1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the [2006] recommendations. The guideline addendum gives details of the methods and the evidence used to develop the [2014] recommendations on co-sleeping and sudden infant death syndrome.

1.1 Planning the content and delivery of care

Principles of care

1.1.1 Each postnatal contact should be provided in accordance with the principles of individualised care. In order to deliver the core care recommended in this guideline, postnatal services should be planned locally to achieve the most efficient and effective service for women and their babies. [2006]

1.1.2 A coordinating healthcare professional should be identified for each woman. Based on the changing needs of the woman and baby, this professional is likely to change over time. [2006]

1.1.3 A documented, individualised postnatal care plan should be developed with the woman, ideally in the antenatal period or as soon as possible after birth. This should include:

  • relevant factors from the antenatal, intrapartum and immediate postnatal period

  • details of the healthcare professionals involved in her care and that of her baby, including roles and contact details

  • plans for the postnatal period.

    This should be reviewed at each postnatal contact. [2006]

1.1.4 Women should be offered an opportunity to talk about their birth experiences and to ask questions about the care they received during labour. [2006]

1.1.5 Women should be offered relevant and timely information to enable them to promote their own and their babies' health and wellbeing and to recognise and respond to problems. [2006]

1.1.6 At each postnatal contact the healthcare professional should:

  • ask the woman about her health and wellbeing and that of her baby. This should include asking women about their experience of common physical health problems. Any symptoms reported by the woman or identified through clinical observations should be assessed.

  • offer consistent information and clear explanations to empower the woman to take care of her own health and that of her baby, and to recognise symptoms that may require discussion

  • encourage the woman and her family to report any concerns in relation to their physical, social, mental or emotional health, discuss issues and ask questions

  • document in the care plan any specific problems and follow‑up. [2006]

1.1.7 Length of stay in a maternity unit should be discussed between the individual woman and her healthcare professional, taking into account the health and wellbeing of the woman and her baby and the level of support available following discharge. [2006]

Professional communication

1.1.8 There should be local protocols about written communication, in particular about the transfer of care between clinical sectors and healthcare professionals. These protocols should be audited. [2006]

1.1.9 Healthcare professionals should use hand‑held maternity records, the postnatal care plans and personal child health records, to promote communication with women. [2006]

Competencies

1.1.10 All healthcare professionals who care for mothers and babies should work within the relevant competencies developed by Skills for Health. Relevant healthcare professionals should also have demonstrated competency and sufficient ongoing clinical experience in:

  • undertaking maternal and newborn physical examinations and recognising abnormalities

  • supporting breastfeeding women including a sound understanding of the physiology of lactation and neonatal metabolic adaptation and the ability to communicate this to parents

  • recognising the risks, signs and symptoms of domestic abuse and whom to contact for advice and management, as recommended by Department of Health guidance[1],[2]

  • recognising the risks, signs and symptoms of child abuse and whom to contact for advice and management, as recommended by Department of Health guidance[1]. [2006]

1.2 Maternal health

Information giving

1.2.1 At the first postnatal contact, women should be advised of the signs and symptoms of potentially life‑threatening conditions (given in table 2) and to contact their healthcare professional immediately or call for emergency help if any signs and symptoms occur. [2006]

Table 2 Signs and symptoms of potentially life-threatening conditions

Signs and symptoms

Condition

Sudden and profuse blood loss or persistent increased blood loss

Faintness, dizziness or palpitations/tachycardia

Postpartum haemorrhage

Fever, shivering, abdominal pain and/or offensive vaginal loss

Infection

Headaches accompanied by one or more of the following symptoms within the first 72 hours after birth:

visual disturbances

nausea, vomiting

Pre‑eclampsia/ eclampsia

Unilateral calf pain, redness or swelling

Shortness of breath or chest pain

Thromboembolism

1.2.2 The Department of Health booklet 'Birth to five'[3], which is a guide to parenthood and the first 5 years of a child's life, should be given to all women within 3 days of birth (if it has not been received antenatally). [2006]

1.2.3 The personal child health record should be given to all women as soon as possible (if it has not been received antenatally) and its use explained. [2006]

1.2.4 Women should be offered information and reassurance on:

  • the physiological process of recovery after birth (within the first 24 hours)

  • normal patterns of emotional changes in the postnatal period and that these usually resolve within 10–14 days of giving birth (within 3 days)

  • common health concerns as appropriate (weeks 2–8). [2006]

Life-threatening conditions: core care and raised concern

Postpartum haemorrhage

1.2.5 In the absence of abnormal vaginal loss, assessment of the uterus by abdominal palpation or measurement as a routine observation is unnecessary. [2006]

1.2.6 Assessment of vaginal loss and uterine involution and position should be undertaken in women with excessive or offensive vaginal loss, abdominal tenderness or fever. Any abnormalities in the size, tone and position of the uterus should be evaluated. If no uterine abnormality is found, consider other causes of symptoms (urgent action). [2006]

1.2.7 Sudden or profuse blood loss, or blood loss accompanied by any of the signs and symptoms of shock, including tachycardia, hypotension, hypoperfusion and change in consciousness, should be evaluated (emergency action). [2006]

Genital tract sepsis

1.2.8 In the absence of any signs and symptoms of infection, routine assessment of temperature is unnecessary. [2006]

1.2.9 Temperature should be taken and documented if infection is suspected. If the temperature is above 38°C, repeat measurement in 4–6 hours. [2006]

1.2.10 If the temperature remains above 38°C on the second reading or there are other observable symptoms and measurable signs of sepsis, evaluate further (emergency action). [2006]

Pre-eclampsia/eclampsia

1.2.11 A minimum of one blood pressure measurement should be carried out and documented within 6 hours of the birth. [2006]

1.2.12 Routine assessment of proteinuria is not recommended. [2006]

1.2.13 Women with severe or persistent headache should be evaluated and pre‑eclampsia considered (emergency action). [2006]

1.2.14 If diastolic blood pressure is greater than 90 mmHg, and there are no other signs and symptoms of pre‑eclampsia, measurement of blood pressure should be repeated within 4 hours. [2006]

1.2.15 If diastolic blood pressure is greater than 90 mmHg and accompanied by another sign or symptom of pre‑eclampsia, evaluate further (emergency action). [2006]

1.2.16 If diastolic blood pressure is greater than 90 mmHg and does not fall below 90 mmHg within 4 hours, evaluate for pre‑eclampsia (emergency action). [2006]

Thromboembolism

1.2.17 Women should be encouraged to mobilise as soon as appropriate following the birth. [2006]

1.2.18 Women with unilateral calf pain, redness or swelling should be evaluated for deep venous thrombosis (emergency action). [2006]

1.2.19 Women experiencing shortness of breath or chest pain should be evaluated for pulmonary thromboembolism (emergency action). [2006]

1.2.20 Routine use of Homan's sign as a tool for evaluation of thromboembolism is not recommended. [2006]

1.2.21 Obese women are at higher risk of thromboembolism and should receive individualised care. [2006]

Mental health and wellbeing

1.2.22 At each postnatal contact, women should be asked about their emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day‑to‑day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. [2006]

1.2.23 Formal debriefing of the birth experience is not recommended. [2006]

1.2.24 All healthcare professionals should be aware of signs and symptoms of maternal mental health problems that may be experienced in the weeks and months after the birth. [2006]

1.2.25 At 10–14 days after birth, women should be asked about resolution of symptoms of baby blues (for example, tearfulness, feelings of anxiety and low mood). If symptoms have not resolved, the woman should be assessed for postnatal depression, and if symptoms persist, evaluated further (urgent action)[4]. [2006]

1.2.26 Women should be encouraged to help look after their mental health by looking after themselves. This includes taking gentle exercise, taking time to rest, getting help with caring for the baby, talking to someone about their feelings and ensuring they can access social support networks. [2006]

Physical health and wellbeing

Perineal care

1.2.27 At each postnatal contact, women should be asked whether they have any concerns about the healing process of any perineal wound; this might include experience of perineal pain, discomfort or stinging, offensive odour or dyspareunia. [2006]

1.2.28 The healthcare professional should offer to assess the perineum if the woman has pain or discomfort. [2006]

1.2.29 Women should be advised that topical cold therapy, for example crushed ice or gel pads, are effective methods of pain relief for perineal pain. [2006]

1.2.30 If oral analgesia is required, paracetamol should be used in the first instance unless contraindicated. [2006]

1.2.31 If cold therapy or paracetamol is not effective a prescription for oral or rectal non‑steroidal anti‑inflammatory (NSAID) medication should be considered in the absence of any contraindications (non‑urgent action). [2006]

1.2.32 Signs and symptoms of infection, inadequate repair, wound breakdown or non‑healing should be evaluated (urgent action). [2006]

1.2.33 Women should be advised of importance of perineal hygiene, including frequent changing of sanitary pads, washing hands before and after doing this, and daily bathing or showering to keep their perineum clean. [2006]

Dyspareunia

1.2.34 Women should be asked about resumption of sexual intercourse and possible dyspareunia 2–6 weeks after the birth. [2006]

1.2.35 If a woman expresses anxiety about resuming intercourse, reasons for this should be explored. [2006]

1.2.36 Women with perineal trauma who experience dyspareunia should be offered an assessment of the perineum. (See perineal care above) [2006]

1.2.37 A water‑based lubricant gel to help ease discomfort during intercourse may be advised, particularly if a woman is breastfeeding. [2006]

1.2.38 Women who continue to express anxiety about sexual health problems should be evaluated (non‑urgent action). [2006]

Headache

For severe headache see section on pre‑eclampsia/eclampsia.

1.2.39 Women should be asked about headache symptoms at each postnatal contact. [2006]

1.2.40 Women who have had epidural or spinal anaesthesia should be advised to report any severe headache, particularly one which occurs while sitting or standing. [2006]

1.2.41 Management of mild postnatal headache should be based on differential diagnosis of headache type and local treatment protocols. [2006]

1.2.42 Women with tension or migraine headaches should be offered advice on relaxation and how to avoid factors associated with the onset of headaches. [2006]

Fatigue

1.2.43 Women who report persistent fatigue should be asked about their general wellbeing, and offered advice on diet, exercise and planning activities, including spending time with her baby. [2006]

1.2.44 If persistent postnatal fatigue impacts on the woman's care of herself or baby, underlying physical, psychological or social causes should be evaluated. [2006]

1.2.45 If a woman has sustained a postpartum haemorrhage, or is experiencing persistent fatigue, her haemoglobin level should be evaluated and if low, treated according to local policy. [2006]

Backache

1.2.46 Women experiencing backache in the postnatal period should be managed as in the general population. [2006]

Constipation

1.2.47 Women should be asked if they have opened their bowels within 3 days of the birth. [2006]

1.2.48 Women who are constipated and uncomfortable should have their diet and fluid intake assessed and offered advice on how to improve their diet. [2006]

1.2.49 A gentle laxative may be recommended if dietary measures are not effective. [2006]

Haemorrhoids

1.2.50 Women with haemorrhoids should be advised to take dietary measures to avoid constipation and should be offered management based on local treatment protocols. [2006]

1.2.51 Women with a severe, swollen or prolapsed haemorrhoid or any rectal bleeding should be evaluated (urgent action). [2006]

Faecal incontinence

1.2.52 Women with faecal incontinence should be assessed for severity, duration and frequency of symptoms. If symptoms do not resolve, evaluate further (urgent action). [2006]

Urinary retention

1.2.53 Urine passed within 6 hours of urination during labour should be documented. [2006]

1.2.54 If urine has not been passed within 6 hours after the birth, efforts to assist urination should be advised, such as taking a warm bath or shower. [2006]

1.2.55 If urine has not been passed by 6 hours after the birth and measures to encourage micturition are not immediately successful, bladder volume should be assessed and catheterisation considered (urgent action). [2006]

Urinary incontinence

1.2.56 Women with involuntary leakage of a small volume of urine should be taught pelvic floor exercises. [2006]

1.2.57 Women with involuntary leakage of urine which does not resolve or becomes worse should be evaluated. [2006]

Contraception

1.2.58 Methods and timing of resumption of contraception should be discussed within the first week of the birth. [2006]

1.2.59 The coordinating healthcare professional should provide proactive assistance to women who may have difficulty accessing contraceptive care. This includes providing contact details for expert contraceptive advice. [2006]

Immunisation

1.2.60 Anti‑D immunoglobulin should be offered to every non-sensitised Rh‑D‑negative woman within 72 hours following the delivery of an RhD‑positive baby. [2006]

1.2.61 Women found to be sero‑negative on antenatal screening for rubella should be offered an MMR (measles, mumps, rubella) vaccination following birth and before discharge from the maternity unit if they are in hospital. [2006]

1.2.62 See the Public Health England/Department of Health guidance, Immunisation against infectious disease (2013) (the Green Book) for guidance on the timing of MMR vaccination in women who are sero-negative for rubella who also require anti-D immunoglobulin injection. [new 2015]

1.2.63 Women should be advised that pregnancy should be avoided for 1 month after receiving MMR, but that breastfeeding may continue. [2006]

Safety

Domestic abuse

1.2.64 Healthcare professionals should be aware of the risks, signs and symptoms of domestic abuse and know who to contact for advice and management, following guidance from the Department of Health[1],[2][2006]

6–8-week check

1.2.65 At the end of the postnatal period, the coordinating healthcare professional should ensure that the woman's physical, emotional and social wellbeing is reviewed. Screening and medical history should also be taken into account. [2006]

1.3 Infant feeding

A supportive environment for breastfeeding

1.3.1 Breastfeeding support should be made available regardless of the location of care. [2006]

1.3.2 All healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff and parents. Each provider should identify a lead healthcare professional responsible for implementing this policy. [2006]

1.3.3 All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative as a minimum standard. [2006]

1.3.4 Healthcare professionals should have sufficient time, as a priority, to give support to a woman and baby during initiation and continuation of breastfeeding. [2006]

1.3.5 Where postnatal care is provided in hospital, attention should be paid to facilitating an environment conducive to breastfeeding. This includes making arrangements for:

  • 24 hour rooming‑in and continuing skin‑to‑skin contact when possible

  • privacy

  • adequate rest for women without interruption caused by hospital routine

  • access to food and drink on demand. [2006]

1.3.6 Formula milk should not be given to breastfed babies unless medically indicated. [2006]

1.3.7 Commercial packs, for example those given to women when they are discharged from hospital, containing formula milk or advertisements for formula should not be distributed. [2006]

1.3.8 Women who leave hospital soon after birth should be reassured that this should not impact on breastfeeding duration. [2006]

1.3.9 Written breastfeeding education materials as a stand‑alone intervention are not recommended. [2006]

Starting successful breastfeeding

1.3.10 In the first 24 hours after birth, women should be given information on the benefits of breastfeeding, the benefits of colostrum and the timing of the first breastfeed. Support should be culturally appropriate. [2006]

1.3.11 Initiation of breastfeeding should be encouraged as soon as possible after the birth, ideally within 1 hour. [2006]

1.3.12 Separation of a woman and her baby within the first hour of the birth for routine postnatal procedures, for example weighing, measuring and bathing, should be avoided unless these measurements are requested by the woman, or are necessary for the immediate care of the baby. [2006]

1.3.13 Women should be encouraged to have skin‑to‑skin contact with their babies as soon as possible after the birth. [2006]

1.3.14 It is not recommended that women are asked about their proposed method of feeding until after the first skin‑to‑skin contact. [2006]

1.3.15 From the first feed, women should be offered skilled breastfeeding support (from a healthcare professional, mother‑to‑mother or peer support) to enable comfortable positioning of the mother and baby and to ensure that the baby attaches correctly to the breast to establish effective feeding and prevent concerns such as sore nipples. [2006]

1.3.16 Additional support with positioning and attachment should be offered to women who have had:

  • a narcotic or a general anaesthetic, as the baby may not initially be responsive to feeding

  • a caesarean section, particularly to assist with handling and positioning the baby to protect the woman's abdominal wound

  • initial contact with their baby delayed. [2006]

Continuing successful breastfeeding

1.3.17 Unrestricted breastfeeding frequency and duration should be encouraged. [2006]

1.3.18 Women should be advised that babies generally stop feeding when they are satisfied, which may follow a feed from only one breast. Babies should be offered the second breast if they do not appear to be satisfied following a feed from one breast. [2006]

1.3.19 Women should be reassured that brief discomfort at the start of feeds in the first few days is not uncommon, but this should not persist. [2006]

1.3.20 Women should be advised that if their baby is not attaching effectively he or she may be encouraged, for example by the woman teasing the baby's lips with the nipple to get him or her to open their mouth. [2006]

1.3.21 Women should be advised of the indicators of good attachment, positioning and successful feeding. These are given in box 1. [2006]

Box 1. Breastfeeding

Indicators of good attachment and positioning:

  • mouth wide open

  • less areola visible underneath the chin than above the nipple

  • chin touching the breast, lower lip rolled down, and nose free

  • no pain.

Indicators of successful feeding in babies:

  • audible and visible swallowing

  • sustained rhythmic suck

  • relaxed arms and hands

  • moist mouth

  • regular soaked/heavy nappies.

Indicators of successful breastfeeding in women:

  • breast softening

  • no compression of the nipple at the end of the feed

  • woman feels relaxed and sleepy.

1.3.22 Women should be given information about local breastfeeding support groups. [2006]

Assessing successful breastfeeding

1.3.23 A woman's experience with breastfeeding should be discussed at each contact to assess if she is on course to breastfeed effectively and identify any need for additional support. Breastfeeding progress should then be assessed and documented in the postnatal care plan at each contact. [2006]

1.3.24 If an insufficiency of milk is perceived by the woman, attachment and positioning should be reviewed and her baby's health should be evaluated. Reassurance should be offered to support the woman to gain confidence in her ability to produce enough milk for her baby. [2006]

1.3.25 If the baby is not taking sufficient milk directly from the breast and supplementary feeds are necessary, expressed breast milk should be given by a cup or bottle. [2006]

1.3.26 Supplementation with fluids other than breast milk is not recommended. [2006]

Expression and storage of breast milk

1.3.27 All breastfeeding women should be shown how to hand express their colostrum or breast milk and advised on how to correctly store and freeze it. [2006]

1.3.28 Breast pumps should be available in hospital, particularly for women who have been separated from their babies, to establish lactation. All women who use a breast pump should be offered instructions on how to use it. [2006]

Preventing, identifying and treating breastfeeding concerns

Nipple pain

1.3.29 Women should be advised that if their nipples are painful or cracked, it is probably due to incorrect attachment. [2006]

1.3.30 If nipple pain persists after repositioning and re‑attachment, assessment for thrush should be considered. [2006]

Engorgement

1.3.31 Women should be advised that their breasts may feel tender, firm and painful when milk 'comes in' at or around 3 days after birth. [2006]

1.3.32 A woman should be advised to wear a well‑fitting bra that does not restrict her breasts. [2006]

1.3.33 Breast engorgement should be treated with:

  • frequent unlimited breastfeeding including prolonged feeding from the affected breast

  • breast massage and, if necessary, hand expression

  • analgesia. [2006]

Mastitis

1.3.34 Women should be advised to report any signs and symptoms of mastitis including flu like symptoms, red, tender and painful breasts to their healthcare professional urgently. [2006]

1.3.35 Women with signs and symptoms of mastitis should be offered assistance with positioning and attachment and advised to:

  • continue breastfeeding and/or hand expression to ensure effective milk removal; if necessary, this should be with gentle massaging of the breast to overcome any blockage

  • take analgesia compatible with breastfeeding, for example paracetamol

  • increase fluid intake. [2006]

1.3.36 If signs and symptoms of mastitis continue for more than a few hours of self management, a woman should be advised to contact her healthcare professional again (urgent action). [2006]

1.3.37 If the signs and symptoms of mastitis have not eased, the woman should be evaluated as she may need antibiotic therapy (urgent action). [2006]

Inverted nipples

1.3.38 Women with inverted nipples should receive extra support and care to ensure successful breastfeeding. [2006]

Ankyloglossia (tongue tie)

1.3.39 Evaluation for ankyloglossia should be made if breastfeeding concerns persist after a review of positioning and attachment by a skilled healthcare professional or peer counsellor. [2006]

1.3.40 Babies who appear to have ankyloglossia should be evaluated further (non‑urgent action).[5] [2006]

Sleepy baby

1.3.41 Women should be advised that skin‑to‑skin contact or massaging a baby's feet should be used to wake the baby. The baby's general health should be assessed if there is no improvement. [2006]

Formula feeding

1.3.42 All parents and carers who are giving their babies formula feed should be offered appropriate and tailored advice on formula feeding to ensure this is undertaken as safely as possible, in order to enhance infant development and health, and fulfil nutritional needs. [2006]

1.3.43 A woman who wishes to feed her baby formula milk should be taught how to make feeds using correct, measured quantities of formula, as based on the manufacturer's instructions, and how to clean and sterilise bottles and teats and how to store formula milk[6]. [2006]

1.3.44 Parents and family members should be advised that milk, either expressed milk or formula should not be warmed in a microwave. [2006]

1.3.45 Breastfeeding women who want information on how to prepare formula feeds should be advised on how to do this. [2006]

1.4 Maintaining infant health

The purpose of this section of the guidance is to provide the framework for the healthcare professional, with the parents, to facilitate the health and wellbeing of a baby up to 8 weeks old. It lays out the care given to a healthy baby and support to be offered to the parents. It should be read in conjunction with 'Birth to five'.

1.4.1 Healthy babies should have normal colour for their ethnicity, maintain a stable body temperature, and pass urine and stools at regular intervals. They initiate feeds, suck well on the breast (or bottle) and settle between feeds. They are not excessively irritable, tense, sleepy or floppy. The vital signs of a healthy baby should fall within the following ranges:

  • respiratory rate normally 30−60 breaths per minute

  • heart rate normally between 100 and 160 beats per minute in a newborn

  • temperature in a normal room environment of around 37°C (if measured). [2006]

1.4.2 At each postnatal contact, parents should be offered information and advice to enable them to:

  • assess their baby's general condition

  • identify signs and symptoms of common health problems seen in babies

  • contact a healthcare professional or emergency service if required. [2006]

1.4.3 Parents, family members and carers should be offered information and reassurance on:

  • their baby's social capabilities as this can promote parent–baby attachment (in the first 24 hours)

  • the availability, access and aims of all postnatal peer, statutory and voluntary groups and organisations in their local community (within 2–8 weeks). [2006]

1.4.4 Both parents should be encouraged to be present during any physical examination of their baby to promote participation of both parents in the care of their baby and enable them to learn more about their baby's needs. [2006]

Parenting and emotional attachment

1.4.5 Assessment for emotional attachment should be carried out at each postnatal contact. [2006]

1.4.6 Home visits should be used as an opportunity to promote parent‑ or mother‑to‑baby emotional attachment. [2006]

1.4.7 Women should be encouraged to develop social networks as this promotes positive mother−baby interaction. [2006]

1.4.8 Group based parent‑training programmes designed to promote emotional attachment and improve parenting skills should be available to parents who wish to access them. [2006]

1.4.9 Healthcare providers should offer fathers information and support in adjusting to their new role and responsibilities within the family unit. [2006]

Physical examination and screening

1.4.10 The aims of any physical examination should be fully explained and the results shared with the parents and recorded in the postnatal care plan and the personal child health record. [2006]

1.4.11 A complete examination of the baby should take place within 72 hours of birth. This examination should incorporate a review of parental concerns and the baby's medical history should also be reviewed including: family, maternal, antenatal and perinatal history; fetal, neonatal and infant history including any previously plotted birth‑weight and head circumference; whether the baby has passed meconium and urine (and urine stream in a boy). Appropriate recommendations made by the UK National Screening Committee should also be carried out.

A physical examination should also be carried out. This should include checking the baby's:

  • appearance including colour, breathing, behaviour, activity and posture

  • head (including fontanelles), face, nose, mouth including palate, ears, neck and general symmetry of head and facial features. Measure and plot head circumference

  • eyes; check opacities and red reflex

  • neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry

  • heart; check position, heart rate, rhythm and sounds, murmurs and femoral pulse volume

  • lungs; check effort, rate and lung sounds

  • abdomen; check shape and palpate to identify any organomegaly; also check condition of umbilical cord

  • genitalia and anus; check for completeness and patency and undescended testes in males

  • spine; inspect and palpate bony structures and check integrity of the skin

  • skin; note colour and texture as well as any birthmarks or rashes

  • central nervous system; observe tone, behaviour, movements and posture. Elicit newborn reflexes only if concerned

  • hips; check symmetry of the limbs and skin folds (perform Barlow and Ortolani's manoeuvres)

  • cry; note sound

  • weight; measure and plot. [2006]

1.4.12 The newborn blood spot test should be offered to parents when their baby is 5‑8 days old. [2006]

1.4.13 At 6–8 weeks, an examination, comprising the items listed in 1.4.11, should be carried out. In addition, an assessment of social smiling and visual fixing and following should be carried out. [2006]

1.4.14 A hearing screen should be completed before discharge from hospital or by week 4 in the hospital programme or by week 5 in the community programme. [2006]

1.4.15 Parents should be offered routine immunisations for their baby according to the schedule recommended by the Department of Health[6]. [2006]

Physical health and wellbeing

Jaundice

1.4.16 Parents should be advised to contact their healthcare professional if their baby is jaundiced, their jaundice is worsening, or their baby is passing pale stools. [2006]

1.4.17 Babies who develop jaundice within the first 24 hours after birth should be evaluated (emergency action). [2006]

1.4.18 If jaundice develops in babies aged 24 hours and older, its intensity should be monitored and systematically recorded along with the baby's overall wellbeing with particular regard to hydration and alertness. [2006]

1.4.19 The mother of a breastfed baby who has signs of jaundice should be actively encouraged to breastfeed frequently, and the baby awakened to feed if necessary. [2006]

1.4.20 Breastfed babies with jaundice should not be routinely supplemented with formula, water or dextrose water. [2006]

1.4.21 If a baby is significantly jaundiced or appears unwell, evaluation of the serum bilirubin level should be carried out. [2006]

1.4.22 If jaundice first develops after 7 days or jaundice remains after 14 days in an otherwise healthy baby and a cause has not already been identified, it should be evaluated (urgent action). [2006]

Skin

1.4.23 Parents should be advised that cleansing agents should not be added to a baby's bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild non‑perfumed soap. [2006]

1.4.24 Parents should be advised how to keep the umbilical cord clean and dry and that antiseptics should not be used routinely. [2006]

Thrush

1.4.25 If thrush is identified in the baby, the breastfeeding woman should be offered information and guidance about relevant hygiene practices. [2006]

1.4.26 Thrush should be treated with an appropriate antifungal medication if the symptoms are causing pain to the woman or the baby or feeding concerns to either. [2006]

1.4.27 If thrush is non‑symptomatic, women should be advised that antifungal treatment is not required. [2006]

Nappy rash

1.4.28 For babies with nappy rash the following possible causes should be considered:

  • hygiene and skin care

  • sensitivity to detergents, fabric softeners or external products that have contact with the skin

  • presence of infection. [2006]

1.4.29 If painful nappy rash persists it is usually caused by thrush, and treatment with antifungal treatment should be considered. [2006]

1.4.30 If after a course of treatment the rash does not resolve, it should be evaluated further (non‑urgent action). [2006]

Constipation

1.4.31 If a baby has not passed meconium within 24 hours, the baby should be evaluated to determine the cause, which may be related to feeding patterns or underlying pathology (emergency action). [2006]

1.4.32 If a baby is constipated and is formula fed the following should be evaluated: (urgent action)

  • feed preparation technique

  • quantity of fluid taken

  • frequency of feeding

  • composition of feed. [2006]

Diarrhoea

1.4.33 A baby who is experiencing increased frequency and/or looser stools than usual should be evaluated (urgent action). [2006]

Colic

1.4.34 A baby who is crying excessively and inconsolably, most often during the evening, either drawing its knees up to its abdomen or arching its back, should be assessed for an underlying cause, including infant colic (urgent action). [2006]

1.4.35 Assessment of excessive and inconsolable crying should include:

  • general health of the baby

  • antenatal and perinatal history

  • onset and length of crying

  • nature of the stools

  • feeding assessment

  • woman's diet if breastfeeding

  • family history of allergy

  • parent's response to the baby's crying

  • any factors which lessen or worsen the crying. [2006]

1.4.36 Healthcare professionals should reassure parents of babies with colic that the baby is not rejecting them and that colic is usually a phase that will pass. Parents should be advised that holding the baby through the crying episode, and accessing peer support may be helpful. [2006]

1.4.37 Use of hypoallergenic formula in bottle‑fed babies should be considered for treating colic, but only under medical guidance. [2006]

1.4.38 Dicycloverine (dicyclomine) should not be used in the treatment of colic due to side effects such as breathing difficulties and coma. [2006]

Fever

1.4.39 The temperature of a baby does not need to be taken, unless there are specific risk factors, for example maternal pyrexia during labour. [2006]

1.4.40 When a baby is suspected of being unwell, the temperature should be measured using electronic devices that have been properly calibrated and are used appropriately[7]. [2006]

1.4.41 A temperature of 38°C or more is abnormal and the cause should be evaluated (emergency action). A full assessment, including physical examination, should be undertaken. [2006]

Vitamin K

1.4.42 All parents should be offered vitamin K prophylaxis for their babies to prevent the rare but serious and sometimes fatal disorder of vitamin K deficiency bleeding. [2006]

1.4.43 Vitamin K should be administered as a single dose of 1 mg intramuscularly as this is the most clinically and cost-effective method of administration. [2006]

1.4.44 If parents decline intramuscular vitamin K for their baby, oral vitamin K should be offered as a second-line option. Parents should be advised that oral vitamin K must be given according to the manufacturer's instructions for clinical efficacy and will require multiple doses. [2006]

Safety

1.4.45 All home visits should be used as an opportunity to assess relevant safety issues for all family members in the home and environment and promote safety education. [2006]

1.4.46 The healthcare professional should promote the correct use of basic safety equipment, including, for example, infant seats and smoke alarms and facilitate access to local schemes for provision of safety equipment. [2006]

Co-sleeping and sudden infant death syndrome

The cause of sudden infant death syndrome (SIDS) is not known. It is possible that many factors contribute but some factors are known to make SIDS more likely. These include placing a baby on their front or side to sleep. We need clear evidence to say that a factor directly causes SIDS. Evidence was reviewed relating to co‑sleeping (parents or carers sleeping on a bed or sofa or chair with an infant) in the first year of an infant's life. Some of the reviewed evidence showed that there is a statistical relationship between SIDS and co‑sleeping. This means that, where co‑sleeping occurs, there may be an increase in the number of cases of SIDS. However, the evidence does not allow us to say that co‑sleeping causes SIDS. Therefore the term 'association' has been used in the recommendations to describe the relationship between co‑sleeping and SIDS. The recommendations on co‑sleeping and SIDS cover the first year of an infant's life.

1.4.47 Recognise that co‑sleeping can be intentional or unintentional. Discuss this with parents and carers and inform them that there is an association between co‑sleeping (parents or carers sleeping on a bed or sofa or chair with an infant) and SIDS. [new 2014]

1.4.48 Inform parents and carers that the association between co‑sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS is likely to be greater when they, or their partner, smoke. [new 2014]

1.4.49 Inform parents and carers that the association between co‑sleeping (sleeping on a bed or sofa or chair with an infant) and SIDS may be greater with:

  • parental or carer recent alcohol consumption, or

  • parental or carer drug use, or

  • low birth weight or premature infants. [new 2014]

Pacifier use

1.4.50 If a baby has become accustomed to using a pacifier (dummy) while sleeping, it should not be stopped suddenly during the first 26 weeks. [2006]

Child abuse

1.4.51 Healthcare professionals should be alert to risk factors and signs and symptoms of child abuse. [2006]

1.4.52 If there is raised concern, the healthcare professional should follow local child protection policies. [2006]



[2] Department of Health (2005) Responding to domestic abuse: a handbook for health professionals. London: Department of Health

[3] Available from: the Department of Health

[4] Antenatal and postnatal mental health (2007) NICE guideline CG45

[5] Division of ankyloglossia (tongue-tie) for breastfeeding (2005) NICE interventional procedure guidance 149

[6] Department of Health (1996) Immunisation against infectious disease. London: Department of Health

[7] Feverish illness in children (2013) NICE guideline CG160