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

Guideline Formal Opt Out Form

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.

  • Operational Escalation Policy

    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.

    Exception Reporting 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.

    Care Pathway Policy

    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 Mortality Policy

    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.

  • Developmental Care Bundle

    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.

    Therapeutic Hypothermia Guideline

    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.

    Atypical Genitalia Guideline

    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.

    Tube Feeding Guideline

    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.

  • 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.

    Perinatal Palliative Care

    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.

  • 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.