Standards › ASF Health Standards v10 › Standard 37
Standard 37
Neonatal and Paediatric Hospital Care
Neonatal and paediatric hospital care: weight-based dosing, neonatal level of care, family involvement, child protection and safe transfers..
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
37.1Medicines Are Dosed for the Child’s Weight and AgeHumanitarian settings: MustTransition and fragile: MustStandard: Must
Every medicine prescribed for a child is dosed against a recorded current weight, with a paediatric dosing check before the first dose. Adult dosing is not used by default.
Why it matters. Children are not small adults. A medicine dose for a child depends on their weight and age, and a wrong dose can cause serious harm. The weight must be current and recorded.
How the surveyor verifies this criterion
Sample. Review prescribing and dose records for 30 child medicines, including any given to infants under 1 year.
Immediate fail (any one means the criterion is not met). A child medicine dosed from the adult table with no weight recorded.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NEO-SOP-002 · NEO-SOP-002 | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Pediatric Ambulatory Care (AMB-23) | Manager; Nurse |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705 Used for: https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
37.2Newborn Care Is Matched to a Defined Level of CareHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
Each neonatal area is assigned a defined level of care. Staffing is set for that level, and a documented pathway moves a baby to a higher level of care when needed.
Why it matters. A newborn needs the right level of care for their condition. A neonatal unit that is staffed for a lower level of care cannot keep a sick baby safe.
How the surveyor verifies this criterion
Sample. Review the level of care assignment and staffing records for each neonatal area for the last 3 months.
1. Each neonatal area has a defined level of care.
Method. Check each area for its assigned level.
Evidence to show. Neonatal level of care (NEO-POL-001).
Pass when. Every neonatal area has a level of care assigned.
2. Staffing matches the level of care on each sampled shift.
Method. Check each shift against the staffing needed for the level.
Evidence to show. Neonatal staffing against level of care register (NEO-REG-001).
Pass when. Every sampled shift meets the staffing for its level.
3. A documented pathway moves a baby to a higher level of care when needed.
Method. Check each transfer up a level for the pathway step and the decision record.
Evidence to show. Neonatal level of care assessment record (NEO-FRM-001).
Pass when. Every step-up has a pathway decision recorded.
Immediate fail (any one means the criterion is not met). A premature baby admitted to a unit with no level of care defined and no staff to match it.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Neonatal level of care policy | Must |
| Secretary (ISCO 3344) | Keeps the Neonatal staffing against level of care register | Must |
| Nurse (ISCO 2221) | Completes the Neonatal level of care assessment record | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NEO-FRM-001 · Neonatal level of care assessment record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NEO-REG-001 · Neonatal staffing against level of care register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NEO-POL-001 · Neonatal level of care | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Pediatric Ambulatory Care (AMB-23) | Manager; Nurse |
References
- WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. Used for: Quality standards for small and sick newborns in facilities: care matched to level, referral, family involvement and protection from harm. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/
37.3Families Are Informed and Present in CareHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Parents or guardians are informed about the child’s condition and the plan. Consent is obtained from the appropriate person, taking account of the child’s age and capacity. Family presence is supported.
Why it matters. Parents know their child best, and they need to understand what is happening to their baby. Informing them and involving them in care supports the child and the family.
How the surveyor verifies this criterion
Sample. Review consent and family involvement records for 15 children admitted in the last 3 months.
Immediate fail (any one means the criterion is not met). Parents not told about the newborn’s condition and asked to sign consent for a procedure with no information.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NEO-SOP-003 · NEO-SOP-003 | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Patient Identification, Informed Consent and Patient Rights (T-07) | Manager; Nurse |
References
- WHO (2025). Parent counselling guide on kangaroo mother care (KMC). Used for: Counselling parents on kangaroo mother care for small newborns. Family-focused, KMC-specific. https://news.gmj.ge/guideline/parent-counselling-guide-on-kangaroo-mother-care-kmc/
- WHO (2019). Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities. Used for: Quality standards for children and young adolescents in facilities: family involvement, presence and protection from harm. Not newborn-specific. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-children-and-young-adolescents-in-health-facilities/
- WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. Used for: Quality standards for small and sick newborns in facilities: care matched to level, referral, family involvement and protection from harm. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/
37.4Children Are Protected From HarmHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
Staff are trained in child protection. A named safeguarding lead is in place. Concerns about a child’s safety are escalated and recorded, and action is tracked to completion.
Why it matters. Children in hospital can be harmed by the people who care for them, or by others. Staff trained in child protection, with a named lead and a clear way to raise concern, keep children safe.
How the surveyor verifies this criterion
Sample. Review safeguarding training and concern records for the last 12 months, including all concerns raised.
Immediate fail (any one means the criterion is not met). A safeguarding concern noted in the notes with no escalation for a week.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NEO-SOP-004 · NEO-SOP-004 | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Child Safety & Safeguarding in Tourism Facilities (CHILD-01) | Manager; Nurse |
References
- WHO (2019). Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities. Used for: Quality standards for children and young adolescents in facilities: family involvement, presence and protection from harm. Not newborn-specific. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-children-and-young-adolescents-in-health-facilities/
- WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. Used for: Quality standards for small and sick newborns in facilities: care matched to level, referral, family involvement and protection from harm. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/
37.5Newborns Are Transferred Safely to a Higher Level of CareHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Transfers of newborns and children to a higher level of care meet the Critical Interfacility Transfer standard (Standard 35). The receiving unit confirms it can accept the child before the transfer begins.
Why it matters. A sick newborn who must move to a higher level of care is at high risk during the journey. A safe, structured transfer protects the baby on the way.
How the surveyor verifies this criterion
Sample. Review transfer records for 15 newborns and children moved to a higher level of care in the last 6 months.
Immediate fail (any one means the criterion is not met). A newborn transferred to another unit with no transfer record and no receiving team informed.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NEO-SOP-005 · NEO-SOP-005 | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Handover & Communication for ASF Accreditation (MT-04) | Manager; Nurse |
References
- WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. Used for: Quality standards for small and sick newborns in facilities: care matched to level, referral, family involvement and protection from harm. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705 Used for: https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
Who is responsible for Standard 37
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 37.1 Medicines Are Dosed for the Child’s Weight and Age | Paediatrician Chief pharmacist |
Pharmacist (dispensing) |
| 37.2 Newborn Care Is Matched to a Defined Level of Care | Neonatologist Gynaecologist / obstetrician |
Paediatric nurse |
| 37.3 Families Are Informed and Present in Care | Paediatric nurse Social worker |
Interpreter (medical) |
| 37.4 Children Are Protected From Harm | Social worker Paediatrician |
Mental health nurse |
| 37.5 Newborns Are Transferred Safely to a Higher Level of Care | Neonatologist Head of emergency department |
Dispatcher / ambulance control officer |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| Gynaecologist / obstetrician | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Paediatrician | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Neonatologist | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Paediatric nurse | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Mental health nurse | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Social worker | Patient services manager | None | Facility induction; safeguarding adults (general recommendation) |
| Interpreter (medical) | Patient services manager | None | Facility induction; safeguarding adults (general recommendation) |
| Chief pharmacist | Medical director | Clinical pharmacist, Pharmacist (dispensing), Pharmacy technician, Clinical trials coordinator | Facility induction; safeguarding adults (general recommendation) |
| Pharmacist (dispensing) | Chief pharmacist | None | Facility induction; safeguarding adults (general recommendation) |
| Head of emergency department | Medical director | Triage nurse, Emergency nurse | Facility induction; safeguarding adults (general recommendation) |
| Dispatcher / ambulance control officer | Transport supervisor | None | Facility induction; safeguarding adults (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 30 apply to?
Hospitals with neonatal and paediatric inpatient care, including newborn units and children’s wards.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
Can a child’s medicine be dosed from the adult table?
No. Under 37.1 medicines are dosed for the child’s weight and age, and a child medicine dosed from the adult table is an immediate fail.
Is a newborn’s level of care matched to their need?
Yes. Under 37.2 newborn care is matched to a defined level of care.
Are parents involved in their baby’s care?
Under 37.3 families are informed and present in care, where the family wishes to be.
What happens to a safeguarding concern?
Under 37.4 children are protected from harm, and a concern noted in the notes must be escalated.
Do I have to use the documents on this page?
No. The policies, SOPs, forms and registers are drafts to help you. Adapt them to your unit, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
What does In process of development mean?
That part of the standard is still being prepared. It may be a document, a course, a reference or a role table. It will be added in a later version.
Guidelines for this standard
12 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU (Society of Critical Care Medicine)
- Neonatal Intensive Care Transport — Service Specification (NHS England)
- Responding to children and adolescents who have been sexually abused: WHO clinical guidelines (2017) (World Health Organization)
- WHO recommendations on newborn health (2017) (World Health Organization)
- Neonatal resuscitation — MSF Essential obstetric and newborn care (Médecins Sans Frontières)
- Standards for improving the quality of care for small and sick newborns in health facilities (World Health Organization)
- Communicating about Vaccine Safety: Guidelines to help health workers communicate with parents, caregivers, and patients (Pan American Health Organization)
- Vaccination of Newborns in the Context of the COVID-19 Pandemic (Pan American Health Organization)
- Evidence-based Clinical Practice Guidelines for the Follow-Up of At-Risk Neonates (Pan American Health Organization)
- Global standards for quality health care services for adolescents (World Health Organization)
- Parent counselling guide on kangaroo mother care (KMC) (World Health Organization)
- Kangaroo mother care: a clinical practice guide (World Health Organization)
Also relevant to this standard:
- Safeguarding Children and Young People: Competencies for Health Care Staff (Intercollegiate Document) (RCPCH & RCN)
- WHO Guidelines for the health sector response to child maltreatment (WHO)
- General Comment No. 12 (2009): The Right of the Child to Be Heard (UN CRC)
- Minimum Standards for Child Protection in Humanitarian Action (2019 Edition) (The Alliance)
- Specific care when the mother has a transmissible infection (Essential obstetric and newborn care, Chapter 10.4) — MSF Essential obstetric and newborn care (Médecins Sans Frontières)
- Care of the sick newborn — MSF Essential obstetric and newborn care (Médecins Sans Frontières)
- Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities (World Health Organization)
- Safe Childbirth Checklist Implementation Guide: Improving the quality of facility-based delivery for mothers and newborns (World Health Organization)
- Paediatric emergency triage, assessment and treatment: care of critically-ill children (World Health Organization)
- Guidelines on the management of chronic pain in children (World Health Organization)
- Consolidated guidelines for the management of common childhood illness: management of asthma in children and adolescents and bronchiolitis in infants and young children (World Health Organization)
- Management of sickle-cell disease in children and adolescents (World Health Organization)