Clinical Guidelines

• Cardiology
• Congenital Conditions
• Haematology and Jaundice
• Infection Control
• LocSSIPs
• Medication
• Metabolism
• Neonatal Transport
• Neurology
• Nutrition
• Procedures
• Renal
• 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
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 TrustNet
Exchange Transfusion – see Jaundice – Exchange Transfusion and Immunoglobulin
IVIg Request Form	Feb 13	Feb 16
Jaundice: Prolonged Jaundice Screening Investigation of Neonatal Conjugated Jaundice Community Management Transcutaneous Bilirubinometer Use Jaundice – Exchange Transfusion and Immunoglobulin Stool Chart
Polycythaemia Guideline	Jul 12	Jul 15
Vitamin K Guideline	Nov 17	Nov 22

 

Infection Control

Title	Last Review	Next Review
COVID-19 Guidelines and Resources – see TrustNet
Hepatitis B immunisation	Oct 20	May 23
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	2018
MRSA – Screening Control and Decolonisation	May 18	May 22
NICU Recovery Roadmap – see TrustNet
TB: BCG SOP BCG High Risk Table	Mar 20	Mar 23

 

LocSSIPs

Title	Last Review	Next Review
Chest Drain	Feb 21	Feb 24
LISA	Feb 21	Feb 24
Lumbar Puncture	Feb 21	Feb 24

 

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	Aug 17	Aug 22
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	Jan 19	Jan 22
Suction & Replogle (transport competency)	Jan 19	Jan 22
Temperature Control (transport competency)	Jan 19	Jan 22
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
Collapse – Sudden Postnatal Collapse	Feb 17	Feb 22
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

 

Nutrition

Title	Last Review	Next Review
Administration and Storage of Enteral Feeds	Feb 18	Feb 21
Expression of Breast Milk and Cleaning of Breast Kits	Nov 20	Nov 23
Feeding and Nutrition (Neonatal): Enteral Feeding Risk Stratification Pathway – Medium and Low Risk Pathway – High Risk Pathway – Extremely High Risk Vitamins and Additives Weighing Baby Guideline – see TrustNet	Feb 20 Feb 20 Feb 20 Feb 20 May 20	Feb 23 Feb 23 Feb 23 Feb 23 May 25
Fluids and PN: Glucose Infusion Rates in Preterm PN How to prescribe PN in NICU Parenteral Nutrition Guideline	Dec 18 Oct 14 Dec 18	Dec 23 Oct 19 Dec 23
Nasogastric feeds – Transition from Tube to Oral Feeds	Sep 19	Sep 22
Neonatal Nutrition on NICU	May 20	May 25
Nutritional Composition of Common Feeds	May 20	May 25
Probiotics: Probiotics Guideline NICU Unlicensed Medicine Record Form (Labinic)	Mar 17	Mar 22

 

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
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
Long Line Insertion	May 20	May 23
Lumbar Puncture in Neonatal Patients Policy	Nov 20	Nov 23
Nasogastric Tube Feeding: Nasogastric Tube Feeding Policy Appendix 1 – X-ray Interpretation Appendix 2 – ASPH Staff Nasogastric or Orogastric Tube Competencies Appendix 3 – ASPH Parent NGT Feeding Booklet Appendix 4 – ASPH Parent Carer Competency Appendix 5 – ASPH Risk Assessment for Short Term use of NGT in Community Appendix 6 – NPSA 09 Appendix 7 – Parent Carer Briefing Appendix 8 – Enteral UK Instructions Appendix 10 – ASPH Individualised Care Plan for Home NGT Use	Mar 21	Mar 24
Naso-Jejunal Tube Insertion	May 18	Jan 22
Neonatal transfers to MRI for self-ventilating babies	Aug 21	Jul 24
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

Title	Last Review	Next Review
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
Budesonide in Preterm Babies	Aug 18	Aug 21
Care of the Ventilated Patient: Endotracheal Suctioning (Oct 20) NeoBar Placement (Apr 20) Turning a ventilated baby two person procedure (Jun 20)
ECMO	Aug 16	Aug 21
LISA Procedure	Sep 18	Sep 23
Oxygen Use in Neonatal Patients	Nov 19	Nov 22
Pneumothorax	May 19	May 24
Transcutaneous CO2 Monitoring in NICU	Mar 19	Mar 24
Vapotherm Use in NICU	Sep 17	Sep 22

 

Resuscitation

Title	Last Review	Next Review
Birthday Cuddle Guideline	Oct 18	Oct 21
Delayed Cord Clamping Neonatal Stabilisation Record (Jul 21) 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 (Jun 19) SOP 2 Less than 32 Weeks DCC (Jun 19)	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	Sep 20	Sep 23
Resuscitation / Stabilisation: Neonatal Stabilization Chart (Jul 21) Resuscitation of the Newborn on Labour Ward (May 2020) Use of polythene bag in labour ward
Thermoregulation Guideline	Mar 21	Mar 24

 

Screening

Title	Last Review	Next Review
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	Apr 17	Apr 22
Blood Culture Guideline for Neonatal Patients – see procedures
Early Onset Sepsis in Term Neonates	Aug 19	Apr 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