Clinical Guidelines

• Cardiology
• Congenital Conditions
• Haematology and Jaundice
• Infection Control
• Medication
• Metabolism
• Neonatal Transport
• Neurology
• Nutrition
• Procedures
• Renal, Electrolyte, and Fluid Management
• Respiratory Care
• Resuscitation
• Safeguarding
• Screening
• Sepsis
• Skincare
• Surgical Neonatal Conditions

 

Cardiology

Title	Last Review	Next Review
Cardiac Disease and Murmurs in the Newborn	Oct 12	Oct 15
Hypotension in Neonates	Feb 21	Feb 24
PDA Paracetamol Dosing Protocol	May 22	May 25
Persistent Pulmonary Hypertension in the Newborn (PPHN)	Jan 21	Jan 24
Postnatal Extrasystoles	Oct 17

 

Congenital Conditions

Title	Last Review	Next Review
Down Syndrome	Jul 21	Jul 24

 

Haematology and Jaundice

Title	Last Review	Next Review
Blood Transfusion, Neonatal Unit	Aug 21	Dec 23
Blood Transfusion Policy and Related Guidelines for Neonatal and Paediatric Patients – See intranet
IVIg Request Form	Feb 13	Feb 16
Jaundice: Neonatal Jaundice (Jan 22) Prolonged Jaundice Screening (Sep 21) Transcutaneous Bilirubinometer Use (Feb 19) Jaundice – Exchange Transfusion and Immunoglobulin (Feb 19) Stool Chart
Polycythaemia Guideline	Mar 22	Mar 25
Vitamin K Guideline	Nov 17	Nov 22

 

Infection Control

Title	Last Review	Next Review
COVID-19 Guidelines and Resources – see intranet
Hepatitis B Immunisation	Jan 21	Jan 24
Hepatitis C positive mothers – neonatal management	Feb 09	Feb 12
Herpes – Genital Herpes management in pregnancy	Oct 17	Oct 22
Herpes Simplex in Staff and Parents	Jun 14	Jun 19
HIV and Management of babies born to HIV positive mothers	2020	2025
MRSA – Screening Control and Decolonisation	May 18	May 22
NICU Recovery Roadmap – see intranet
TB: BCG Vaccinations for Neonates (Jan 22) BCG High Risk Table	Mar 20	Mar 23

 

Medication

Title	Last Review	Next Review
Intravenous Vancomycin on NICU – See intranet	Sep 22	Sep 24
Medication Errors in NICU	Nov 21	Nov 26

 

Metabolism

Title	Last Review	Next Review
Glucose Infusion Calculations	Mar 17	Mar 22
Hyperglycaemia: Neonatal Management	Mar 21	Mar 24
Hypernatraemia	Oct 19	Oct 24
Hypoglycaemia Prevention and Management of Hypoglycaemia in Newborns Flowchart A: Hypoglycaemia Pathway Flowchart B: Pre-feed BG 1.0-1.9mmol/L with NO Clinical Signs Flowchart C: Blood glucose <1.0mmol/l AND/OR Clinical signs consistent with hypoglycaemia Blood Sugar – Parent Information How to take a CBG	Nov 22	Dec 25
Metabolic Bone Disease	Mar 20	Oct 22

 

Neonatal Transport

Title	Last Review	Next Review
Nurse only Transfer	Jan 19	Jan 22
Operational Remit Guidelines for NTS – CATS – STPRS Teams	Jul 14
SEC NTS Referral Pathway	Jul 22	Jul 24
Suction & Replogle (transport competency)	Jan 19	Jan 22
Temperature Control (transport competency)	Jan 19	Jan 22
Transfer to SPH Maternity and Neonatal Unit – Leaflet	Jan 23	Jan 25
Transport Guidelines	Jan 19	Jan 22
Transport Incubator Ventilation Competencies	Sep 12

 

Neurology

Title	Last Review	Next Review
Abstinence and Withdrawal from Drugs	Aug 16	Aug 21
Cranial Ultrasound CrUSS Reporting Form	Oct 16	Oct 21
Dropped Babies Guideline	Oct 19	Oct 24
Drug Withdrawal – see Neonatal Abstinence
Neonatal encephalopathy: Neonatal Encephalopathy and Seizure NICHD When to Cool? Eligibility Form
Pain: Sucrose & non-drug pain relief, PINC score	Nov 14	Nov 19
Sudden and Unexpected Postnatal Collapse (BAPM)	May 22

 

Nutrition

Title	Last Review	Next Review
Infant Feeding on Maternity Unit
Feeding Management Pathway	Jun 22	Jun 24
Infant Feeding Guideline	Sep 22	Jun 24
Nutrition in the Neonate – Part 1
BDA Preparation and Storage	Nov 20	Nov 23
Expression of Breast Milk and Cleaning of Breast Kits	Jan 21	Nov 24
Feeding via Nasojejunal Route and Tube Insertion	May 18	Jan 22
Nutrition in the Neonatal Infant	Jan 23	May 24
Transition from Tube to Oral Feeding	Jan 23	Jan 26
Nutrition Feeding Pathway – Part 2
Enteral Feeding Risk Stratification	Sep 21	Sep 24
Pathway – Medium and Low Risk	Feb 20	Feb 23
Pathway – High Risk	Feb 20	Feb 23
Pathway – Extremely High Risk	Feb 20	Feb 23
Vitamins and Additives	Mar 20	Mar 23
Nutrition via Parenteral Route – Part 3
KSS – PN Maintenance (Electrolyte Containing)	May 22	May 25
KSS – PN Starter (Electrolyte Free)	May 22	May 25
Parenteral Nutrition Guideline	May 22	Mar 25
Nutritional Composition of Feeds on NICU – Part 4
Composition of Feeds Used on NICU	Jan 23	Jan 26
Composition of MEBM and BMF with SMA	Jan 23	Jan 26
Nutritional Complications Associated with Prematurity – Part 5
Hypoglycaemia Guideline	Nov 22	Dec 25
Impedence – Ph study for GORD	Mar 20	Mar 23
Metabolic Bone Disease	Mar 20	Oct 22
Nutritional Complications Associated with Prematurity	Jan 23	May 23
Probiotics Guideline	Oct 22	Nov 25
Unlicensed Medicine Record Form (Labinic)	Mar 17	Mar 20

 

Procedures

Title	Last Review	Next Review
Blood Cultures	Mar 20	Mar 23
Blood Sampling Guideline	Mar 20	Mar 23
Central Line Care Bundle	Jan 21	Jan 24
ETT length by GA	Jan 18	Jan 23
Exchange Transfusion – Double Volume	Feb 22	Aug 23
Immunisation on NICU	Nov 20	Nov 23
Intraosseus Needle Insertion on NICU (EZ-IO)	Mar 21	Mar 24
Intubation Drugs on NICU	Oct 17	Oct 22
LocSSIPs: Chest Drain (Feb 21) Intubation Checklist (Jun 22) LISA (Feb 21) Lumbar Puncture (Feb 21)
Long Line Insertion	May 20	May 23
Lumbar Puncture in Neonatal Patients Policy	Nov 20	Nov 23
Nasogastric and Orogastric Tubes – Insertion and Safe Management	Sep 22	Feb 24
Nasojejunal Tube Insertion	May 18	Jan 22
Neonatal transfers to MRI for self-ventilating babies	Aug 21	Jul 24
NICU Escalation Policy – see TrustNet	Feb 23	Feb 26
Peripheral Arterial Access in Neonates	Mar 19	Mar 24
Peripheral Venous Cannulation Guideline	Mar 20	Mar 23
pH Study Guideline	May 20	Apr 23
Retinopathy of Prematurity Policy	Dec 20	Dec 22
Skin Cleansing Guideline	Mar 21	Mar 23
Umbilical Arterial Lines	Oct 19	Oct 24
Umbilical Venous Lines	Sep 19	Sep 24
Videolaryngocope: Pathway for video laryngoscopy use Standard Operating Procedure Training for Tristel cleaning for Video Laryngoscope Tristel Trio Wipes System	Mar 18	Mar 21
X-rays on the Neonatal Unit	Oct 14	Oct 19

 

Renal, Electrolyte, and Fluid Management

Title	Last Review	Next Review
IV Fluid and Electrolyte Management in Neonates	Oct 21	Oct 25
Kidney Problems – Neonatal: Antenatally Detected Kidney Problems – Management Renal Pelvis Dilation – Proforma for Notes	Feb 17	Feb 22

 

Respiratory Care

Title	Last Review	Next Review
Care of the Ventilated Patient: Endotracheal Suctioning (Oct 20) NeoBar Placement (Apr 20) Turning a ventilated baby two person procedure (Jun 20)
Chronic Lung Disease of Prematurity	Aug 22	Sep 25
Difficult Airway Management	May 22	May 25
ECMO	Aug 16	Aug 21
LISA Procedure	Sep 18	Sep 23
Oxygen Assist Module (OAM) Guide	Mar 22	Mar 27
Oxygen Use in Neonatal Patients	Nov 19	Nov 22
Pneumothorax	May 19	May 24
Respiratory Support on NICU	Jul 22	Nov 24
SLE600 Flow Sensor – See intranet	Oct 22	Oct 25
Transcutaneous CO2 Monitoring in NICU	Mar 19	Mar 24

 

Resuscitation

Title	Last Review	Next Review
Birthday Cuddle Guideline	Oct 18	Oct 21
Delayed Cord Clamping Neonatal Stabilisation Record (Mar 22) NICU Staff Feedback Form DCC BC (Jun 19) Parents DCC and Birthday Cuddle Audit Form (Jun 19) SOP 1 – 32 to 37 Weeks Delayed Cord Clamping (May 22) SOP 2 – Less than 32 Weeks DCC (May 22)	Apr 21	Jun 24
Dextrose gel in delivery room for preterm infants	Mar 20	Mar 23
Extreme Prematurity: Management of Extremely Preterm Infant Pitstop Prems Pre-Term Delivery Checklist	May 22	Sep 23
Resuscitation / Stabilisation: Neonatal Stabilisation Record (Mar 22) Resuscitation of the Newborn on Labour Ward (May 2020) Use of polythene bag in labour ward
Thermoregulation in the NICU	Aug 22	Aug 25

 

Safeguarding

Title	Last Review	Next Review
Baby Abduction Policy – see intranet	Apr 21	Apr 24
SSCP Legal Terms Explained	Oct 20
Trust Safeguarding Children Resources – see intranet

 

Screening

Title	Last Review	Next Review
Blood Spot Screening in the Newborn	Apr 19	Apr 22
ROP (Retinopathy of Prematurity) Laser Treatment – see procedures

 

Sepsis

Title	Last Review	Next Review
Antibiotic Policy for NICU	Aug 22	Aug 25
Blood Culture Guideline for Neonatal Patients – see procedures
Early Onset Sepsis in Term Neonates	Sep 21	Nov 24

 

Skincare

Title	Last Review	Next Review
Extravasation Injuries	Mar 16	Apr 21
Nappy Rash Guideline	Apr 20	Apr 23
Neonatal Skin and Wound Care	Mar 16	Feb 21
Sticky Eyes	Dec 18	Dec 23

 

Surgical Neonatal Conditions

Title	Last Review	Next Review
Gastroschisis and Exomphalos Initial Management	Jan 18	Jan 22
Stoma Care	Mar 16	Apr 21