South West Guidelines & Policies
On this page you will find all ratified South West regional guidelines and policies, including those developed jointly with paediatric, maternity and fetal medicine colleagues.
Provider Trusts who decline to adopt a regional guideline should complete the opt-out form below and send a scanned signed copy to SWNeonatalNetwork@uhbw.nhs.uk
We also share (with permission) other local guidelines from Trusts in the South West which may be of interest to neonatal professionals across the region.
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This policy aims to manage neonatal pathways during heightened operational pressure. The policy addresses service limitations, such as full capacity, insufficient staffing, local damage, and infection prevention instructions. This live document should be accessed via the ODN website.
Provides a clear framework and guidance to define thresholds for repatriation, to ensure the best location of care and transfer to a unit as close to home as possible, as soon as needs can be met. This document should be considered alongside the Care Pathway Policy.
Policy for exception reporting and facilitating the standardised reporting for neonatal uplift criteria based on the National Neonatal Service Specification. Providing details of care levels by NICUs, LNUs, and SCUs, the transfer process, duties, responsibilities, and communication protocols for neonatal care.
Policy outlining care pathways for neonates in the South West. Highlighting the importance of high-quality care, efficient use of resources, and support family-centred care.
Neonatal units are responsible for recording and reviewing deaths according to national statutory requirements. This document outlines the South West Neonatal Network Mortality Process, which supports the sharing of learning from cases across the region and facilitates external peer review.
Policy for the Development and Management of Guidelines
This policy outlines the process for developing, ratifying, and managing network guidelines, policies, and frameworks within the South West Neonatal Network. The aim is to ensure consistency, appropriate consultation, and governance of these documents, in line with national service specifications. The policy applies to all network guidelines, policies, and frameworks relating to neonatal and perinatal services.
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Providing clinical guidance for consistent delivery of developmental care practices. It includes the primary principles involved in Developmental Care and supporting the developing brain.
Metabolic Bone Disease of Prematurity Prevention and Management Guideline
Focusing on early diagnosis, targeted treatment, and nutritional management using phosphate, calcium, and vitamin D. It highlights MBD's under recognition, risk factors, and changes in supplement management to prevent poor bone mineralization.
Use of Donor Breastmilk Guideline
Outlining the use, benefits and risks for using donor breast milk within neonatal units. Covering safe storage, traceability, consent processes, and transition strategies from donor milk to formula, aiming to reduce necrotizing enterocolitis risks among very low birth weight infants.
Presenting a therapeutic hypothermia care pathway for neonatal encephalopathy secondary to perinatal asphyxia. The document includes guidance on resuscitation, documentation, communication, general setup, monitoring, investigations, intensive care during therapeutic hypothermia, neurological assessment and care, and seizure management.
Parenteral Nutrition Guideline
Providing guidance on the application of parenteral nutrition in neonates, focusing on safe and optimal management, including indications, administration, monitoring, and weaning protocols for preterm and term infants.
Post Haemorrhagic Ventricular Dilatation Guideline
Providing guidance for the assessment and management of PHVD in neonates. It demonstrates the importance of monitoring and measurement techniques for ventricular dilatation. The document highlights drainage interventions and their role in managing PHVD. The guideline aims to improve neurodevelopmental outcomes in neonates with PHVD.
Management of Infant of Mother with Thyroid Disease Guideline
Providing guidance on when to inform neonatologists and recommended investigations, based on the risk level of the baby. It outlines the signs and symptoms of hyperthyroidism in newborns and provides a framework for the management of these babies.
Aiming to minimise uncertainty and distress for families while conducting appropriate genetic, endocrine, and anatomical investigations. Highlights the importance of involving key consultants, using gender neutral language, and ensuring timely multidisciplinary assessments.
Taking a baby home after death guideline
This guideline facilitates staff in supporting parents who wish to take their baby home or to a children's hospice after death. It underlines the importance of choice, treating babies and their family with dignity, and ensuring good documentation.
Focuses on empowering parents to become primary carers for their babies by teaching them about nasogastric or orogastric tube feeding. It highlights individualised care, safety, and the importance of parental involvement in the care pathway. The document also covers transfer between units and a section on short term home tube feeding. Please also see the Parent Information Leaflet and Learner Pack in the ‘Parent Resources’ section.
Seizure Management in Neonates
Providing guidance for managing seizures in neonates and the use of CFM for seizure detection and monitoring treatment response. Including initial management, first line investigations and second line investigations.
Framework for Neonatal Respiratory Physiotherapy Services
This document outlines the framework for practice in neonatal respiratory physiotherapy services. It emphasizes the importance of specialized skills and knowledge for physiotherapists working in this area, including advanced clinical reasoning and competency in managing vulnerable infants with complex medical conditions.
Guideline for Caffeine Use in Preterm Infants
This guideline provides guidance for the use of caffeine in preterm infants and discusses potential benefits and risks of caffeine therapy. It outlines dosage and regimen for caffeine citrate and provides guidance on monitoring and stopping caffeine therapy. The guideline aims to promote consistent and evidence-based practice in the use of caffeine for preterm infants.
Perinatal Palliative Care Symptom Management
This guideline provides a framework for the management of symptoms in neonates with life-limiting conditions. Emphasising the importance of holistic care, family integrated care, and the use of assessment tools to identify and manage symptoms. Highlights the need for early conversations with families to enable informed choices and the importance of supporting the psychological wellbeing of parents and carers.
Guideline for Standardised Concentration Infusions (SCIS)
Providing guidance for the use of standardised concentration infusions in neonatal care. It outlines the benefits, including improved safety and efficiency, and provides information on how to prescribe, prepare, and administer them. The guideline applies to all units and transport services within the Network.
Calculation Worksheets for Standardised Concentration Infusions (SCIS)
This document provides worksheets for calculating standardised concentration infusions (SCIs) for neonates. It includes examples of calculations for different drugs and concentrations, as well as methods for calculating the rate and dose of infusions.
Monographs for Standardised Concentration Infusions (SCI’s)
To be used in conjunction with the South West Neonatal Network Guideline for Standardised concentration infusions (SCIs). This document contains links to individual drug monographs for each of the 17 drugs included in the guideline.
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Admission and Care of Critically Unwell Infants on Neonatal Unit
This document provides guidance for the admission and care of critically unwell infants on neonatal units. Principles of decision making for admission, the role of infection control, and the importance of ongoing medical oversight for infants who would normally be transferred to a paediatric intensive care unit PICU. It highlights the importance of continuous review of the decision to admit and retain an infant on a neonatal unit, and the need to minimize the movement of critically ill infants between hospitals.
Providing optimal care for neonates with life-limiting conditions and their families. and highlighting the importance of advance care planning and the involvement of parents in all decisions. The guideline outlines indications and categories for considering palliative care in infants.
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SoNAR Uplift Decision Support Tool
Framework designed by Southwest Neonatal Advice and Retrieval to support uplift decision making.
Quality Statements to Support Paediatric Advance Care Planning in Southwest England 2025
Quality statements describing best practice in advance care planning for babies, children and young people and their families (BCYPF).
Chronic Lung Disease of Prematurity / Bronchopulmonary Dysplasia
Sets out a clear pathway for referral between neonatal units in the region and the Bristol Royal Hospital for Children (BRHC), as well as outline some of the options for assessment and therapy.
Management of Genital Herpes in Pregnancy and the Newborn
Guidelines for maternity and neonatal services, focusing on managing genital herpes during pregnancy and delivery. It discusses best practices, the role of acyclovir, and the importance of avoiding invasive procedures during delivery.
Diagnosis and Management of Congenital and Postnatally Acquired Cytomegalovirus (CMV) Infection
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