Standard 30: Neonatal and Paediatric Hospital Care (Version 11)

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.

Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Children are not small adults. The dose of most medicines depends on the child's weight and age, so the prescriber records the current weight before the first dose. A weight from a previous visit is not used for a new prescription without re-weighing.

Before the first dose, a paediatric dosing check confirms the dose against the weight and age, the route, and the frequency. Infants under 1 year are checked with particular care. Adult dosing tables are not used for a child unless the paediatric check has been completed and recorded.

What good looks like

• A paediatric medicine dosing procedure (NEO-SOP-002) that requires a current weight and a recorded dosing check before the first dose.
• A current weight recorded on the chart for every child at admission and at each new prescription.
• A dosing check recorded before the first dose, including for infants under 1 year.
• Regular review of prescribing records against the weight and age.

Common mistakes

• A weight copied forward from an earlier admission and not re-measured.
• An adult dosing table used for a child because no paediatric table is available on the ward.
• A dose rounded up to the nearest adult tablet without a check against the weight.
• The dosing check is done verbally and never written down.

Questions the surveyor asks

• Every child medicine is dosed against a recorded current weight. The surveyor checks each prescription in the sample for a recorded weight and the date it was taken.
• A paediatric dosing check is recorded before the first dose. The surveyor checks each sampled first dose for the dosing check and its time.

How the surveyor verifies this criterion

References

1. 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

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.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Each neonatal area is assigned a level of care in the neonatal level of care policy (NEO-POL-001). The assigned level sets the minimum staffing, equipment and skills for every shift in that area.

When a baby needs a higher level of care, the step-up follows the documented pathway. The assessment record (NEO-FRM-001) shows the reason for the step-up, the decision and the time it was made. Staffing on each shift is checked against the level in the staffing register (NEO-REG-001).

What good looks like

• A neonatal level of care policy (NEO-POL-001) that defines each level and the staffing it requires.
• A staffing register (NEO-REG-001) checked against the level on each shift.
• A level of care assessment record (NEO-FRM-001) completed for every step-up.
• A review of staffing against level at a set interval.

Common mistakes

• A unit that admits premature babies without a level of care being assigned.
• A shift recorded as adequately staffed without the staffing being compared with the level.
• A step-up made in an emergency with no decision record completed afterwards.
• The levels are on paper but unknown to the staff on the ward.

Questions the surveyor asks

• Every neonatal area has a level of care assigned. The surveyor checks each area for its assigned level.
• Staffing meets the level of care on each sampled shift. The surveyor checks each shift against the staffing needed for the level.
• Every step-up to a higher level of care has a pathway decision recorded. The surveyor checks each step-up for the pathway step and the decision record.

How the surveyor verifies this criterion

References

1. WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/

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.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Parents or guardians are told about the child's condition, the options and the plan in words they understand. Where an interpreter is needed, one is used. The information given is recorded in the notes.

Consent is obtained from the parent or guardian, and the child is involved in decisions as far as their age and capacity allow. Family presence is supported, including for kangaroo mother care where it is clinically appropriate.

What good looks like

• A family information and consent procedure (NEO-SOP-003).
• Consent recorded with the name and relationship of the person who gave it.
• Family presence recorded in the notes, including kangaroo mother care where used.
• Interpreter use recorded when needed.

Common mistakes

• Consent signed by a parent who did not understand the procedure.
• Family presence limited without a clinical reason and without recording it.
• The child's age and capacity not considered when consent is obtained.
• Information given only verbally and not recorded.

Questions the surveyor asks

• Parents or guardians are informed about the child's condition and plan. The surveyor checks each sampled record for the information given and the date.
• Consent is obtained from the appropriate person. The surveyor checks each consent form for the name and relationship of the person who gave it.

How the surveyor verifies this criterion

References

1. WHO (2025). Parent counselling guide on kangaroo mother care (KMC). https://news.gmj.ge/guideline/parent-counselling-guide-on-kangaroo-mother-care-kmc/
2. WHO (2019). Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-children-and-young-adolescents-in-health-facilities/

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.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Every member of staff who cares for children is trained in child protection, and the training is recorded. A named safeguarding lead is in place for every shift and is known to all staff.

Any concern about a child's safety is recorded at the time it is raised and escalated to the safeguarding lead the same day. Each action is tracked until it is closed and the outcome is recorded.

What good looks like

• A child protection and safeguarding escalation procedure (NEO-SOP-004).
• A training record for every member of staff who cares for children.
• A concern record for each concern raised, with the time of escalation.
• Action tracked to closure, with the outcome recorded.

Common mistakes

• A concern noted in the notes but not escalated.
• Training recorded for some staff, not those on night shifts.
• No named safeguarding lead known to the ward staff.
• Actions open for months with no review.

Questions the surveyor asks

• Staff are trained in child protection. The surveyor checks the training record of each member of staff in the sample.
• Every concern is escalated and recorded. The surveyor checks each concern for the time raised, the time escalated and the action.

How the surveyor verifies this criterion

References

1. WHO (2019). Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-children-and-young-adolescents-in-health-facilities/
2. WHO (2017). Responding to children and adolescents who have been sexually abused: WHO clinical guidelines.

Transfers of newborns and children to a higher level of care meet the transfer requirements of Standard 42 (Critical Interfacility Transfer). The receiving unit confirms it can accept the child before the transfer begins.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Before a newborn or child is moved to a higher level of care, the receiving unit confirms that it can accept the child. The confirmation is recorded with the name of the person who gave it and the time.

The transfer follows the structured handover in NEO-SOP-005 and the transfer requirements of Standard 42. Every transfer has a transfer record, and the receiving team is informed before the child leaves.

What good looks like

• A transfer procedure (NEO-SOP-005) that meets the requirements of Standard 42.
• A recorded acceptance from the receiving unit before every transfer.
• A structured handover record that goes with the child.
• Regular review of transfers against the procedure.

Common mistakes

• A baby sent to another unit with no record of acceptance.
• The receiving team learns of the transfer from the ambulance crew.
• No handover record kept after an urgent transfer.
• Transfers reviewed only when something goes wrong.

Questions the surveyor asks

• The receiving unit confirms acceptance before each transfer. The surveyor checks each transfer record for the acceptance, the name of the person and the time.
• Each transfer has a transfer record and a structured handover. The surveyor checks each sampled transfer for the record and the handover content.

How the surveyor verifies this criterion

References

1. WHO (2020). Standards for improving the quality of care for small and sick newborns in health facilities. https://news.gmj.ge/guideline/standards-for-improving-the-quality-of-care-for-small-and-sick-newborns-in-health-facilities/
2. 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