Deterioration of the Newborn

(NEWTT 2)
A Framework for Practice

January 2023
 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Contents
Working group ........................................................................................................................................ 3
Summary: Deterioration of the Newborn ............................................................................................... 4
Introduction ............................................................................................................................................ 5
NEWTT2 .............................................................................................................................................. 5
PIER principles ..................................................................................................................................... 6
Surveys ................................................................................................................................................ 6
Parent information.............................................................................................................................. 7
Table 1: Assessments and monitoring recommended for every newborn baby ................................ 8
Table 2: Monitoring of at risk groups using NEWTT2 observations ................................................... 9
Identification: The NEWTT2 chart ......................................................................................................... 11
What changes have been made and why? ....................................................................................... 11
NEWTT2 Chart ....................................................................................................................................... 12
Escalation and Response ....................................................................................................................... 14
Escalation Tool .................................................................................................................................. 14
Response and Review Tools .............................................................................................................. 14
NEWTT2 Testing and Additional Recommendations ............................................................................ 16
References ............................................................................................................................................ 17

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Working group

Sara Abdula Advanced Neonatal Nurse Practitioner, Chelsea & Westminster Hospital

Annette Ballard Matron, Ipswich Hospital, ESNEFT

Amarpal Bilkhu Trainee, Neonatal Special Interest SPIN, West of Scotland Deanery

Patrick Blundell Paediatric Trainee, University Hospital of Wales, Cardiff

Susan Broster Consultant Neonatologist, Addenbrookes, Cambridge

Elisabeth Corlett Parent representative, NeoMates and School Nurse

Gemma Finch Advanced Neonatal Nurse Practitioner, St Peter’s Hospital, Chertsey

Tony Kelly National Clinical Advisor for National Maternity and Neonatal Safety
Improvement Programme, NHS England and NHS Improvement
John Madar Consultant Neonatologist, University Hospitals Plymouth

Kathryn Macallister Neonatal GRID Trainee, BAPM Trainee EC Representative, Co-Chair

NEWTT2 working group
Shalini Ojha Consultant Neonatologist, University Hospitals of Derby and Burton

Kelly Phizaclea Parent representative, NeoMates

Oliver Rackham Consultant Neonatologist, Glan Clwyd Hospital, North Wales

Hannah Rutter Registered Midwife and Senior Improvement Manager

Maternity and Neonatal Safety Improvement Programme
NHS England and NHS Improvement
Wendy Tyler Consultant Neonatologist, BAPM Honorary Treasurer, Chair NEWTT2
working group

(Members listed in alphabetical order.)

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Summary: Deterioration of the Newborn

1. This framework is designed for use in postnatal care settings including the delivery suite,
postnatal ward and transitional care unit.
2. The framework describes at risk groups of newborns and provides an updated Newborn Early
Warning Trigger and Track (NEWTT2) chart.
3. The NEWTT2 chart and framework encompass parental concern to acknowledge the
importance of the opinion of the family in addition to the wider multi-disciplinary team.
4. This extended framework provides an escalation tool and a standard response and review
tool for the multidisciplinary team to use jointly.
5. The framework uses the PIER principles adopted by the National Patient Safety Improvement
Programme.
6. Recommendations for assessment and monitoring are given for all newborn infants (Table 1)
and for at risk groups (Table 2).
7. Frequency of observations are determined by national guidance and frameworks for practice
where available.
8. Numerical values are assigned to yellow-amber (a score of 1) and pink-red (a score of 2)
triggers to permit a total NEWTT2 score to be calculated and documented.
9. The total NEWTT2 score informs the escalation response including who is responsible and the
timing of a review and supports further escalation if indicated.
10. The escalation and response tools use standardised language to minimise the potential for
errors in communication and encourage joint multi-disciplinary team working.

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Introduction
Every newborn infant should be provided with the environment and healthcare professional support
required to enable the transition of their physiology following delivery, the establishment of infant
feeding, and the early development of the family. Additionally, they should be protected to prevent
avoidable morbidity and mortality during this phase of adaptation. While the majority of newborn
infants require only short-term surveillance there are groups at risk of developing complications
particular to the perinatal period (1-10). By planning and preparing for these at risk newborn infants
we aspire to prevent morbidity that could have life-long consequences for their health and
wellbeing.

There is no clear evidence of the effectiveness of any specific system or set of observations in the
newborn. The National Reporting and Learning System (NRLS) does however identify delays in
response to deteriorating observations as contributory to the morbidity of hospitalised patients and
NHSE is promoting the development of early warning systems across all disciplines (11).

This framework is designed for use in postnatal care settings including the delivery suite, postnatal
ward and transitional care unit. In the rare event that a baby is deteriorating or at risk of
deterioration in a community setting (home or midwifery-led unit (MLU)) the NEWTT2 chart can be
used to support monitoring of the baby while transfer to the consultant unit is undertaken without
delay (12). The NEWTT2 working group advise immediate contact with the neonatal team and
urgent transfer into the consultant unit from community settings for infants with any observations
outside the acceptable normal range. NEWTT2 is not designed to be used for patients being cared
for on a paediatric ward.

NEWTT2
The revised deterioration of the newborn framework for practice describes at risk groups and
provides an updated Newborn Early Warning Trigger and Track (NEWTT2) chart aligning to current
recommendations for newborn care and acknowledging feedback from healthcare professionals.
The chart encompasses parental concern to acknowledge the importance of the opinion of the
family in addition to the wider multi-disciplinary team. The inclusion of parental concern supports
concerns highlighted and recommendations made in recent national maternity investigations (13-
15).
When to escalate and call for assistance using the NEWTT tool has been described previously and
this update builds on this advice. The extended framework provides an escalation tool and a
standard response and review tool for the multidisciplinary team to promote consistency between
healthcare professionals and ensure that the team and family are involved in and fully informed of
the actions required for a baby to receive safe and quality care. The response tool facilitates the
documentation of the response taken and subsequent actions required.

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

PIER principles

This framework was developed using the PIER principles adopted by the National Patient Safety
Improvement Programme (Figure 1):
P: Planning, preparation and prevention ensure that all newborn infants at risk of deterioration
after birth are identified, have their risks clearly communicated and that actions are taken to
minimise these and intervene where required.
I: Identification of any change in their physiological parameters, clinical examination, or behaviour,
as well as any concerns raised by their parents or caregivers facilitates early escalation for
intervention where indicated.
E: Escalation ensures appropriate involvement of the multi-disciplinary team in a timely manner that
is standardised
R: Response tools promote a consistent approach by providing a data set for multidisciplinary team
assessment and management of a neonate with triggers on the NEWTT2 chart.

Figure 1: NHS National Patient Safety Improvement Programme PIER principles applied to NEWTT2

Surveys

Two national surveys were conducted to inform the development of this framework. The results of
the first survey revealed that the majority of UK units were using a neonatal early warning score, and
that 79% of these were using the NEWTT tool or a modified version. Adaptations made locally
included enhanced instruction for when a neonate would trigger a medical review, adding guidance
around timescales for escalation and including details of the frequency and duration of observations
for different risk factors. Whilst certain elements of the framework will need to be determined at an
individual Trust level, depending on local factors such as staffing skill mix and environment, the
NEWTT2 framework supports a consistent approach to the identification and observation of at risk
newborn infants, and to the escalation and response when a trigger level is reached.
The second survey was distributed to health professionals to gather opinions relating to the current

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

version of NEWTT and to suggest changes identified in practice. The electronic survey was
disseminated via social media and BAPM and other organisational newsletters. 430 responses (162
midwives; 90 consultant paediatricians/neonatologists; 83 neonatal nurses; 42 nurse practitioners;
34 junior doctors; 12 health care assistants; and 5 others) were received. Users of the tool mostly
agreed with current recommendations. Some key areas were identified as needing revision including
aligning the revised NEWTT2 recommendations with current NICE and other national
recommendations such as for management of infants at risk of sepsis and for neonatal
hypoglycaemia. Many respondents suggested removing bilirubin levels from the chart. The survey,
overall, suggested agreement with current recommendations and improved clarity of instructions,
avoidance of unnecessary recordings, and aligning with national guidance and emerging practices
(16,17).

A full analysis of all the responses is given in Appendix 7.

Parent information

Parents and caregivers have an important role to play in identifying any changes in their baby which
should trigger a further review by the clinical teams responsible for their care. For
parents/caregivers to be able to advocate for their child it is essential that clinical teams explain
verbally what the purpose of the NEWTT2 Tool is and describe the signs/symptoms that the clinical
team are using this tool to look for. This information should be supplemented by signposting
parents/caregivers to appropriate written material e.g. NHS Illness in Newborn Babies leaflet;
Neonatal Infection: antibiotics for prevention and treatment NH195.

In addition to outlining the purpose of the NEWTT2 Tool, it is important for clinical teams to
maintain an open dialogue with parents/caregivers, ensuring that families are listened to, including
when their concerns fall outside the immediate scope of this tool. Acknowledging these concerns
and making a clear plan together with the parents/caregivers to keep their baby safe and well is an
important part of shared care between the clinicians and the family supported by national maternity
investigations (13-15). It is essential that all such conversations explaining the NEWTT2 Tool and/or
raising concerns are clearly documented in the clinical records and should include the agreed plan
and next steps.

Plan, Prepare, Prevent

Recommendations for assessment and monitoring are given for all newborn infants (Table 1) and for
at risk groups (Table 2). Frequency of observations are determined by national guidance and
frameworks for practice where available.

A summary quick reference version of Table 2 is available in Appendix 1.

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Table 1: Assessments and monitoring recommended for every newborn baby

Recommendation Frequency
Immediately Follow recommendations for recording observations given within NICE postnatal
following birth and national guidance (3, 4, 18) care, NICE
within the first hour intrapartum care
of life and RC (UK) NLS
guidance
Identify any risk factors that require observations or intervention
Prior to and
within the first hour of life such as management of early onset
following birth to
bacterial infection
enable timely
intervention
Perform the initial midwifery examination to detect any major
physical abnormality and identify any problems that require referral Once
During skin-to-skin For a significant minority of infants positioning for skin-to-skin Throughout every
contact contact may have contributed to sudden unexpected postnatal skin-to-skin
Skin-to-skin contact collapse and serious adverse outcome (7). contact
is recommended for The level of risk for sudden collapse during skin-to-skin contact is
newborn infants influenced by maternal body mass index, antenatal use of opiate
within the first hour medication, sedation and staff focus on other tasks.
to promote
Airway and breathing - check the baby’s position is such that a clear
thermoregulation,
airway is maintained – observe respiratory rate and chest
colonisation with
movement. Listen for unusual breathing sounds or absence of noise
maternal flora and
from the baby.
biological nurturing
Colour – the baby should be assessed by looking at the whole of the
baby’s body as the limbs can often be discoloured first. Subtle
changes to colour indicate changes in the baby’s condition.
Tone – the baby should have a good tone and not be limp or
unresponsive
Temperature – ensure the baby is kept warm during skin contact
1-2 hour of age Record body temperature soon after the first hour (3). Target the Until target
temperature range 36.5-37.5oC. reached
Feeding and Follow UNICEF guidance providing information to assess infant Continuous
excretion feeding including frequency of feeds, wet and dirty nappies assessment with
(19). parent
Newborn infants considered suitable for early discharge should have
a risk assessment completed by the maternity team that
incorporates feeding establishment (3, 6).
If there are any concerns regarding feeding, observations using the
NEWTT2 tool are recommended with escalation for review as
indicated. Bilious vomiting warrants immediate escalation.
Jaundice Examine* all infants for jaundice at every opportunity especially At every contact
within the first 72 hours; if jaundiced monitor bilirubin and use
gestational age charts to guide treatment (5).
At risk groups include gestation <38 weeks, previous sibling
requiring treatment, male, low birth weight, multiple birth and Asian
ethnicity (1, 5). *skin, cornea, gums
NICE: National Institute Clinical Excellence; RC (UK): Resuscitation Council UK ; HSIB: Healthcare Safety
Investigation Branch; UNICEF: United Nations Children’s Fund; ATAIN: Avoiding Term Admissions Into Neonatal
Units

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Table 2: Monitoring of at risk groups using NEWTT2 observations

At risk groups Recommendation Frequency
Risks identified Fetal compromise (refer to hypoglycaemia) NICE intrapartum
intrapartum care guidance
Meconium-stained amniotic fluid (MSAF)
(2017)
Newborns delivered in the presence of thick, particulate meconium
At 1 & 2h, then 2
should be observed for at least 12 hours as detailed in NICE
hourly until 12
intrapartum care guidance; such infants should be observed on a site
hours
with access to a resident neonatal team (4).
For all other newborns where meconium is present observe for 2 hours At 1 & 2 hours
in all care settings.
Risks Elective pre-labour Caesarean section <39 weeks’ gestation Not set by national
associated with Evidence advises against pre-labour Caesarean section prior to 39 guidance*
mode of weeks’ gestation to avoid adverse outcomes. Admission to a neonatal
delivery unit with respiratory distress is more likely (1, 20, 21).
Newborns born before arrival of a healthcare professional (BBA)
Rates of neonatal unit admission are increased in this cohort, with the
most likely complications including hypothermia, suspected infection
and respiratory distress (22, 23)
Infants at risk Newborn infants with infection can deteriorate rapidly or insidiously NICE neonatal
of early onset and often after a period of apparent health. infection guidance
infection It is recommended that the following newborn infants are monitored for risk factors and
using the NEWTT2 tool: clinical indicators
Infants with risk factors for early-onset infection (2)
Infants with clinical indicators for early-onset infection (2)
Infants being treated with antibiotics for early-onset infection
Not set by national
Other infants being treated with antivirals or alternative intravenous
guidance*
antibiotics for other indications in the newborn period
Infants at risk Significant hypoglycaemia can lead to irreversible brain injury. BAPM
of Monitoring newborn infants at risk of developing hypoglycaemia or Hypoglycaemia
hypoglycaemia those with concerning clinical signs, such as a reluctance to feed or any Framework for
deterioration in feeding behaviour, has the potential to prevent the practice
life-long impact of brain injury.
Recommendations made are in line with national documents (1, 9):
In-utero growth restriction (≤ 2nd centile plotted on gestational age and
sex-specific charts) and/or evidence of clinical wasting in keeping with
growth-restriction in utero
The need for resuscitation and/or fetal compromise (IPPV at 5 min of
age, low cord pH ≤ 7.1, low Apgar score ≤ 7@5 minutes, Base deficit
>/=12.0)
Maternal B-blocker medication
Maternal diabetes mellitus
Late preterm infants (34+0 – 36+6 weeks gestation)
Hypothermia not improving with initial steps to provide thermal care
(see NEWTT2 chart)
Suspected/confirmed early onset infection
Abnormal feeding behaviour including not waking for feeds, an
ineffective suck, being unsettled and demanding very frequent feeds or
a deterioration in feeding (10)
Infants Consider observing infants using NEWTT2 who have not been described BAPM Transitional
requiring elsewhere and who are admitted to transitional care as described in Care Framework

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

transitional the BAPM Transitional Care framework for practice (8).

care

Infants with Early jaundice in the first 24 hours mandates a bilirubin measurement NICE jaundice
early jaundice and a clinical assessment. The use of the transcutaneous guidance
within 24 hours bilirubinometer is not recommended within 24 hours of birth (5).
of birth
Infants Grunting respirations Not set by national
demonstrating Newborn infants with transitional grunting commencing at birth guidance*
clinical signs without any respiratory distress are usually healthy and do not require
that warrant escalation in care (1). The NEWTT2 observation chart can support
additional assessment of these infants and guide escalation.
monitoring Any new grunting developing following birth is not consistent with NICE early onset
transitional grunting and warrants escalation to the neonatal team (2). infection guidance
Feeding concerns without other risks
NICE early onset
Any newborn infant with concerns regarding feeding should be
infection guidance
observed using the NEWTT2 tool. Feed refusal or reluctance to feed are
symptoms of concern for sepsis and/or hypoglycaemia and should
trigger a neonatal team review (6, 10). Bilious vomiting warrants
immediate escalation.
Reduced tone or behaviour NICE early onset
Newborn infants with altered behaviour or tone warrant observations infection guidance
using the NEWTT2 tool with escalation as indicated. Poor tone or
inactivity can be signs of sepsis or hypoglycaemia and warrant
escalation (1, 10).
Not set by national
Elevated lactate identified on cord or neonate blood gas
guidance*
This can reflect concerns with fetal or neonatal wellbeing. Umbilical
cord blood lactate of 4 mmol/L has been shown to predict adverse
outcome (need for intubation, hypoxic-ischaemic encephalopathy,
meconium aspiration syndrome) in term infants. Such elevated cord or
early neonatal blood lactate levels should prompt a neonatal team
assessment. A repeat blood lactate measurement in 4 to 6 hrs may be
appropriate to ensure a falling or normal blood lactate (24-28).
Maternal Maternal opiate pain relief <6 hours prior to delivery Not set by national
medications Due to the effect on respiratory drive and establishment of feeding, guidance*
potentially infants warrant monitoring using the NEWTT2 chart.
impacting on
Maternal drugs of addiction, prescribed or illicit
newborn
Use of a neonatal withdrawal scoring chart is indicated as determined
behaviour
by local or regional guidelines
Prescribed maternal SSRIs and SNRIs and other psychotropic
medications within the 3rd trimester
Assessment in the first few hours after birth to ensure effective
transition and absence of clinically significant persistent pulmonary
hypertension of the newborn, and ongoing assessment of infant
behaviour including feeding is advised (29).
Monitoring frequency
*For monitoring using NEWTT2 beyond 12 hours of age, or for those at risk groups where clear
recommendations are not within national guidance, consider performing NEWTT2 observations at 4-hourly
intervals. It is not possible to be prescriptive for each infant’s unique situation and observations may need to
be more or less frequent in order to ensure safe care and provide an appropriate balance between
observations of, and interruptions to, the parent and baby. Please refer to your local guidance where present.

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Identification: The NEWTT2 chart

NEWTT2 is an evolution of the previous system and is based upon the ability to ‘track’ the
behaviours and observations of infants deemed to justify observation over time to identify trends.
When variables fall outside the defined ‘normal’ range then actions are ‘triggered’ based upon the
degree/magnitude of the deviation. A progressive ‘amber/red/purple’ scale defines the extent of the
change and guidance on the actions to be undertaken should variables move into the alert zones.
At any single time point when observations are taken, values within the amber or red zone
contribute to a total ‘score’ for the infant which will either achieve the threshold for an action or
indicate that the infant remains within the defined ‘safe’ zone. Even in the ‘safe’ zone, however,
trends may be observed over time which indicate emerging instability, and even if thresholds are not
crossed, trends might also prompt earlier review or more frequent observations. Scores within the
purple zone warrant urgent neonatal review.

Healthcare professional concern can initiate a neonatal review at any time regardless of the zone
colour of an observation or total score.

The tool draws upon previous experience including a review of existing tools (30-39). It is a
consensus document in the absence of objective evidence on the precise nature of the key
parameters and thresholds to guide escalation.

What changes have been made and why?

• Numerical values are assigned to yellow-amber (a score of 1) and pink-red (a score of 2)

triggers to permit a total score to be calculated and documented.
• The total score informs the escalation response including who is responsible and the timing
of a review and supports further escalation if indicated.
• The previous box for urgent referral has been incorporated into the NEWTT2 chart identified
as purple coloured trigger boxes.
• Mild hypothermia requiring immediate intervention to prevent further deterioration is
highlighted in blue.
• Respiratory rate ranges are aligned with NICE postnatal care guidance (3).
• Feeding and neurological behaviour assessments score separately for clarity and to support
findings from HSIB (6).
• Blood glucose measurements (where taken) are aligned with the BAPM hypoglycaemia
framework for practice (9).
• Parental concern is included to support the findings of the Ockenden report (13).
• Bilirubin is not within the NEWTT2 chart; please use the NICE Jaundice guidance charts to
plot bilirubin values to guide treatment (5).
• The chart now permits, for any set of observations, a record of whether any threshold of
concern has been reached and for any action taken.
• Guidance for completion of the NEWTT2 chart provides additional information for the health
care professionals using the tool. Training to support the completion of the NEWTT2 tool,
knowledge of escalation thresholds and the need for shared responsibility should be given
to all healthcare staff prior to implementation and certainly prior to use for patient care.

NEWTT2 guidance for completion: see Appendix 2.

NEWTT2 front of chart: see Appendix 3.

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Newborn Early Warning Name:
Track and Trigger (NEWTT 2) Date of Birth:
Time of Birth:
NEWTT2 score 0 1 2 Hospital Number:
A score for each vital sign is required NHS Number:
at each entry
ANY critical (PURPLE) observation = immediate escalation. Consider 2222
Reason for observations Signed Print name & GMC/NMC number
Frequency & duration
Date
Time
Temperature 39.0
2
39.0
2
°C 2
38.0 38.0
1
0
37.0 37.0
0
1
36.0 36.0
2
2
Temperature alert: Implement thermal control measures and re-check temperature within 1 hour
2
Respirations 80
1
80
Breaths/min 1
70 70
1
1
60 60
0
0 50
50
0
0 40
40
0
0
30 30
1
2
20 20

Grunting present? 1
2
Heart rate 180
2
180
Beats/min 170
1
170
1
160 1 160
0
150 0 150
0
140 0 140
0
130 0 130
0
120 0 120
0
0
110 110
0
0
100 100
1
1
90 90
1
1
80 80
2
2
60 60

SpO2 <90% (or very pale / Blue)

Colour

SpO2 90–94% 1
SpO2 ≥95% (or Pink / Normal) 0
Unrousable / Floppy / ?Seizure
Neuro

Lethargy / Irritable / Poor tone 1

Responsive / Good tone 0
Not feeding 2
Feeds

Feeding reluctantly 1
Feeding well 0
High parental concern 2
Carer

Some parental concern 1

No parental concern 0
< 1.0 mmol/l
Glucose

1.0 – 1.9 mmol/l 2

2.0 - 2.5 mmol/l 1
≥ 2.6 mmol/l 0
Glucose when measured – Should be considered in any baby feeding reluctantly/poorly, or other observations suggest unwell

NEWTT2 TOTAL TOTAL

Monitoring frequency Monitoring
Escalation of care YES/NO Escalation
Initials Initials
Refer to back page for thresholds and triggers
Newborn Early Warning
Trigger & Track 2 (NEWTT2)

How to use the NEWTT2 trigger and track tool to determine the level and timelines
of escalation
Calculate and document the total NEWTT2 score for a set of observations by adding together the
individual scores (0-2) for every individual observation entered in a single column of the chart
Check the total against the NEWTT2 escalation tool and follow instructions in the escalation table for
that set of observations
Healthcare professional concern can initiate a neonatal review at any time regardless of the zone
colour of an observation or total score
For a score of zero continue routine care

Thresholds and Triggers

• The grade of team member indicated as the primary contact for each level of clinical concern is a guide and may
need to be adapted depending on the local skill mix within that care setting or organisation
Score 1 Score 2-3 Score 4-5 Score ≥6 Any critical
observation
Inform shift leader - Consider SpO2 +/- blood glucose if not done already
Primary escalation Repeat Refer to paediatric/ Refer to paediatric/ Refer to paediatric/ Refer to paediatric/
and response (use observations in <1 neonatal Tier 1 neonatal Tier 1 neonatal Tier 1 neonatal Tier 1
SBAR framework) hour doctor/ANNP doctor/ANNP doctor/ANNP. doctor/ANNP AND
The Tier 2 doctor/ Tier 2 doctor/ANNP
ANNP should be .
informed

Review timings Escalate as for Request a Request a Request Immediate review

score 2-3 if the review within review within immediate and consider
repeat score 1 hour 15 minutes review neonatal emergency
remains 1 call (2222)

Take steps to manage/address any obvious concerns/problems

Secondary If no review within expected time frame, escalate
contact to Tier 2 doctor/ANNP and inform shift leader If no review within expected time
frame, escalate to consultant and
If still no response within required time inform shift leader
frame, escalate to consultant

• When the primary team member(s) contacted is unable to attend or fails to attend within the expected time for the level
of clinical concern, escalation to the secondary contact is required
• The secondary contact would be expected to attend within the initial review timing, calculated from the documented
time of primary escalation

SBAR Handover
S Situation

B Background

A Assessment

R Recommendation
Document all actions and discussions in patient record
 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

Escalation and Response

This framework builds on the previous 2015 NEWTT framework, providing a standardised pathway
for responding to infants who display abnormal observations and reach a trigger on the NEWTT2
tool. Experiences of the working group confirmed variation between units in how quickly infants
with abnormal observations are reviewed and by whom, leaving some infants at risk of further
deterioration if they are not seen and adequately assessed in a timely fashion.
A review of current literature did not identify relevant evidence to inform either the time frame or
level of response; consequently, the recommendations produced are a consensus opinion. We
recommend evaluation of the framework in order to review the escalation and response pathway.
A key feature is the use of standardised language to minimise the potential for errors in
communication. The seniority of review required is described in terms of Tier 1, 2 or 3. We use
simple, recognised, safety-critical language, including an assessment of whether the infant is ‘well’
or ‘unwell’ at the point a review is triggered. All escalation and handover should use an SBAR
(Situation, Background, Assessment, Recommendation) structure, as this has been shown to reduce
adverse clinical events and improve perception of effective communication (40).
A second key feature is the shared responsibility between all healthcare professionals and parents.
The concept that involvement with a patient is complete once a review has been requested or
performed is discouraged, and the concept of joint ownership and collaboration between all is
promoted. The pathway mandates that parents are updated by the multi-disciplinary team after any
review, and the NEWTT2 tool ensures ‘parental concern’ is documented as an abnormal observation.

Contemporaneous sharing of accurate information throughout the process including at the point of
escalation, during and following review with the wider multidisciplinary team is essential (41).

The escalation and response pathway has been designed to align with current MEWS (Maternal Early
Warning Score) and PEWS (Paediatric Early Warning Score) pathways to reduce error.

Escalation Tool

This is a decision support tool and designed as the reverse of the NEWTT2 chart. This guides
healthcare professionals through the appropriate timeliness and level of response required.
Escalation Tool NEWTT2 reverse of chart: see Appendix 3 (hyperlink here)

Response and Review Tools

We have produced several documents to standardise the response to infants who display abnormal
observations on the NEWTT2 chart. These can be found in Appendices 5-7 and are designed to be
used as paper documents or integrated into electronic systems to support decision-making.
NEWTT2 Escalation Record: see Appendix 4 – this is designed as a sticker, a separate
document, or a dataset for electronic patient records to be completed by the person
escalating when a baby triggers.
Response Record: see Appendix 5 – this can be used as a sticker, a separate document, or a
dataset, to be completed by the doctor or ANNP reviewing the infant, prompting them to
consider further investigation or review and providing a reminder to update the parents.
Joint Escalation and Response Record: see Appendix 6 – this incorporates the information
from both Appendix 5 & 6 described above and is designed to document the entire process
from trigger through to medical review, repeat medical review if required, to parent update
and clinical care.

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These documents seek to replace existing documentation to avoid additional workload. We

anticipate that units will implement the escalation and response tools which best suit their needs,
depending on the structure of their medical and nursing notes as well as the skill mix of the
healthcare professionals using the NEWTT2 chart.

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 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

NEWTT2 Testing and Additional Recommendations

The NEWTT2 framework for practice has been tested prior to consultation using clinical observation
data, and through prototype testing assessing accuracy of use and preference of layout for the
escalation tool. Additional testing for colour followed the framework’s consultation feedback. Prior
to final publication, point of care clinical implementation testing within pilot Trusts supported the
content and practical application of the NEWTT2 tool. Instructions for hypothermia were adapted to
be in line with a score of 1.

The Deterioration of the Newborn framework for practice including the NEWTT2 tool is owned by
the British Association of Perinatal Medicine (BAPM). Development and testing have been in
conjunction with the National Maternity and Neonatal Safety Improvement Programme, NHS
England and NHS Improvement. Implementation and use of the framework within individual
organisations is the responsibility of each individual Trust. All feedback from individual Trusts or
other organisations should be directed to the BAPM office (bapm@rcpch.ac.uk).

Perinatal units should audit compliance with the NEWTT2 framework, and all unexpected neonatal
unit admissions should be formally reviewed, including adherence to recommended NEWTT2
monitoring. Awareness of frequency and category of admissions, coupled with thematic analysis of
learning from reviews can support local perinatal teams target resources to improve.

National research should be planned to evaluate the utility of the NEWTT2 framework, including
identification of at risk groups, physiological parameters, frequency of monitoring and the ability of
the tool to identify early, or even to prevent, deterioration in health and improve longer-term
outcomes.

© BAPM, 2023 16
 Deterioration of the Newborn (NEWTT 2)
A BAPM Framework for Practice

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Thank you to Dr Sanjeev Deshpande for his contribution to the section on lactate levels in the
perinatal period and to Dr Helen Mactier for her guidance.

© BAPM, 2023 18
Leading Excellence in Perinatal Care

This document was produced by the

British Association of Perinatal Medicine (BAPM).

BAPM a membership organisation that is here to support

all those involved in perinatal care to optimise their skills
and knowledge, deliver and share high-quality safe and
innovative practice, undertake research, and speak out for
babies and their families.

We are a professional association of neonatologists,

paediatricians, obstetricians, nurses, midwives, trainees,
network managers and other health professionals
dedicated to shaping the delivery and improving the
standard of perinatal care in the UK.

Our vision is for every baby and their family to receive the
highest standard of perinatal care. Join us today.

www.bapm.org/join

British Association of Perinatal Medicine (BAPM)

is registered in England & Wales
under charity number 1199712 at
5-11 Theobalds Road, London, WC1X 8SH