World Health Organization · 1st edition, 2020 · 152 pages
A comprehensive framework of 8 standards and 68 quality statements for inpatient care of preterm, low-birth-weight and sick newborns.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2020
- Audience
- Policy-makers, health service planners, programme managers, regulators, professional bodies, neonatologists, paediatricians, nurses, midwives, technical partners
- Evidence
- Based on WHO guidelines, Cochrane systematic reviews, expert consensus; quality measures adapted from NICE quality standards methodology
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 152-page WHO technical document establishes global standards for inpatient care of small (birth weight <2500 g) and sick newborns in health facilities. It defines quality of care across eight domains: evidence-based practices, actionable information systems, functioning referral systems, effective communication, respect for newborn rights, emotional and developmental support, competent human resources, and essential physical resources.
The standards are built on the recognition that approximately 2.5 million newborns die annually in the first 28 days of life, 80% of whom had low birth weight and two-thirds were born prematurely. The framework emphasizes family-centred care, kangaroo mother care (KMC), early exclusive breastfeeding, safe oxygen therapy, continuous positive airway pressure (CPAP), surfactant replacement, infection prevention, and developmental supportive care. Each standard includes quality statements with measurable input, process, and outcome indicators.
The document integrates newborn rights as central to care delivery, acknowledges that newborns feel pain and benefit from nurturing interaction, and stresses that care must never separate babies from their families unnecessarily. It provides specific guidance on respiratory support (targeting oxygen saturation 90–95% in preterm infants), feeding (exclusive breast milk when possible), thermal care (KMC for stable infants <2000 g), and management of common complications including jaundice, seizures, hypoglycaemia, and neonatal encephalopathy.
Key points
For clinicians — doses and thresholds as stated in the guideline
- All newborns <2000 g or preterm should receive kangaroo mother care (KMC) as soon as clinically stable; nearly continuous skin-to-skin contact reduces mortality by 50% and sepsis by 60%
- Preterm newborns ≤32 weeks requiring respiratory support start on 21–30% oxygen (not 100%), titrated to maintain oxygen saturation 90–95% using pulse oximetry
- Newborns with respiratory distress receive CPAP as soon as diagnosis is made; surfactant replacement therapy is given to preterm infants within the first 2 hours of birth
- All newborns receive 1 mg vitamin K intramuscularly as soon as possible after birth; very-low-birth-weight infants also receive vitamin D, calcium, phosphorus and iron supplements
- Hypoglycaemia is defined as blood glucose <2.5 mmol/L (45 mg/dL); at-risk newborns (preterm, low birth weight, asphyxia, maternal diabetes) are screened and managed promptly
- Preterm infants <32 weeks receive caffeine or another methylxanthine to prevent apnoea; therapeutic hypothermia for moderate-to-severe hypoxic ischaemic encephalopathy is provided only in well-resourced neonatal ICUs
- All newborns are exclusively breastfed or receive expressed breast milk when possible; assisted feeding by cup or nasogastric tube is used when needed, avoiding bottles and teats
- Standard infection prevention includes hand hygiene per WHO standards, one newborn per incubator/cot, appropriate spacing between beds, and cleaning protocols; during outbreaks, staff wear personal protective equipment as recommended
Eight standards for improving quality of care for small and sick newborns
Table extracted from the guideline
| Standard | Theme | Focus |
|---|---|---|
| 1. Evidence-based practices | Provision of care | Routine care and management of complications per WHO guidelines |
| 2. Actionable information systems | Provision of care | Collection, analysis and use of data for early action |
| 3. Functioning referral systems | Provision of care | Timely referral with continuity of care including transport |
| 4. Effective communication | Experience of care | Meaningful participation and parental involvement |
| 5. Newborn rights and dignity | Experience of care | Respect, protection and fulfilment without discrimination |
| 6. Emotional and developmental support | Experience of care | Family-centred developmental care and follow-up |
| 7. Human resources | Health system | Competent, motivated, empathetic multidisciplinary staff |
| 8. Physical resources | Health system | Appropriate environment, water, sanitation, energy, medicines, equipment |
Source: World Health Organization, Standards for improving the quality of care for small and sick newborns in health facilities. Reproduced in summary form.
From the guideline
Verbatim
“Kangaroo mother care reduces neonatal mortality, halving the number of deaths among infants weighing < 2000 g. Kangaroo mother care also reduces infection and sepsis rates by nearly 60%.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As WHO consultant and chair of the Public Health Institute of Georgia, I see these standards as a roadmap for bridging the quality gap between tertiary centres in Tbilisi and regional maternity hospitals. Georgia has invested in Universal Health Coverage since 2013 and maternal-child health infrastructure, yet neonatal mortality from prematurity and intrapartum complications remains higher than the European average, particularly in rural areas. The single most actionable recommendation for Georgian clinicians is the immediate, universal adoption of kangaroo mother care for stable newborns under 2000 grams—a zero-cost intervention with proven 50% mortality reduction that requires only training, space for rooming-in, and a culture shift away from routine separation of mothers and babies. The caveat is infrastructure: implementing safe oxygen therapy, CPAP, and pulse oximetry at level II and III facilities requires not only equipment procurement but sustainable maintenance contracts, uninterrupted oxygen supply, and competency-based training of neonatal nurses—investments that must be planned now within the State Programme for Maternal and Child Health and the accreditation framework.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia has made substantial progress in reducing neonatal mortality (from 12.8 per 1000 live births in 2010 to 6.5 in 2019), yet challenges remain in caring for very preterm and very-low-birth-weight infants, particularly in regional facilities. Implementation of these standards would require: (1) establishing designated levels of neonatal care with clear referral pathways and integrated newborn networks; (2) ensuring availability of essential equipment (pulse oximeters, CPAP devices, phototherapy, infusion pumps) and supplies (surfactant, caffeine, appropriate-size nasal prongs) at referral centres; (3) training neonatal nurses and physicians in KMC, safe oxygen therapy, developmental care, and family-centred communication; (4) strengthening infection prevention and control, particularly hand hygiene compliance and environmental cleaning; and (5) implementing routine data collection on prematurity, birth weight, and neonatal morbidity using standardized definitions. Georgia’s Universal Health Coverage programme and public health infrastructure provide a platform for systematic scale-up, though investment in neonatal transport systems and follow-up services for high-risk infants would be essential.
Questions this guideline answers
Quick answers
When should kangaroo mother care (KMC) be started for preterm or low-birth-weight babies?
KMC should be initiated as soon as possible after birth for all clinically stable newborns weighing <2000 g or born preterm. The baby is placed in continuous skin-to-skin contact with the mother, breastfed frequently and exclusively, and can be discharged early once gaining weight, maintaining temperature, and the mother is confident. Unstable babies are cared for in an incubator or under a radiant warmer until stable enough for KMC.
What oxygen saturation targets should be used for preterm newborns on respiratory support?
Preterm newborns born at or before 32 weeks of gestation who require respiratory support should be started on 21–30% oxygen (not 100% oxygen). Oxygen saturation should be maintained between 90% and 95%, guided by continuous pulse oximetry. The need for increasing oxygen concentrations should be regularly reviewed. Lower oxygen concentrations reduce mortality and retinopathy of prematurity.
How is neonatal hypoglycaemia defined and managed?
Hypoglycaemia is defined as blood glucose <2.5 mmol/L (45 mg/dL). At-risk newborns—those born preterm, with low birth weight, sepsis, hypothermia, hypoxic ischaemic encephalopathy, polycythaemia, inadequate feeding, or born to diabetic mothers—should have blood glucose checked routinely. Management includes appropriate feeding (breast milk is best), and dextrose gel or intravenous 10% dextrose if needed. All newborns with seizures must have blood glucose checked immediately.
Which newborns should be screened for retinopathy of prematurity (ROP)?
Screening protocols vary, but typically preterm infants born at <30–32 weeks' gestation or weighing <1500 g at birth should be screened by an experienced ophthalmologist starting around 4–6 weeks of age. The examination schedule depends on gestational age at birth and disease severity. Timely treatment reduces the risk of visual loss. Lower oxygen concentrations (targeting saturation 90–95%) during respiratory support reduce ROP incidence.
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- Issuer
- World Health Organization
- Type
- Standards
- Edition
- 1st edition, 2020
- Status
- Current
- Published
- 2020-09-02
- Languages
- English (original); translations available in multiple languages via WHO repository
- Scope
- Global; applicable to all health facilities providing inpatient newborn care, adaptable to resource settings
- Audience
- Policy-makers, health service planners, programme managers, regulators, professional bodies, neonatologists, paediatricians, nurses, midwives, technical partners
- Pages
- 152
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978 92 4 001076 5
- Evidence
- Based on WHO guidelines, Cochrane systematic reviews, expert consensus; quality measures adapted from NICE quality standards methodology
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Standards for improving the quality of care for small and sick newborns in health facilities. Geneva: World Health Organization; 2020. 152 p. Licence: CC BY-NC-SA 3.0 IGO. ISBN 978-92-4-001076-5.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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