Quality standard

Quality statement 2: Assessment for early-onset neonatal infection

Quality statement

Newborn babies are assessed for the risk factors and clinical indicators of early-onset neonatal infection. [2014, updated 2024]


Assessment for the risk factors and clinical indicators of early-onset neonatal infection can identify those babies who are at increased risk or who are showing possible signs of infection. Early identification of these risk factors or clinical indicators should prompt a physical examination, which can lead to healthcare professionals starting antibiotic treatment promptly, if needed. A risk assessment tool can be used to help carry out this assessment. The Kaiser Permanente neonatal sepsis calculator, which should be used only as part of a prospective audit, is an example of the type of tool that can be used.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.


Proportion of newborn babies who are assessed for the risk factors and clinical indicators of early-onset neonatal infection.

Numerator – the number in the denominator who are assessed for the risk factors and clinical indicators of early-onset neonatal infection.

Denominator – the number of newborn babies.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (maternity, paediatric and neonatal services) ensure that processes are in place for risk factors and clinical indicators of early-onset infection in newborn babies to be identified. They also ensure that healthcare professionals are trained to identify these risk factors and clinical indicators in babies of all skin colours.

Healthcare professionals (for example, midwives, neonatal nurses, obstetricians, neonatologists and paediatricians) assess newborn babies for risk factors and clinical indicators of early-onset neonatal infection. If any are present, they perform an immediate physical examination of the baby, including an assessment of the vital signs.

Commissioners ensure that maternity, paediatric and neonatal service providers develop and adhere to protocols to support the identification of risk factors and clinical indicators of early-onset neonatal infection, performing immediate physical assessments of newborn babies if any have been identified.

Newborn babies have an assessment to check if they are at risk of infection.

Source guidance

Neonatal infection: antibiotics for prevention and treatment. NICE guideline NG195 (2021), recommendations 1.3.1 and 1.3.3

Definitions of terms used in this quality statement

Newborn babies

Babies up to 72 hours old. [Adapted from NICE's guideline on neonatal infection, full guideline]

Risk factors

Red flag risk factor:

  • suspected or confirmed infection in another baby in the case of a multiple pregnancy.

Other risk factors:

  • invasive group B streptococcal infection in a previous baby, or maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy

  • preterm birth following spontaneous labour before 37 weeks' gestation

  • confirmed rupture of membranes for more than 18 hours before a preterm birth

  • confirmed prelabour rupture of membranes at term for more than 24 hours before the start of labour

  • intrapartum fever of more than 38°C if there is suspected or confirmed bacterial infection

  • clinical diagnosis of chorioamnionitis.

[NICE's guideline on neonatal infection, box 1]

Clinical indicators

Red flag clinical indicators:

  • apnoea (temporary stopping of breathing)

  • seizures

  • need for cardiopulmonary resuscitation

  • need for mechanical ventilation

  • signs of shock.

Other clinical indicators:

  • altered behaviour or responsiveness

  • altered muscle tone (for example, floppiness)

  • feeding difficulties (for example, feed refusal)

  • feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension

  • abnormal heart rate (bradycardia or tachycardia)

  • signs of respiratory distress (including grunting, recession and tachypnoea)

  • hypoxia (for example, central cyanosis or reduced oxygen saturation level)

  • persistent pulmonary hypertension of newborn babies

  • jaundice within 24 hours of birth

  • signs of neonatal encephalopathy

  • temperature abnormality (less than 36°C or more than 38°C) unexplained by environmental factors

  • unexplained excessive bleeding, thrombocytopenia or abnormal coagulation

  • altered glucose homeostasis (hypoglycaemia or hyperglycaemia)

  • metabolic acidosis (base deficit of 10 mmol/litre or more).

[NICE's guideline on neonatal infection, box 2]

Equality and diversity considerations

One of the clinical indicators of early-onset neonatal infection is hypoxia, which can present as central cyanosis (a generalised bluish discoloration of the body and the visible mucous membranes). Other changes to skin colour can also be a symptom of neonatal infection, for example where the baby becomes very pale, blue/grey or dark yellow.

It is important that healthcare professionals are aware that central cyanosis may present differently depending on the baby's skin colour and understand how best to identify changes in skin colour on different skin tones, such as where on the body to look for changes in colour.

There are some resources that healthcare professionals can use to help identify skin colour changes because of infection, such as Skin Deep, developed by Don't Forget The Bubbles, Mind the Gap clinical handbook and web resource, developed by Black & Brown Skin, and Symptom spotting on darker skin tones, developed by Bliss. These resources have not been produced by NICE and are not maintained by NICE. NICE has not made any judgement about the quality and usability of the resources. Other resources may also be available.

It is important that healthcare professionals recognise that some pulse oximetry devices have been reported to overestimate oxygen saturation levels in babies with darker skin, especially if the saturation level is borderline. Adjustments should be made when interpreting the test results to ensure that treatment is provided when appropriate. While the effectiveness of pulse oximeters can vary on darker skin, they are more accurate than a visual assessment alone for identifying low oxygen saturation levels.