We are pleased to advise that deep linking capability, enabling users to directly download individual mobile toolkits, has now been released on the RDS mobile app. When you install the update, you will see that each toolkit has a small QR code icon the header area beside the search icon – see screenshot below. Clicking on this icon will open up a window with a full-size QR code and the alternative of a short URL for sharing with users. Instructions are provided.
You may need to actively install the update to install RDS app version 4.7.1 to see this improvement. Installing this update is also strongly recommended to get the full benefits of the new contingency arrangements – specifically, that if the RDS website should fail, you will still be able to download new mobile app toolkits.
To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. To install latest updates:
On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.
On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.
Please get in touch with ann.wales3@nhs.scot with any questions.
There are now a number of licensed melatonin products, however no melatonin product is licensed for the treatment of sleep onset difficulties in children. Melatonin 3mg tablets have been added to the NHS Highland Formulary as a clinically effective and cost-effective treatment for sleep onset difficulties in children (off-label indication). No other melatonin products are recommended.
Initial referral:
GPs, Community Paediatricians or Child Psychiatrists who have patients with a sleep onset difficulty must, in the first instance, refer the patient to a Health Visitor, School Nurse or Community Nurse, in order that behavioural measures, good sleep hygiene and sleep diaries may be introduced.
See the Sleep Diary and www.sleepscotland.org
Treatment failure onward referral:
Refer to Sleep Councillor for advice, where this is available.
It is well known that improving sleep patterns leads to a general improvement in health, behaviour and wellbeing.
Drug therapy may only be commenced AFTER behavioural interventions and sleep hygiene measures have been carried out.
Behavioural modification and appropriate sleep hygiene measures may require a long period of adherence before benefit is seen and occasionally they are ineffective.
Advice about sleep hygiene should be discussed with the family, backed up with written information (Appendices 3 and 4), and in consultation with the Health Visitor, School Nurse, Community Children’s Nurse or Community Nurse for Learning Disabilities, as appropriate.
If melatonin is being considered, behavioural measures MUST be used first and maintained during the trial. The benefits of behaviour change continue longer over time than drugs.
Appendices
Detailed sleep histories are key to the diagnosis of sleep disorders, which can be a major source of stress for the whole family and limited solutions are available.
Appendices
Melatonin may be viewed as an alternative to sedatives and hypnotics, which have adverse side-effects. It may be prescribed to assist development of improved sleep patterns and behaviours, ONLY WHEN, appropriate behavioural sleep interventions fail.
NICE state that evidence for use of melatonin has shown a total increase in sleep time of only 20 minutes and reduction in time taken to fall asleep of approximately 20 minutes. There are still ongoing concerns over the lack of long-term safety data in children, and there is uncertainty as to the effect on other circadian rhythms including endocrine or reproductive hormone secretion.
For information on side effects, cautions and contra-indications see:
Any serious reaction should be reported to the Commission of Human Medicines (CHM) by whomever they are highlighted to. Use the Yellow Card System to report adverse drug reactions, see: https://yellowcard.mhra.gov.uk/
Any child being considered for a trial of melatonin MUST have:
| NHS Highland recommends: |
Melatonin 3mg tablets are a clinical and cost-effective option. The Ceyesto brand is cost-effective; the tablets can be crushed and given in a small drink or soft food for patients with swallowing difficulties. |
| Medicine status: |
Melatonin 3mg tablets are licensed in the UK for short-term use for Jet lag in adults (this is not a formulary indication). |
| Dosing information | |
|
Route of administration |
Oral |
|
Initial trial: 7 to 14 days
|
3mg tablets daily |
| Assess response and adjust dose |
If non response (delayed time to sleep onset, disturbed sleep, early morning awakening), increase to 6mg or 9mg (maximum dose). |
| Stabilise the patient on therapy |
Supply medicine for one further month after the dose has stabilised |
| Review |
Stop melatonin for 1 week during a non-stressful period; repeat the sleep diary and review. |
| Adjunctive treatment |
Behavioural measures and sleep diaries. |
| Treatment duration |
Indefinite if significant sleep problem persists and patient continues to benefit. |
| Discontinuation |
Discontinue if ineffective. Provide necessary supervision and support during drug discontinuation phase. Withdrawal of melatonin can be immediate. Monitor for recurrence of sleep disorders, depending on the frequency of use. |
As this group of patients move into adult care, consideration should be given to continuation of their therapy. If therapy continues beyond children’s services, care should be transferred to young persons or adult services as appropriate. The principles in this guideline apply equally to this group of patients as they become adults.
TAM (Treatments and Medicines) NHS Highland