is very brief.
If examined while sleep, just after a feeding a healthy fullterm neonate when asleep may require painful stimuli to be aroused. Once aroused, they do not remain awake for long, even if continuously stimulated. Premature neonates often go through a similar period after gavage feeding. A history of recent feeding prior to the examination and the transient nature of postprandial sleep distinguishes sleep from coma in these cases.

A comatose neonate has a heartbeat and does not meet brain death criteria. Brain death criteria in the United States has only been established for fullterm neonates after 7 days of age (Figure 63.1).

Figure 63.1.— Brain death criteria for fullterm neonates from 7 to 30 days of age. 1: no brain flow for 10 minutes; 2: two EEG isoelectric 48 hours apart; 3: two neurological examinations 48 hours apart showing no clinical evidence of cortical or brainstem functions; 4: no movements other than spinal movements for 48 hours; 5: no brainstem activity for 48 hours; H: hours.