Helder O, Tissières P, Mader S, Thiele N

Target group

Infants, parents, families, and everybody entering the neonatal unit

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Hand hygiene is practiced consistently according to the guidelines in order to reduce the spread of hand carried pathogens.


Newborn infants admitted to a neonatal unit especially very low birth weight infants (<1500 g) and infants subjected to intensive care are at risk for nosocomial or hospital acquired infections due to the immature host defence and invasive procedures. (1) The incidence of nosocomial bloodstream infections among these infants in neonatal intensive care units world-wide varies between 11 and 53%. (2) These infections are associated with increased mortality and morbidity, and prolonged hospital stay, compared to non-infected infants. (1,3–5)

Hand hygiene to reduce nosocomial bloodstream infections is recommended by the leading institutions like the World Health Organisation (WHO) and Centers of Disease and Infection Control (CDC), as well as the European Center of Disease and Infection Control (ECDC). The WHO’s campaign ‘my five moments for hand hygiene’ is currently internationally regarded as standard of care. (6) High compliance with hand hygiene protocols among healthcare professionals is recognised as one of the most important means of prevention of hospital acquired infections. (2,7,8)


Short-term benefits

Long-term benefits

  • Reduced risk of antibiotic resistant bacteria (consensus)
  • Reduced risk of chronic lung disease (2,4)
  • Reduced risk of hearing loss (2,4)
  • Reduced risk of cerebral palsy (2,4)
  • Reduced risk of poor neurodevelopmental outcome (4)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed and instructed by healthcare professionals about hand hygiene according to the World Health Organisation’s (WHO) ‘my five moments of hand hygiene’. (6,9) A (High quality)
B (High quality)
Parent feedback, patient information sheet
2. Parents are asked to instruct the own family and relatives to apply hand hygiene guidelines. B (Moderate quality) Patient information sheet
3. Rings, watches, and bracelets are not to be worn in the neonatal unit. B (Moderate quality) Patient information sheet
For healthcare professionals    
4. A unit guideline on hand hygiene is adhered to by all healthcare professionals. (2) A (High quality)
B (High quality)
5. Training on hand hygiene is attended by all responsible healthcare professionals. (2) A (Moderate quality)
B (High quality)
Training documentation
6. Hand hygiene according WHO’s ‘my five moments of hand hygiene’ is applied. (6) A (High quality) Guideline
7. Single use non-sterile gloves are used where there is risk of body fluid contact. (10) A (High quality) Guideline
8. Single use non-sterile gloves, gown, and mask are used where there is risk of multi resistant bacteria. (11) A (High quality) Guideline
9. Artificial nails, rings, watches, bracelets, ties and long sleeves are not to be worn in the neonatal unit. (12) A (Moderate quality) Guideline
For neonatal unit    
10. A unit guideline on hand hygiene is available and regularly updated. (13,14) A (High quality)
B (High quality)
11. Regular, and at least annually, audit and feedback on hand hygiene protocol adherence are conducted. A (Low quality) Audit report
12. A designated healthcare professional to promote hygiene is available. B (Moderate quality) Audit report
For hospital    
13. Training on hand hygiene is ensured. B (High quality) Training documentation
14. Hand hygiene facilities e.g. sinks and disinfection solutions are provided near the patient. (15) A (Moderate quality) Audit report
For health service    
15. A national guideline on hand hygiene is available and regularly updated. (13,14) A (High quality)
B (High quality)
Audit report, guideline

Where to go

Further development Grading of evidence
For parents and family  
  • Report on hand hygiene adherence.
A (Low quality)
For healthcare professionals  
  • Report on hand hygiene adherence.
A (Low quality)
For neonatal unit  
  • Establish an integrated hand hygiene adherence system that electronically provides quality feedback on hand hygiene performance.
A (Moderate quality)
For hospital  
  • Compare adherence with other neonatal units.
A (Low quality)
For health service  
  • Report on hand hygiene adherence.
A (Low quality)

Getting started

Initial steps
For parents and family
  • Parents and family are verbally informed and instructed by healthcare professionals about hand hygiene.
  • Family and relatives are informed about hand hygiene by parents.
For healthcare professionals
  • Attend training on hand hygiene.
For neonatal unit
  • Develop and implement a unit guideline on hand hygiene.
  • Develop information material on hand hygiene for parents and family.
  • Develop a formal education programme to cover all aspects of hand hygiene.
  • Measure adherence to hand hygiene guideline on regular basis.
  • Monitor nosocomial infection rate.
For hospital
  • Support healthcare professionals to participate in training on hand hygiene.
For health service
  • Develop and implement a national guideline on hand hygiene.


  1. Aziz K, McMillan DD, Andrews W, Pendray M, Qiu Z, Karuri S, et al. Variations in rates of nosocomial infection among Canadian neonatal intensive care units may be practice-related. BMC Pediatr. 2005 Jul 8;5:22.
  2. Helder OK, Brug J, Looman CWN, van Goudoever JB, Kornelisse RF. The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison. Int J Nurs Stud. 2010 Oct;47(10):1245–52.
  3. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002 Aug;110(2 Pt 1):285–91.
  4. Stoll BJ, Hansen NI, Adams-Chapman I, Fanaroff AA, Hintz SR, Vohr B, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA. 2004 Nov 17;292(19):2357–65.
  5. Donovan EF, Sparling K, Lake MR, Narendran V, Schibler K, Haberman B, et al. The investment case for preventing NICU-associated infections. Am J Perinatol. 2013 Mar;30(3):179–84.
  6. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control. 2009 Dec;37(10):827–34.
  7. Pessoa-Silva CL, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007 Aug;120(2):e382-390.
  8. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010 Mar;31(3):283–94.
  9. Bellissimo-Rodrigues F, Pires D, Zingg W, Pittet D. Role of parents in the promotion of hand hygiene in the paediatric setting: a systematic literature review. J Hosp Infect. 2016 Jun;93(2):159–63.
  10. Kaufman DA, Blackman A, Conaway MR, Sinkin RA. Nonsterile Glove Use in Addition to Hand Hygiene to Prevent Late-Onset Infection in Preterm Infants: Randomized Clinical Trial. JAMA Pediatr. 2014 Oct 1;168(10):909.
  11. Garner JS. Guideline for isolation precautions in hospitals. Part I. Evolution of isolation practices, Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1996 Feb;24(1):24–31.
  12. Hoffman PN, Cooke EM, McCarville MR, Emmerson AM. Micro-organisms isolated from skin under wedding rings worn by hospital staff. Br Med J Clin Res Ed. 1985 Jan 19;290(6463):206–7.
  13. Won S-P, Chou H-C, Hsieh W-S, Chen C-Y, Huang S-M, Tsou K-I, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2004 Sep;25(9):742–6.
  14. Picheansathian W, Pearson A, Suchaxaya P. The effectiveness of a promotion programme on hand hygiene compliance and nosocomial infections in a neonatal intensive care unit. Int J Nurs Pract. 2008 Aug;14(4):315–21.
  15. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet Lond Engl. 2000 Oct 14;356(9238):1307–12.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Helder O, Tissières P et al., European Standards of Care for Newborn Health: Hand hygiene. 2018.

Read lien

    For the purpose of evaluation, we would be grateful if you could send us details on your profession and country. This information is optional, anonymous and the data processed will exclusively be used for the aforementioned purpose, in line with Article 6, Para. 1 lit. a GDPR (General Data Protection Regulation).

    Thank you for your support!