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Aim Many children with sleep difficulties are prescribed melatonin, a hormone playing a key role in the timing of sleep-wake cycle, however the drug is costly and evidence for its efficacy is limited. The aim of this study was to evaluate a nurse-led sleep clinic, in which a behavioural sleep programme is delivered, to look at outcomes in terms of melatonin prescribing. Methods All new referrals attending a nurse-led Sleep Clinic were examined over a 9 month period from June 2016 to March 2017. Patients attending the clinic were given an individualised sleep programme for the parent to implement with their child at home, with ongoing support from the sleep nurse. Families received an average of 3 face to face clinic visits and 3 follow up telephone calls from first visit to discharge. Retrospective data was gathered from clinic records. Melatonin prescribing data was analysed. Results 69 patients aged 1–17 years (45% male; 55% female) were analysed. The primary complaint was ‘problem with sleep initiation and maintenance’ in 81%, ‘problem with sleep initiation’ in 13% and ‘problem with sleep maintenance’ in 6%. Of the 69 patients, 84% had medical co-morbidities. 54% of which were neuro-disability, the commonest being Autistic Spectrum Disorder and/or Attention Deficit Hyperactivity Disorder. 40/69 patients were successfully discharged from the clinic during the study period. 65% were discharged without melatonin (23% with neurodisability; 42% without neurodisability), of which 35% were weaned off melatonin and 30% avoided melatonin prescriptions. 12% felt that the sleep intervention had been successful but still required melatonin, 15% were referred to medical/psychology clinics, and 8% were non-compliant with the behavioural sleep programme and were discharged still taking melatonin. Conclusion In this cohort of patients with sleep initiation and maintenance problems despite taking melatonin, a brief but intensive behavioural programme with support from a sleep nurse was effective in resolving the sleep problems. We recommend that standardised sleep support from trained practitioners should be available prior to prescribing melatonin for children suffering sleep difficulties. This approach is not only beneficial in effectively resolving sleep problems but is cost-effective when compared with melatonin prescribing costs.

Aim A partnership involving a Children’s Trust, the City Council and a Sleep Charity evaluated a behavioural intervention to provide support to parent/carers and young people to improve sleep patterns. Methods The intervention entailed basic education about sleep, a one-to-one session with a sleep practitioner to create an individual sleep programme and telephone support to empower the parent to carry out the sleep programme at home. Results 39 children completed the intervention and evaluation, median age 8.56 years (range 1.82–15.75 years). 79.5% were male. 75% had a diagnosis of ADHD or were awaiting assessment, the remaining 25% were Looked After or Adopted Children (of whom 10% also had ADHD). Parents’ ratings of their child’s ability to self-settle to sleep improved from 1.13/10 to 6.73/10 after the intervention (MD 5.62, 95% confidence intervals 4.56–6.69, p The primary word used to describe the mood of the child on wakening before the intervention was ‘grumpy’ and after the intervention was ‘happy’. The impact of sleep deprivation on the parents’ wellbeing improved for all measures. The overall WEMWBS score improved significantly following the intervention (MD 8.84, 95% CI 5.32–12.36, p Conclusion The evaluation gave us confidence in the delivery model. ‘Regular telephone calls and support’ and ‘Learning about sleep’ were the main positive factors. Our partnership working brought together the individual strengths, drive and passion that were critical for delivery, planning, and influencing better provision for families. We have established a strategic group to support local implementation and produced a draft delivery model which we believe is replicable for other areas.

Background Respiratory rate (RR) is an important vital sign used in the initial and ongoing assessment of unwell children. Measuring respiratory rate can be difficult and time consuming, especially in an uncooperative child. There are concerns that there may be high levels of inconsistencies in measurements of respiratory rate. This may impact greatly on the child, their clinical assessment and subsequent management, and the accurate identification of possible deterioration. Aim To determine the reliability of a respiratory rate count on a child when assessed by three independent observers. Method From August 2016 to October 2016 the respiratory rate of 169 children was measured by three independent observers in one tertiary children’s hospital. The first respiratory rate was taken by different healthcare professionals from within the hospital using their own method of measurement. A further count of respiratory rate was then taken by two different observers simultaneously within 30 min of the first measurement. They measured the respiratory rate using the WHO recommended method of measurement by observing chest movements over 60 s. All observers were blinded to each of the others’ measurements. Results A total of 507 respiratory rate measurements were taken on 169 children aged between 3 days and 15 years. The 95% limits of agreement between the first RR measurement and second and third measurements was 10.15 to 17.68 and 11.36 to 18.73 respectively. For simultaneous measurements the 95% limits of agreement were 7.11 to 6.95, meaning that that the difference in measurements could have been anything from 7 breaths less to 6 breaths more. Significantly, in 25% of the children the difference in the measured RR was such that the child would not have been assessed as being tachypnoeic by one or more of the three observers. Conclusion There exists a large variation in respiratory rate measurements taken in children. The agreement between measurements and the identification of tachypnoea was poor. The effect that this variation may have on the clinical assessment of a child is significant. These findings highlight the need for a robust review of our current reliance and interpretation of such an important vital sign.