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The objective of early feeding is to stimulate gut maturation, motility and hormone release. As starvation leads to atrophy of the gut, withholding feeds may render subsequent feeding less safe and protract the time to reach full enteral feeding. (2) A systematic review of 10 trials of early introduction of feeding conducted in 2005 (9) concluded that early introduction of feeding did not increase the incidence of NEC and shortened the time to both full feeds and discharge. This review was updated in 2013 (11) and the conclusions remained the same. These findings were confirmed by a further controlled trial along with a significant reduction in serious infections with "early" enteral feeding. (43) Preliminary reports from the ADEPT trial indicate that growth restricted preterm infants born after absent or reversed end-diastolic flow in the umbilical artery who are fed from the second day after birth achieve full feeds earlier than those commencing feeds on day 6 with no increase in the incidence of sepsis or NEC(8). No work has yet addressed whether initial feeds should be exclusively breast milk (mother's own or donor); most evidence suggests that any enteral feed given early may be better than gut starvation.(12)
Colostrum as mouth care
Studies have been conducted comparing colostrum with sterile water as mouth care and outcomes conclude that oropharyngeal administration of colostrum may decrease clinical sepsis, inhibit secretion of pro-inflammatory cytokines, and increase levels of circulating immune-protective factors in extremely premature infants. (10)

In addition, in sick and/or preterm infants, it has been shown to:

They also comment that when infants are able to absorb colostrum through the oral mucosa they also absorb maternal antibodies and anti-inflammatory substances which are protective against disease and infection. (9)

A study by Lee et al (2015) reported reduced rates of ventilator acquired pneumonia, infection and necrotising enterocolitis in infants who were given colostrum as mouth care versus sterile water. (10)

No studies have been conducted comparing the protective benefits of colostrum as mouth care versus trophic feeding. Larger studies are warranted in particular looking at the oropharyngeal exposure to colostrum as a potential protective measure against sepsis and NEC.
Trophic feeding
Trophic feeds are small volumes of milk given to stimulate the bowel that are maintained for up to 7 days and not intended to contribute to nutrition. The maximum volume is 1ml/kg/hour or 24ml/kg/day.(9) There is no recognised consensus on duration or method of delivery.(10)

Evidence suggests that trophic feeding is beneficial for reducing length of stay and infection rates without increasing the risk of NEC (10), although the most recent Cochrane review (9) concludes that available trial data do not provide evidence of important beneficial or harmful effects of early trophic feeding for very preterm or very low birth weight infants. They commented that the applicability of these findings to extremely preterm, extremely low birth weight or growth restricted infants is limited. In a small recent study early trophic feeding of preterm infants with IUGR and abnormal antenatal Doppler results did not have a significant impact on incidence of NEC or feed intolerance.(12) None of the papers makes recommendations for optimal duration of trophic feeds and all call for further research.
Rate of increase of feeds
The recent Cochrane review on rate of advancement of feeds concluded that available trial data suggested that advancing enteral feed volumes at daily increments of 30 to 40 mL/kg (compared to 15 to 24 mL/kg) does not increase the risk of NEC or death in VLBW infants. Advancing the volume of enteral feeds at slow rates results in several days of delay in establishing full enteral feeds and increases the risk of invasive infection. They did however comment that the applicability of these findings to extremely preterm, extremely low birth weight, or growth-restricted infants was limited and that further randomised controlled trials in these populations may be warranted to resolve this uncertainty. (13)

The most recent evidence from the SIFT study showed that slow advancement of feeding in very low birthweight infants did not reduce the risk of NEC showing no advantage in increasing at 18ml/kg/day versus 30ml/kg/day. (14)
Assessing feed tolerance
The volume of feed aspirated from the stomach prior to a feed is one of the factors used to judge progression of feeding. It is important to note that volume and colour of aspirate may indicate level of gut maturity rather than gut dysfunction (17).

Gastric motility more rapidly normalises if feeds are started early and offered frequently rather than being withheld.(50) Despite this feeds are frequently stopped, or advances held on the basis of "feed intolerance". The definition of intolerance includes not only the presence and colour of gastric residuals, but also vomiting, increases in abdominal girth or abdominal tenderness, presence of abnormal or blood stained stool, absence of bowel sounds, abdominal wall discolouration, or a combination(1). As all of these can occur in the healthy premature infant who is tolerating feeds(55) careful clinical assessment is essential to prevent unnecessary limitations of enteral feeds, reliance on parenteral nutrition, increase nosocomial infection, delay enteral feeding and poor growth.

Clearly defining feeding intolerance can lead to dramatic improvements in nutritional outcomes. (57)

Gastric residuals up to 2ml in infants <750g and up to 3ml in infants 750g - 1500g were treated as normal in the studies by Mihatsch and Bertino(54,16).

Maximum gastric residuals in premature infants who develop NEC have been shown to be 40% of feed volume compared to 14% in those who did not develop NEC, with residuals increasing dramatically over the three days before the onset of NEC.(17) For the early detection of VLBW infants at risk for NEC, both gastric residual volumes and bloody residuals represent an early relevant marker.(16) Where feed intolerance does occur continuing with trophic feeds rather than stopping feeds has been associated with less sepsis and shorter time to full enteral feeds with no increase in NEC.(55)

A recent study published in JAMA Pediatrics (97) showed that preterm infants (<32 weeks <1250g) who did not have their gastric residual volume measured routinely reached full enteral feeds quicker, had fewer episodes of abdominal distension and no increase in NEC.

As residuals vary so much in the early stages of feeding significant increases should not be used in isolation when deciding to limit advancement of feeds(1).
Frequency and method of delivery
Feeds given by intermittent bolus method promote a cyclical surge of gut hormones similar to that in adults and term infants so are considered more physiologic in the preterm infant (17). They also experience less feed intolerance and have a greater rate of weight gain when fed a bolus technique compared to continuous infusion (18). Animal studies have shown enhanced protein synthesis in bolus versus continuous feeding. (19) A recent Cochrane review showed no differences in time to achieve full enteral feeds and no significant difference in growth, days to discharge or the incidence of NEC and concluded that there was insufficient evidence to support one method over the other. (20). Previous authors have demonstrated that continuously fed infants achieved full feeds more quickly than those receiving bolus feeds, however no assessment was made of growth and feed tolerance in the longer term - there are risks that growth could be compromised as human milk fat adheres to the tubing during continuous feeding (19). Higher behavioural stress responses in bolus fed infants have recently been reported by the same group (21), and a 2014 study reported splanchnic oxygenation changed significantly over time and differed between the two feeding techniques, with a significant increase after bolus feeding and a reduction during continuous feeding.(22) These findings need balancing against the advantages reported for bolus feeding .

Occasionally intolerance is seen in a bolus fed preterm infant with duodenal motility decreasing following a feed (56), however a bolus feed administered over a longer period of time results in a return of motility and improved tolerance.(57)

Gastric feeding stimulates digestive processes whereas transpyloric feeding has the potential benefits of delivering nutrients past the pylorus and gastro oesophageal junction for the management of gastro oesophageal reflux (GOR) disease. These feeds have to be continuous, which may account for the reduction in symptoms of GOR. Transpyloric feeding is not routinely recommended in preterm infants as no benefits have been found and they have been associated with a greater incidence of gastrointestinal disturbance. (22)
Maternal breast milk
Human milk is the preferred feed for premature infants as it offers in the short term, strong protection against infection and necrotising enterocolitis (NEC), and in the long term improved neurocognitive development. Recent evidence shows the reduction in NEC risk using human milk to be dose dependent. (59)
Maternal breast milk (handling)
See WoS Guideline Expressed Breast Milk: Guideline for expression, storage and use
Donor breast milk (DBM)
In the absence of a mother's own expressed breast milk donor milk is generally considered the next milk of choice. Observational studies suggest that donor milk is similar to mothers own milk with regard to improved feed tolerance (62) anti infective properties and reduced NEC risk (63, 55). Both the role of donor milk in current neonatal practice and the feasibility, cost and impact of its use on nutrient intake, growth and development remain to be established (32, 33).

Current UK practice strongly advocates the use of donor milk as a supplement to mother's milk or to establish enteral feeds. Likewise the recent AAP publication on use of DBM recommends use for those infants <30 weeks gestation and/or <1500g.

Donor milk generally has a lower calorie content than milk expressed by the mother of a preterm infant, reflecting the fact that much of the donated milk comes from lactating mothers of older term infants.

It is important to bear in mind that donor milk is a human body fluid and as such carries risks of transmission of infective agents. All donor screening, handling, testing and processing of DBM in the Milk Bank is carried out according to NICE Guidelines (64). Documentation and traceability of DBM is essential, particularly when milk is transported from a central milk bank to a recipient neonatal unit.
Breast milk Fortification
Increased preterm nutritional requirements persist beyond the time when early milk composition changes to that of mature milk. This often coincides with a slowing of weight gain and a sequential reduction in serum urea, where a level <1.6mmol/l is indicative of a protein intake of <3g/kg (65).

In order to maintain the benefits of breast milk whilst optimising the nutritional status and growth of preterm infants single multi nutrient fortifiers (BMF) have been developed. The two available in the UK are Nutriprem BMF (Cow & Gate) and SMA BMF (Wyeth). Both are bovine based products. Neither formulation has clear indications for introduction nor guidance for infant suitability, so practice varies considerably between units. (36)

Fortification of EBM using dried human milk fortifiers has been studied (66, 67) and showed improved growth but low serum phosphate levels due to inadequate bone mineral concentrations.

Concerns with the use of BMFs include tolerance and effects of storage. Most studies have found no significant problems with the tolerance of fortified EBM (68,69) whilst those investigating gastric emptying have been contradictory (70,71). Storage concerns include the reduction of anti infective components (72), increased bacterial loads (73) and increasing osmolality over time secondary to hydrolysis of glucose polymers by human milk amylase (74). The majority of these effects can be reduced by adding the BMF as close to feeding as possible, though recent work shows osmolality of fortified EBM reaches a peak within 10 minutes of addition and remains consistent to 24 hours of storage (75). A Cochrane review concludes that although available trial data show that multi-nutrient fortification increases growth rates of preterm infants during their initial hospital admission, they do not provide consistent evidence on effects on longer-term growth or development. Additional trials are needed to resolve this issue it recommends further research seeking to evaluate long term outcomes of BMF therapy and identify the optimum composition of BMF products. (82)

Breast milk is fortified without knowing the nutritional composition of an individual mother's EBM. As the composition of breast milk, particularly protein concentration, varies from one mother to the next and from expression to expression in the same mother, individual analysis prior to fortification would appear to be of value. Such analysis is at present impractical in day to day practice.

Multi-nutrient fortification may be especially important for infants who receive donated (donor) expressed breast milk, which contains lower levels of protein, energy and minerals than their own mother's expressed breast milk. (83)
Protein supplementation
Assumed protein intake in preterm infants fed fortified own mother's milk or banked milk is greater than what infants actually received (85)

Estimate of milk protein content less than measured protein content

Protein intakes 0.6 to 0.8 g/kg/day less than estimated

A Cochrane review in 2000 concluded that protein supplementation of human milk in relatively well preterm infants results in increases in short term weight gain, linear and head growth. (86) They found that urea levels are increased, which may reflect adequate rather than excessive dietary protein intake and commented that further research should be directed towards the evaluation of specific levels of protein intake in preterm infants and the clinical effects of supplementation with protein, including long term growth and neurodevelopmental outcomes. This may best be done in the context of refinement of available multicomponent fortifier preparations.

Concerns about protein toxicity have largely been disputed in current research. Hay et al questioned whether an additional 1 g/kg/day would be too much for those infants whose mothers had good milk protein content but concluded that this was unlikely given measurements of human milk protein content, including those in their study, consistently showed that concentrations above 2g per 100 ml are relatively rare. (85) Further, adding 1 g/kg/day of protein to such milk would produce 3g per 100 ml and an intake of 4.5 g/kg/day at 150 ml kg/day, higher than most such infants ordinarily receive, but still within the range calculated to produce normal rates of fetal growth. They also commented the higher milk protein concentrations from mothers providing milk to preterm infants decreases significantly over the first 1 to 3 weeks, research that has been widely duplicated in other studies, making it even less likely that excessive amounts of protein would be provided. Nevertheless, the authors recommend further clinical trials to address potential toxicity.
Probiotics
Probiotic therapy has demonstrated promising efficacy for the prevention of NEC, as evidenced by a very strong treatment effect in favor of probiotic therapy in two recent meta-analyses (40). In an updated systematic review, enteral probiotic supplementation significantly reduced the incidence of severe necrotizing enterocolitis and mortality, with no significant reduction in nosocomial sepsis (41).

Recent data in addition to a report by the European Society for Pediatric Gastroenterology (ESPGAN) concluded probiotics could be generally considered safe. However, clarity regarding type and dosage strategy continue to temper widespread use and these concerns are likely to remain until large, multicenter trials adequately designed to address safety are completed. (40)
Preterm Formulas
Preterm formulas are designed to meet the basic nutritional requirements of most preterm infants when fed between 150 and 180ml/kg.

There are currently three formulas available in the UK. Nutriprem 1, Aptamil Preterm and SMA Gold Prem Pro.

Preterm formulas can be used as soon as commencement of enteral feeding is recommended. Term formulas should not be used as they fail to meet the nutritional needs of premature infants.

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Information for parents | Epilepsy Society

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Information for parents of children with epilepsy or a childhood epilepsy syndrome.

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The NICE British National Formulary for Children (BNFc) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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Salbutamol inhaler for asthma and wheeze – Medicines For Children

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This leaflet is for parents and carers about how to use this medicine in children. Our information may differ from that provided by the manufacturers, because their information usually relates to adults. Read this leaflet carefully. Keep it somewhere safe so that you can read it again.

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Breathing through the nose warms up the air we breathe in. But when we exercise, particularly exercise that is more strenuous like running, we usually breathe through the mouth instead of the nose. This means we're breathing in air that's colder and drier than normal.

If you have asthma, breathing in this cold, dry air causes your airways to tighten and get narrower. This can trigger your asthma symptoms like coughing, wheezing, and breathlessness.

You may come across other triggers when you exercise too, like pollution or pollen if you exercise outside, or dust if you exercise indoors. Chlorine in swimming pools can also trigger symptoms for some people.

You're more likely to get asthma symptoms when you exercise if:

'Exercise-induced' asthma

Rarely, someone not diagnosed with asthma might get asthma-like symptoms from exercising.

This is often called 'exercise-induced asthma', but a better term is 'exercise-induced bronchoconstriction' (EIB) because it is not caused by having asthma. However, it's important to be assessed for asthma if you have symptoms of EIB.

Bronchoconstriction is when the airways get tighter and narrower as a result of strenuous exercise, particularly if someone is also breathing in cold air.

Elite athletes, particularly athletes that exercise in cold air like cross-country skiers, are more likely to have EIB.

Find out more about exercise-induced asthma and bronchoconstriction.

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Breathing through the nose warms up the air we breathe in. But when we exercise, particularly exercise that is more strenuous like running, we usually breathe through the mouth instead of the nose. This means we're breathing in air that's colder and drier than normal.

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Universal Health Visiting Pathway in Scotland: pre-birth to pre-school

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Universal Health Visiting Pathway in Scotland: pre-birth to pre-school

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Continued Getting it Right for Every Child ( GIRFEC) assessment process and identification of child/family health strengths and wellbeing needs.

Build on and strengthen therapeutic relationship between practitioner and mother/father/ family

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Observe/ discuss developmental progress of infant

If previously disclosed, routine enquiry for gender based violence and risk assessment undertaken

Agree plan of ongoing care

Domestic Abuse Risk Assessment Checklist ( DASH RIC)

Getting it Right for Every Child ( GIRFEC) Practice Model

National Risk Assessment Tool

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required.

Co-production approach to support parents/carers to maximise the wellbeing of their baby

Women and children are protected through provision of support and referral to Multi-Agency Risk Assessment Case Conferences as appropriate when abuse identified

Families recognise Health Visitor as professional offering credible and positive information, advice, support and help to access services

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

Income of families with young children who are at risk of, or experiencing, poverty is maximised.

More structured continuity of care and continuous assessment

6 - 8 weeks
(All Families)
(Suggested time: 45 - 60 minutes)

Continued Getting it Right for Every Child ( GIRFEC) assessment process and identification of child/family health/mental health strengths and wellbeing needs and update recording of Health Plan Indicator

Discuss and enquire about depressive symptoms and complete the Edinburgh Post Natal Depression Scale ( EPDS)

If not previously carried out undertake routine enquiry for gender based violence and risk assessment undertaken following disclosure Build on and strengthen therapeutic relationship between practitioner and mother/family

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Agree plan of ongoing care

Domestic Abuse Risk Assessment Checklist ( DASH RIC)

Edinburgh Postnatal Depression Scale Questionnaire

Standard assessment/ recording proforma (Child Health Surveillance Programme) as appropriate

National Risk Assessment Tool

Getting it Right for Every Child ( GIRFEC) Practice Model

Chief Executives Letter ( CEL) 41

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required.

Early identification and management of perinatal mood disorders

Early intervention to reduce risk of dental caries

Initial recording of Health Plan Indicator

Early evidence of attachment

Routine enquiry, recording of disclosure and risk assessment as appropriate

Women and children are protected through provision of support and referral to Multi-Agency Risk Assessment Case Conferences as appropriate when abuse identified.

Early referral and intervention where assessment of growth and or development indicates that child is not achieving age appropriate milestones

Families recognise Health Visitor as professional offering credible and positive information, advice, support and help to access services

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

More structured continuity of care and continuous assessments

Continuous assessment and identification of child/family health/mental health and wellbeing needs

Discuss and enquire about depressive symptoms and complete Edinburgh Postnatal Depression Scale

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Continue to observe child's developmental progress

If not previously carried out undertake routine enquiry for gender based violence and risk assessment undertaken following disclosure

Advise on sources of community support

Following assessment commission additional support via Early Years Support Workers as required

Complete Getting it Right for Every Child ( GIRFEC) assessment process and update Health Plan Indicator

Introduce the subject of weaning and highlight importance of delaying introducing solids until around 6 months.

Agree plan of ongoing care

Edinburgh Postnatal Depression Scale Questionnaire

Domestic abuse Risk Assessment Checklist ( DASH RIC)

National Risk Assessment Tool

Getting it Right for Every Child ( GIRFEC) Practice Model

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required.

Early identification and management of perinatal mood disorders

Early intervention to reduce risk of dental caries

Women are supported and risks reduced to children through support provided where gender based violence is identified

Women and children are protected through provision of support and referral to Multi-Agency Risk Assessment Case Conferences as appropriate when abuse identified.

Prevention of unintentional injury

Evidence of timeous immunisation uptake

Weaning at appropriate age

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

Families recognise Health Visitor as professional offering credible and positive information, advice, support and help to access services

More structured continuity of care and continuous assessment

Review Getting it Right for Every Child ( GIRFEC) assessment and identification of child/family health/mental health and wellbeing needs and update Health Plan Indicator if required

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Continue to observe child's developmental progress and undertake additional interventions as required e.g. advice; referral

Signpost to local Community Services

Agree future plan of care

National Risk Assessment Tool

Getting it Right for Every Child ( GIRFEC) Practice Model

Ages & Stages Questionnaires: ( ASQ:3)

Continued relationship building with family

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required

Parents/carers receive appropriate information and support to maximise the wellbeing of their child

Achievement of age appropriate developmental milestones

Early identification of concerns

Commission of additional intervention and support as required

Early identification and management of perinatal mood disorders

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

Families recognise Health Visitor as professional offering credible and positive information, advice, support and help to access services

More structured continuity of care and continuous assessment

Review Getting it Right for Every Child ( GIRFEC) assessment and identification of child/family health/mental health and wellbeing needs and update Health Plan Indicator if required

Assessment should include: quality of parent - child relationship and mental health of the principal carer

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Undertake developmental and wellbeing review

Child Health Review - refer to guidance in Appendix 2 (Guidance on delivery and national minimum dataset)

Advise on local services for children and families

Review immunisation status and prompt attendance where required

Routine enquiry about family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services

Agree future plan of care

Standard assessment/ recording proforma (Child Health Screening Programme)

Ages & Stages Questionnaires: ( ASQ:3) should be used universally with continued access to validated development assessment tools and there appropriate age range as listed in and .

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required Early identification of growth/ developmental concerns

Parents/carers receive appropriate support and advice to maximise the wellbeing of their child

Children's listening and communication skills are enhanced through the introduction of early reading

Children are protected from infectious disease

Ensuring follow up when concerns are identified

Request for assistance as appropriate

Attendance at appointments

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

Income of families with young children who are at risk, or experiencing, poverty is maximised

Families recognise Health Visitor as professional offering credible and positive information, advice, support and help to access services

More structured continuity of care and continuous assessments

27-30 Months (Suggested time: 45 - 60 minutes)

As above

In addition to the above routine enquiry for gender based violence and risk assessment conducted

Ages & Stages Questionnaires: ( ASQ:3) should be used universally with continued access to validated development assessment tools and there appropriate age range as listed in and . These should be used in conjunction with 27 - 30 Month Guidance.

Domestic Abuse Risk Assessment ( DASH RIC)

Standard assessment/recording proforma (Child Health Screening Programme)

Continuum of parent/carer and child assessment and care providing maximum opportunity to intervene early where additional support is required.

Parents involved and received advice and support in maximising the wellbeing of their child.

Children are protected against infectious diseases

Referral where necessary

Women are supported and risks reduced to children through support provided where gender based violence is identified

Women and children are protected through provision of support and referral to Multi-Agency Risk Assessment Case Conferences as appropriate when abuse identified.

Parents/carers receive appropriate public health advice to maximise child/family wellbeing

Income of families with young children who are at risk, or experiencing, poverty is maximised

Families recognise Health Visitor as professional offering credible and positive advice and support

More structured continuity of care and continuous assessments

4 - 5 Years (Suggested time: 30 - 45 minutes)

Undertake pre-school review

Child Health Review - refer to guidance in Appendix 3 (Guidance on delivery and national minimum dataset)

Update Getting it Right for Every Child ( GIRFEC) assessment and Health Plan Indicator

Engage and share public health information and guidance to promote positive attachment and health and wellbeing

Routine enquiry about family finances/money worries and raise awareness of the advice available and offer families a direct referral to advice services

Arrange discussion/meeting with School Nurse for children with an Health Plan Indicator of additional

Transition to School

Arrangements for transition to the incoming Named Person e.g. Education.

Ages & Stages Questionnaires: ( ASQ:3) should be used universally with continued access to validated development assessment tools and there appropriate age range as listed in and .

Continuum of child assessment

Seamless transition to School Nursing Services

Parents/carers receive appropriate support/advice to maximise the wellbeing of their child

Income of families with young children who are at risk, or experiencing, poverty is maximised

Children benefit from effective care planning between services

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Universal Health Visiting Pathway in Scotland: pre-birth to pre-school

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Continued Getting it Right for Every Child ( GIRFEC) assessment process and identification of child/family health strengths and wellbeing needs.

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Our vision

Our vision is that any parent or carer, wherever they are, has information on their child's medicines that they can trust.

What we offer

Our medicines information pages cover many of the medicines that are prescribed or recommended for children by health professionals. They answer frequent questions, such as how and when to give the medicine, what to do if you forget to give the medicine, and any possible side-effects.

You can also read information or watch our short videos about giving different types of medicines, including tablets, capsules, liquid medicine, inhalers, eye drops/ointment and ear drops.

Who are we?

Medicines for Children is a partnership programme of Royal College of Paediatrics and Child Health (RCPCH), Neonatal and Paediatric Pharmacists Group (NPPG) and WellChild. Read more about us and our work.

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Medicines For Children - We provide practical and reliable advice about giving medicine to your child

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Our vision is that any parent or carer, wherever they are, has information on their child's medicines that they can trust. Our medicines information pages cover many of the medicines that are prescribed or recommended for children by health professionals.

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https://www.nice.org.uk/guidance/ng217

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This guideline covers diagnosing and managing epilepsy in children, young people and adults in primary and secondary care, and referral to tertiary services. It aims to improve diagnosis and treatment for different seizure types and epilepsy syndromes, and reduce the risks for people with epilepsy.

MHRA advice on antiepileptic drugs in pregnancy: Recommendations in this guideline on carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, pregabalin, topiramate and zonisamide are in line with the MHRA updated safety advice on antiepileptic drugs in pregnancy.

MHRA advice on valproate: Recommendations on valproate are in line with the MHRA guidance on valproate use by women and girls. Valproate must not be used in women and girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years), unless other options are unsuitable and the pregnancy prevention programme is in place. The MHRA has published temporary advice on the valproate pregnancy prevention programme during the COVID-19 pandemic.

August 2023: The MHRA issued new safety advice on risks associated with valproate for the under 55s in December 2022. The valproate recommendations in this guideline will be reviewed once further advice from the MHRA is available. People currently taking valproate should not stop taking it unless they are advised by a specialist to do so.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals in primary, secondary and tertiary care

Commissioners, providers and voluntary organisations

People with epilepsy, their families and carers

Guideline development process
How we develop NICE guidelines
This guideline updates and replaces NICE guideline CG137 (January 2012) and NICE evidence summaries ESNM7, ESNM17 and ESNM37.

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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Epilepsies in children, young people and adults

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This guideline covers diagnosing and managing epilepsy in children, young people and adults in primary and secondary care, and referral to tertiary services. It aims to improve diagnosis and treatment for different seizure types and epilepsy syndromes, and reduce the risks for people with epilepsy

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https://www.epilepsyscotland.org.uk/

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What is Epilepsy?

In Scotland 58,000 people are affected by epilepsy. Children and older people are most at risk of developing this common serious neurological condition but anyone can develop epilepsy at any time, and eight people a day in Scotland do.

We want to make sure the needs of people with epilepsy are met. This is why we campaign for improved healthcare, better information provision and an end to stigma.

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Home - Epilepsy Scotland - Scotland's voice for epilepsy

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In Scotland 58,000 people are affected by epilepsy. Children and older people are most at risk of developing this common serious neurological condition but anyone can develop epilepsy at any time, and eight people a day in Scotland do. We want to make sure the needs of people with epilepsy are met.

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What to do during an asthma attack | Asthma + Lung UK

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An apnoea is defined as a pause in breathing for 20 seconds or longer or a shorter pause accompanied by bradycardia (<100 beats per minute), cyanosis, or pallor ¹

Apnoeas can be central in origin (cessation of breathing effort), obstructive (blockage of airflow at pharyngeal level) or mixed

Apnoeas can be caused by:

Apnoea of prematurity (<35weeks): The most common cause of apnoea, attributable to the immaturity of the respiratory centre in the brain.

Airway obstruction: Position not neutral, obstruction with secretions/vomit

Infections: Sepsis, necrotising enterocolitis, meningitis

Cardiovascular: Anaemia, hypotension, cardiac failure

Pain: Acute and chronic

Central nervous system: Intraventricular haemorrhage, seizures, hypoxic injury, raised intra cranial pressure, neuromuscular disorders, brainstem infarction or anomalies, birth trauma, congenital malformations, central hypoventilation, syndromic

Respiratory: Infection, lesions causing airway obstruction, respiratory distress syndrome, hypoxia, malformations of chest, phrenic nerve paralysis, pulmonary haemorrhage, aspiration

Gastrointestinal: Intestinal perforation, gastro oesophageal reflux, abdominal distension

Metabolic: Hypoglycaemia, electrolyte disturbance, metabolic conditions, hypothermia

Drugs: Maternal drugs, opiates, prostin, high levels of phenobarbitone, chloral hydrate or other sedatives, general anaesthetic.

Immunisations

It is therefore important that in babies with new onset apnoeas a full clinical review and examination is performed before commencing any treatment for apnoea of prematurity.
Apnoea of prematurity is extremely common in preterm neonates. Previous studies have shown that treatment of AoP has lead to improved survival rates without neurodisability at 5 years of age. The aim of this guideline is to provide a streamlined approach to the assessment and management of a neonate with suspected AoP

Current studies suggest that the incidence of AoP is inversely proportional to age, with 100% of infants born <28 weeks developing AoP as defined above. 85% of babies born at 30 weeks gestation developed AoP, which reduced to 20% at 34 weeks. The natural history of AoP is that the more severe episodes resolve first, with isolated bradycardias last to resolve. However persistent events beyond 40 weeks cGA are more common in babies born less than 28 weeks cGA with several studies suggesting on going apnoeas were occurring post 40 weeks cGA in up to 22% of babies born with a gestational age of 23-28 weeks.

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An apnoea is defined as a pause in breathing for 20 seconds or longer or a shorter pause accompanied by bradycardia (<100 beats per minute), cyanosis, or pallor 1 Apnoeas can be central in origin (cessation of breathing effort), obstructive (blockage of airflow at pharyngeal level) or mixed Apnoeas can be caused by: Apnoea of prematurity (<35weeks): The most common cause of apnoea, attributable to the immaturity of the respiratory centre in the brain.

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The NICE British National Formulary for Children (BNFc) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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NICE Guidelines- Fever in under 5s: assessment and initial management

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NICE Guidelines- Fever in under 5s: assessment and initial management

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This guideline covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care.

This guideline should be read in conjunction with the NICE guidelines on sepsis, neonatal infection, meningitis (bacterial) and meningococcal septicaemia in under 16s, urinary tract infection in under 16s, diarrhoea and vomiting caused by gastroenteritis in under 5s and antimicrobial prescribing for common infections.

In November 2021, We added a definition of sepsis to recommendation 1.2.2. We also added a cross reference to table 2 to guide users to the risk stratification tool for children aged under 5 years with suspected sepsis (table 3 in the NICE guideline on sepsis).

Recommendations

This guideline includes new recommendations on Kawasaki disease. These supplement the existing recommendations on:

Who is it for?

Healthcare professionals

Parents and carers of children under 5 with feverish illness

Guideline development process
How we develop NICE guidelines
This guideline updates and replaces NICE guideline CG160 (May 2013)

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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Fever in under 5s: assessment and initial management

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This guideline covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care

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The NICE British National Formulary for Children (BNFc) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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NICE Guidelines- Asthma: diagnosis, monitoring and chronic asthma management

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NICE Guidelines- Asthma: diagnosis, monitoring and chronic asthma management

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Overview | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE

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This guideline covers diagnosing, monitoring and managing asthma in adults, young people and children. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks. It does not cover managing severe asthma or acute asthma attacks

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NICE Guidelines- Constipation in children and young people: diagnosis and management.

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NICE Guidelines- Constipation in children and young people: diagnosis and management.

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NICE Constipation in Children and Young People

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The NICE British National Formulary for Children (BNFc) site is only available to users in the UK (England, Scotland, Wales and Northern Ireland)

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website.

If you believe you are seeing this page in error please contact us.

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The NICE Clinical Knowledge Summaries (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. CKS content is produced by Clarity Informatics Limited. It is available to users outside the UK via subscription from the Prodigy website. If you believe you are seeing this page in error please contact us.

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Breastfeeding Assessment Tool (Health Visiting)

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Breastfeeding Assessment Tool (Health Visiting)

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Please watch this video for advice on the correct inhaler technique for Fu.

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Please watch this video for advice on the correct inhaler technique for Fu.

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Pharmacological treatment of chronic asthma in children and young people aged 5 to 16

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Pharmacological treatment of chronic asthma in children and young people aged 5 to 16

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Asthma