The challenge

Currently in the UK, standard management of suspected EOI involves a minimum of 36 hours of IV antibiotics. Antibiotics are typically stopped after 36 hours if the baby is well, C-Reactive Protein (CRP) results are reassuring, and any cultures taken are negative. However, when there are ongoing concerns about neonatal infection, intravenous antibiotics are continued for up to seven days.  

IV antibiotics can present several disadvantages including increased duration of hospital stay and multiple intravenous cannulations, a procedure which is both painful and may be technically challenging.  Additionally, IV gentamicin, a recommended first-line antibiotic for EOI, poses potential risks to renal function and hearing. 

Oral antibiotics have not been widely used in high-resource settings for the treatment of EOI due to concerns about efficacy, particularly around gastrointestinal absorption in the neonate.  However emerging evidence supports the safety of a switch from IV to oral therapy in a specific cohort of babies receiving treatment for suspected EOI. 

Moving newborn care from hospital to home is particularly important in a rural region like South West England, where many families face long journeys to hospitals and other neonatal care services. More people in Devon live further from a neonatal unit than average in England and few live within 50km of more than one unit. There are a limited number of beds across the neonatal network in the South West, with very few trusts operating Neonatal Intensive Care Units. Optimal management of bed capacity across the network is vital for families to avoid travelling potentially hundreds of miles to the next closest unit with availability.

The solution

Neonatal Oral Antibiotics at Home (NOAH) allows eligible newborns with suspected early-onset infection (EOI) to transition from intravenous (IV) antibiotics in the hospital to oral antibiotics at home after 36 hours.

This innovative approach (based in the RAIN study) is already in use in both Devon and outside of the UK, delivering a range of benefits:

• Improved patient experience: Reducing hospital stays allows families to care for their newborns in a more comfortable home environment, enhancing bonding and supporting breastfeeding
• Reduced length of hospital admission: Freeing up hospital capacity and keeping families together
• Cost savings: Significant reductions in hospital costs related to extended stays, medication, and equipment use
• Environmental impact: Reduced travel and lower hospital resource consumption results in reduced carbon emissions

An infographic outlining these benefits and more can also be found here. 

Our work in partnership

In June 2024, the Royal Devon and Exeter (Wonford) Hospital site of the Royal Devon University Healthcare NHS Foundation Trust introduced the NOAH pathway.

 The NOAH protocol, based on the published evidence, outlines strict eligibility criteria to ensure safety. Babies must be born at term and currently be receiving IV antibiotics for suspected EOI. Babies must be clinically well and tolerating oral feeds. A reassuring CRP trend is required, with a peak CRP not greater than 50. Additionally, blood and cerebrospinal fluid cultures must be negative. 

Through the period of the pilot, 27 families were discharged onto the new pathway. The parents of babies discharged home on NOAH received a telephone follow-up at around day five of their seven-day course of antibiotics.

Following a six-month pilot, a comprehensive evaluation was conducted by Health Innovation South West. Overall, the NOAH pilot was a success, and NOAH has now been integrated into standard practice at the Royal Devon.

You can read Health Innovation South West’s full evaluation of the pilot here.

For neonatal teams wishing to adopt this quality improvement initiative, Health Innovation South West supported Royal Devon to develop a range of implementation resources to help you plan, execute, and sustain NOAH – find these at the bottom of this page.

The project is a collaboration between Health Innovation South West, Royal Devon, the NIHR Applied Research Collaborative South West Peninsula (PenARC) and the South West Neonatal Network.

In 2025/26, our focus has been on working with our partners to spread the project more widely across other Trusts in the South West, whilst undertaking an implementation evaluation across sites to assess the impact of the pathway in different settings and provide additional learning about the model.

Our impact 

A comprehensive evaluation conducted by Health Innovation South West in 2024-25 demonstrated the six-month NOAH pilot at Royal Devon University Healthcare NHS Foundation Trust was a success, with impact including: 

• 2.7 hospital days saved per baby (on average) by introducing NOAH 
• £66.5k potential annual cost saving for the Trust by reducing hospital stays, medication, and the use of associated equipment. 
• Reduction from 3 to 1.7 in the average number of doses of gentamicin per baby. 
• 97% of staff felt that the NOAH pathway has a positive impact on babies, families, and the hospital. 
• 8,230kg CO2 estimated saving when implementing NOAH for one year. 

Following the successful pilot, NOAH has achieved significant national traction: the pathway has now been adopted across the South West region and beyond, including sites in London, Wales, Leeds, Northern Ireland, the South Coast, and the North West region.

Each baby switched saves an estimated £1,900 to £2,500 in bed costs; if adopted at scale across England and Wales, the pathway could avoid up to 32,000 neonatal cot-days and save up to £30 million annually.  

In addition: 

• NOAH was the winner of Best Local Project at the British Association of Perinatal Medicine Gopi Menon Awards 2025. Read the NOAH poster here.
• NOAH was Commended in the NHSE South West Regional Champions Excellence Awards 2026 in the Delivering Value category.
• NOAH is shortlisted for the 2026 HSJ Award for Maternity, Midwifery and Neonatal Safety Initiative of the Year.
• NOAH implementation resources have been downloaded by over 100 organisations nationwide with continued geographical spread.
• In May 2026, NICE (National Institute for Health and Care Excellence) updated national guidance NG195 to include oral antibiotics for neonates – a change directly informed by the systematic review conducted by the NOAH team, alongside NOAH service evaluation data and expert witness testimony.
• NOAH has been endorsed by the Neonatal Nurses Association.

Resources

The Royal Devon neonatal team and Health Innovation South West are pleased to share these resources to help teams considering the implementation of NOAH. Teams should be advised to follow their local governance processes and decision making before they implement NOAH.

The following resources are available for download. You can view any of the linked resources, or alternatively complete the below form to download a folder containing all of the following resources:

• NOAH ‘Explainer’ Video Presentation by Harriet Aughey 
• NOAH Digital Patient Information Leaflets (including translations) 
• NOAH Printable Patient Information Leaflet
• NOAH Benefits Infographic
• NOAH Guideline Template
• Pathways for babies with suspected EOI
• NOAH Frequently Asked Questions
• NOAH References and Websites
• NOAH Telephone Follow-up Proforma
• NOAH Driver Diagram
• NOAH Staff Poster
• NOAH PDSA Cycle
• NOAH Data Collection Tool
• NOAH evaluation
• NOAH evidence Summary
• NOAH QI poster
• NOAH Toolkit March 2025
• NOAH Alignment to National Guidance
  
• NOAH Systematic Review – PROSPERO
• Evaluation of the Early Adopters of the Neonatal Oral Switch Pathway in the UK
• Recorded Implementation Webinar: Practical How‑To & Live Q&A – led by NOAH Clinical Leads Dr Harriet Aughey and Dr Kelly Boxall

Please note that as of 3 November 2025, the NOAH pathway transitioned from using oral Co-amoxiclav to oral Amoxicillin for babies completing antibiotic treatment at home. Find out more in the rational for change document. All resources have been updated accordingly as of 5 November 2025. 

Health Innovation South West is focused on learnings from ongoing implementation methodology for this innovation. We recognise that other systems might be applying other approaches in this area and welcome the ongoing exchange of insight. This will ensure the most efficient and effective route to impact for families and to support patient safety practices and principles across these approaches.