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DelRosso LM, Picchietti DL, Sharon D, Spruyt K, Owens JA, Walters AS, Zucconi M, Ferri R. Periodic limb movement disorder in children: A systematic review. Sleep Med Rev 2024; 76:101935. [PMID: 38652932 DOI: 10.1016/j.smrv.2024.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/09/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024]
Abstract
This systematic review evaluates the scientific literature on pediatric periodic limb movement disorder (PLMD), adhering to PRISMA guidelines and utilizing PICOS criteria. The search across PubMed, EMBASE, and Scopus yielded 331 articles, with 17 meeting inclusion criteria. Diagnostic criteria evolved, with polysomnography and PLMS index ≥5 required since 2003. Also, PLMD diagnosis mandates clinical consequences like insomnia, hypersomnia, and fatigue, excluding comorbidities causing sleep disruption. Prevalence in children is low (0.3%), emphasizing the need for meticulous investigation. Comorbidities, particularly the bidirectional relationship with ADHD, were explored. Challenges in diagnosis and understanding arise from overlapping conditions such as sleep disordered breathing, psychotropic medication, and criteria non-adherence. Despite generally good study quality, weaknesses include sample size justification and biases. The periodic leg movement index shows high sensitivity but low specificity, underscoring strict diagnostic criteria adherence. Diverse metrics for symptoms necessitate standardized approaches. Family history of RLS in children with PLMD suggests unexplored aspects. Treatment, mainly iron supplementation, lacks standardized assessment metrics. The review emphasizes diagnostic and treatment challenges, recommending unbiased studies with precise techniques. Comprehensive research, quantifying PLMS and objectively assessing sleep parameters, is crucial for advancing understanding in pediatric PLMD. PROSPERO REGISTRATION NUMBER: CRD42021251406.
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Affiliation(s)
| | - Daniel L Picchietti
- University of Illinois School of Medicine, Carle Illinois College of Medicine, and Carle Health, Urbana, IL, USA.
| | - Denise Sharon
- Pomona Valley Hospital and Medical Center, Claremont, CA, USA.
| | - Karen Spruyt
- Université de Paris, NeuroDiderot, INSERM, Paris, 75019, France.
| | - Judith A Owens
- Division of Neurology, Boston Children's Hospital, Harvard Medical School, Waltham, MA, USA.
| | - Arthur S Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Marco Zucconi
- Sleep Disorders Center, Department of Neurology, Scientific Institute and University Ospedale San Raffaele, Vita-Salute University, Institute and Ospedale San Raffaele, Milan, Italy.
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy.
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2
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DelRosso LM, Mogavero MP, Baroni A, Bruni O, Ferri R. Restless Legs Syndrome in Children and Adolescents. Psychiatr Clin North Am 2024; 47:147-161. [PMID: 38302203 DOI: 10.1016/j.psc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Children with psychiatric comorbidities frequently are referred for evaluation of sleep complaints. Common sleep symptoms can include difficulty falling asleep, frequent nocturnal awakening, restless sleep, and symptoms of restless legs syndrome (RLS). The understanding of the sleep condition in relation to the psychiatric comorbidity often is a challenge to the physician and often sleep disorders remain undiagnosed, untreated, or undertreated. Restless legs syndrome has been associated with psychiatric comorbidities and with certain medications, such as antidepressants, antihistamines, and antipsychotics. This article reviews the presentation of RLS and restless sleep, the association with psychiatric comorbidities, and treatment options.
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Affiliation(s)
- Lourdes M DelRosso
- Department of Internal Medicine, University of California San Francisco, Fresno, CA 93721, USA
| | - Maria Paola Mogavero
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, Italy; San Raffaele Scientific Institute, Division of Neuroscience, Sleep Disorders Center, Via Stamira d'Ancona 20, 20127 Milan, Italy
| | - Argelinda Baroni
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 7th Floor, New York, NY 10016, USA
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Via dei Marsi 78, 00185 Rome, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Via C. Ruggero 73, Troina 94018, Italy.
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DelRosso LM, Mogavero MP, Bruni O, Ferri R. Restless Legs Syndrome and Restless Sleep Disorder in Children. Sleep Med Clin 2023; 18:201-212. [PMID: 37120162 DOI: 10.1016/j.jsmc.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Restless legs syndrome (RLS) affects 2% of children presenting with symptoms of insomnia, restless sleep, decreased quality of life, and effects on cognition and behavior. The International RLS Study Group and the American Academy of Sleep Medicine have published guidelines for the diagnosis and treatment of RLS in children. Restless sleep disorder has been recently identified in children and presents with frequent movements during sleep and daytime symptoms with polysomnography findings of at least 5 large muscle movements at night. Treatment options for both disorders include iron supplementation, either oral or intravenous with improvement in nighttime and daytime symptoms.
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Affiliation(s)
- Lourdes M DelRosso
- University of California San Francisco, Fresno, USA; University Sleep and Pulmonary Associates, 6733 North Willow Avenue, Unit 107, Fresno, CA 93710, USA.
| | - Maria Paola Mogavero
- Institute of Molecular Bioimaging and Physiology, National Research Council, Milan, Italy; Division of Neuroscience, Sleep Disorders Center, San Raffaele Scientific Institute, Milan, Italy; Centro di Medicina Del Sonno, IRCCS Ospedale San Raffaele, Turro, Via Stamira D'Ancona, 20, Milano 20127, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, Sapienza University, Via dei Marsi 78, Rome 00185, Italy
| | - Raffaele Ferri
- Department of Neurology I.C., Sleep Research Centre, Oasi Research Institute - IRCCS, Via C Ruggero 73, Troina 94018, Italy
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O'Keeffe M, Kamper SJ, Montgomery L, Williams A, Martiniuk A, Lucas B, Dario AB, Rathleff MS, Hestbaek L, Williams CM. Defining Growing Pains: A Scoping Review. Pediatrics 2022; 150:188581. [PMID: 35864176 DOI: 10.1542/peds.2021-052578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Up to one third of children may be diagnosed with growing pains, but considerable uncertainty surrounds how to make this diagnosis. The objective of this study was to detail the definitions of growing pains in the medical literature. METHODS Scoping review with 8 electronic databases and 6 diagnostic classification systems searched from their inception to January 2021. The study selection included peer-reviewed articles or theses referring to "growing pain(s)" or "growth pain(s)" in relation to children or adolescents. Data extraction was performed independently by 2 reviewers. RESULTS We included 145 studies and 2 diagnostic systems (ICD-10 and SNOMED). Definition characteristics were grouped into 8 categories: pain location, age of onset, pain pattern, pain trajectory, pain types and risk factors, relationship to activity, severity and functional impact, and physical examination and investigations. There was extremely poor consensus between studies as to the basis for a diagnosis of growing pains. The most consistent component was lower limb pain, which was mentioned in 50% of sources. Pain in the evening or night (48%), episodic or recurrent course (42%), normal physical assessment (35%), and bilateral pain (31%) were the only other components to be mentioned in more than 30% of articles. Notably, more than 80% of studies made no reference to age of onset in their definition, and 93% did not refer to growth. Limitations of this study are that the included studies were not specifically designed to define growing pains. CONCLUSIONS There is no clarity in the medical research literature regarding what defines growing pain. Clinicians should be wary of relying on the diagnosis to direct treatment decisions.
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Affiliation(s)
- Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Steven J Kamper
- Centre for Pain, Health and Lifestyle, New South Wales, Australia.,School of Health Sciences.,Nepean Blue Mountains Local Health District, Penrith, Australia
| | - Laura Montgomery
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Amanda Williams
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, New South Wales, Australia
| | - Alexandra Martiniuk
- School of Public Health, Faculty of Medicine, and Health.,The George Institute for Global Health, Sydney Medical School, The University of Sydney, New South Wales, Australia.,Dalla Lana School of Public Health, The University of Toronto, Ontario, Canada
| | - Barbara Lucas
- Discipline of Paediatrics and Child Health, Sydney Medical School.,John Walsh Center for Rehabilitation Research, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Physiotherapy Department, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | | | - Michael S Rathleff
- Center for General Practice at Aalborg University, Aalborg, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Lise Hestbaek
- Department of Sports Science and Clinical Biomechanics, Clinical Biomechanics, University of Southern Denmark, Campus vej 55, 5230, Odense, Denmark.,The Chiropractic Knowledge Hub, Odense, Denmark
| | - Christopher M Williams
- Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Hunter New England Population Health Unit, Newcastle, Australia.,University of Newcastle, Callaghan, Australia
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Abstract
Early-onset restless legs syndrome has a relatively high prevalence in pediatrics, is highly familial, and is often preceded by a diagnosis of periodic limb movement disorder or childhood insomnia. Diagnostic criteria are derived but not equal to those of the adult syndrome and are adapted according to children's age and linguistic competence. Diagnosis requires parents or caregivers to participate; video-polysomnographic nocturnal recording, although not mandatory, may help confirm dubious cases. The syndrome severely impacts children's sleep and cognitive-behavioral abilities. Iron supplementation is currently the most used and viable therapeutic option.
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Affiliation(s)
- Rosalia Silvestri
- Department of Clinical and Experimental Medicine, Sleep Medicine Center, University of Messina, AOU G Martino, Pad. H, Via Consolare Valeria 1, Messina, Messina 98125, Italy.
| | - Lourdes M DelRosso
- Seattle Children's Hospital, OC.7.720 - Pulmonary, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
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DelRosso LM, Mogavero MP, Baroni A, Bruni O, Ferri R. Restless Legs Syndrome in Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2021; 30:143-157. [PMID: 33223058 DOI: 10.1016/j.chc.2020.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Children with psychiatric comorbidities frequently are referred for evaluation of sleep complaints. Common sleep symptoms can include difficulty falling asleep, frequent nocturnal awakening, restless sleep, and symptoms of restless legs syndrome (RLS). The understanding of the sleep condition in relation to the psychiatric comorbidity often is a challenge to the physician and often sleep disorders remain undiagnosed, untreated, or undertreated. Restless legs syndrome has been associated with psychiatric comorbidities and with certain medications, such as antidepressants, antihistamines, and antipsychotics. This article reviews the presentation of RLS and restless sleep, the association with psychiatric comorbidities, and treatment options.
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Affiliation(s)
- Lourdes M DelRosso
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, 4800 Sand Point Way, Northeast, Seattle, WA, USA
| | - Maria Paola Mogavero
- Istituti Clinici Scientifici Maugeri, IRCCS, Scientific Institute of Pavia, Via Salvatore Maugeri 4, Pavia 27100, Italy
| | - Argelinda Baroni
- Child Study Center, Hassenfeld Children's Hospital at NYU Langone, 430 E 34th St, New York, NY, USA
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Via dei Marsi 78, 00185 Rome, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Via C. Ruggero 73, Troina 94018, Italy.
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Al-Shawwa B, Ehsan Z, Perry GV, Ingram DG. Limb movements during sleep in children: effects of age, sex, and iron status in more than 1,000 patients referred to a pediatric sleep center. J Clin Sleep Med 2020; 16:49-54. [PMID: 31957651 DOI: 10.5664/jcsm.8120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Limb movements during sleep (LMS) and periodic limb movements during sleep (PLMS) have been shown to vary by age in children. In the current study, we examined this relationship in more detail in a large clinically referred sample adjusting for iron status and sex. METHODS Retrospective data analysis was done on a large pediatric population who underwent an overnight sleep study and had ferritin levels measured within 30 days of sleep study between May 2013 and October 2017 at pediatric sleep center. Patients with obstructive or central sleep apneas were excluded. RESULTS A total of 1,070 patients were included in the study, with 60% males. Younger age and male sex were associated with increased PLMS and LMS. In addition, there was an increase in PLMS and LMS during adolescence that subsided at a later age, independent of sex. These associations remained significant in models controlling for ferritin level. Ferritin level, in contrast, was not a significant predictor of PLMS or LMS when controlling for sex and age. CONCLUSIONS Age and sex may need to be considered when interpreting limb movement indices in pediatric sleep patients regardless of ferritin level.
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Affiliation(s)
- Baha Al-Shawwa
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Zarmina Ehsan
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Gayln V Perry
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - David G Ingram
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
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Sierra Montoya AC, Mesa Restrepo SC, Cuartas Arias JM, Cornejo Ochoa W. Prevalence and Clinical Characteristics of the Restless Legs Syndrome (RLS) in Patients Diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) in Antioquia. Int J Psychol Res (Medellin) 2018; 11:58-69. [PMID: 32612771 PMCID: PMC7110177 DOI: 10.21500/20112084.3381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is the most common behavioral issue for children. One of the sleeping disorders most frequently related to ADHD is the Restless Legs Syndrome (RLS), characterized by an irresistible urge to move the legs, something that is generally associated with paresthesias and motor restlessness. The prevalence rate of RLS in children diagnosed with ADHD is close to 18%, but in Colombia, these cases have been hardly studied. Objective: To determine the frequency of RLS, in children with ADHD. Methods: A cross-sectional study, filled out by parents of children diagnosed with ADHD, were analyzed. This questionnaire contained clinical criteria for classifying ADHD according to the DSM-IV, as well as diagnostic criteria for RLS by the National Institutes of Health (2003). Results: A predominance rate of 65.6% in combined ADHD was observed in children with RLS criteria. Upon carrying out an exploratory data analysis, it was found that having a family history of RLS and belonging to the middle or low socioeconomic strata are conditions associated with the presence of RLS in children with ADHD, with a significant p (p < 0.000) and a PR of 4.47 (3.16-6.32). Conclusions: The prevalence of RLS was similar to the findings of other clinical investigations. However, it highlights new prevalence values in relation to the comorbidity between ADHD and RLS, suggesting the need for new clinical and therapeutic alternatives amidst the presence of both syndromes.
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Affiliation(s)
- Ana Carolina Sierra Montoya
- Pediatrics Section of Child Neurology, Hospital Pablo Tobón Uribe, Medellin Colombia. Pediatrics Section of Child Neurology Hospital Pablo Tobón Uribe Medellin Colombia
| | - Sandra Catalina Mesa Restrepo
- Pediatrics Section of Child Neurology, Hospital Pablo Tobón Uribe, Medellin Colombia. Pediatrics Section of Child Neurology Hospital Pablo Tobón Uribe Medellin Colombia
| | - Jorge Mauricio Cuartas Arias
- Psychiatry Research Group - GIPSI, Department of Psychiatry, School of Medicine, Universidad de Antioquia, Medellín - Colombia. Universidad de Antioquia Department of Psychiatry School of Medicine Universidad de Antioquia Medellín Colombia.,Psychology and Neurosciences Research Group, School of Psychology, Universidad de San Buenaventura, Medellín - Colombia. Universidad de San Buenaventura Universidad de San Buenaventura Medellín Colombia
| | - William Cornejo Ochoa
- Full member of the Colombian Association of Neurology (ACN) and Child Neurology Colombian Association (Asconi)-Group Director of Research in Child and Adolescent Disorders (PEDIACIENCIAS)-Titular Professor Department of Pediatrics, School of Medicine, Universidad de Antioquia, Medellín, Colombia. Universidad de Antioquia Department of Pediatrics School of Medicine Universidad de Antioquia Medellín Colombia
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Heubi CH, Meinzen-Derr J, Shott SR, Smith DF, Ishman ASL. Polysomnography in Pediatric Otolaryngology: If Not Obstructive Sleep Apnea, What Is It? Otolaryngol Head Neck Surg 2017; 157:1053-1059. [DOI: 10.1177/0194599817726977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective To determine common polysomnographic (PSG) diagnoses for children referred by otolaryngologists. Study Design Retrospective case series with chart review. Setting Single tertiary pediatric hospital (2010-2015). Subjects and Methods Review of the medical records of 1258 patients undergoing PSG by otolaryngology referral. Patients who underwent previous otolaryngologic surgery were excluded. Data distributions were evaluated using means with standard deviations for continuous variables and frequencies with percentages for categorical variables. Results A total of 1258 patients were included; 55.9% were male, 64.5% were Caucasian, 16.6% had Down syndrome, and 48% had public insurance. The median age at the time of PSG was 5.2 years (range = 0.2-18.94). Indications for PSG were sleep-disordered breathing (SDB; 69.4%), restless sleep (12.7%), airway anomalies (7.5%), and laryngomalacia (7.2%). SDB was seen in 73.4%, obstructive sleep apnea (OSA) in 53.2%, OSA + central sleep apnea (CSA) in 4.5%, CSA in 0.9%, and non-OSA snoring in 15%. Other diagnoses included periodic limb movements of sleep (PLMS; 7.4%), hypoventilation (6.8%), and nonapneic hypoxemia (2.6%). SDB was more common in younger children and seen in 91.4% of children <12 months and in 69.2% of children ≥24 months, while non-OSA snoring was more common with increasing age (3.7% in children <12 months, 17.7% of children ≥24 months). PLMS were seen in 8.9% of children ≥24 months and in no children <12 months. Conclusion While OSA and snoring were the most common diagnoses reported, PLMS, alveolar hypoventilation, and CSA occurred in 7.4%, 6.8%, and 5.4%, respectively. These findings indicate that additional diagnoses other than OSA should be considered for children seen in an otolaryngology clinic setting who undergo PSG for sleep disturbances.
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Affiliation(s)
- Christine H. Heubi
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical, Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jareen Meinzen-Derr
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical, Center, Cincinnati, Ohio, USA
| | - Sally R. Shott
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical, Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - David F. Smith
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical, Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - and Stacey L. Ishman
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical, Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Sherbin N, Ahmed A, Fatani A, Al-Otaibi K, Al-Jahdali F, Ali YZ, Al-Harbi A, Khan M, Baharoon S, Al-Jahdali H. The prevalence and associated risk factors of restless legs syndrome among Saudi adults. Sleep Biol Rhythms 2017. [DOI: 10.1007/s41105-017-0089-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sander HH, Eckeli AL, Costa Passos AD, Azevedo L, Fernandes do Prado LB, França Fernandes RM. Prevalence and quality of life and sleep in children and adolescents with restless legs syndrome/Willis-Ekbom disease. Sleep Med 2017; 30:204-209. [DOI: 10.1016/j.sleep.2016.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/16/2016] [Accepted: 10/05/2016] [Indexed: 11/25/2022]
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Per H, Gunay N, Ismailogullari S, Oztop DB, Gunay O. Determination of restless legs syndrome prevalence in children aged 13-16years in the provincial center of Kayseri. Brain Dev 2017; 39:154-160. [PMID: 27666468 DOI: 10.1016/j.braindev.2016.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/09/2016] [Accepted: 08/30/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study was conducted to determine the prevalence rate of restless legs syndrome (RLS) and associated factors in adolescents aged 13-16years in the provincial center of Kayseri. MATERIALS AND METHODS The study sample included 5720 adolescents who were selected from among 74,421 grade 7-10 students aged 13-16years in the provincial center of Kayseri. Overall, datas from 4792 subjects were included into analysis. Data were collected by using a self reported questionnaire and the Epworth Sleepiness Scale (ESS). The prevalence rate of RLS was determined by questionnaire datas and phone interviews. The effects of age, gender, economical status and body weight on RLS prevalence rate were analyzed. Mean ESS score was calculated. The effect of RLS on academic success, as measured by grade point average, was also assessed. The subjects were stratified as underweight, normal, overweight and obese according to the body mass index and the RLS prevalence rate was compared among groups. RESULTS The RLS prevalence rate was determined to be 2.9% among adolescents aged 13-16years in the study group. It was found that gender and economical status had no significant effect on RLS prevalence. Mean age at symptom onset was 11.4years of age. There was a positive family history in 11.3% of subjects. Mean body mass index (BMI) was found to be significantly higher in subjects with RLS (21.5±3.8 vs. 20.5±3.2). Academic success (72.0±11.2 vs. 77.0±12.0) was found to be poorer and daytime sleepiness level, as measured by ESS (11.4±3.9 vs. 6.3±4.0), was found to be higher in subjects with RLS. CONCLUSION The RLS prevalence rate was 2.9% in the study sample while gender and economical status had no significant effect on prevalence rate. The RLS, which results in decreased sleep quality and academic success, is an important disorder with a considerable prevalence in the population.
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Affiliation(s)
- Huseyin Per
- Erciyes University Medical Faculty, Department of Pediatrics, Division of Pediatric Neurology, Kayseri, Turkey.
| | - Neslihan Gunay
- Erciyes University Medical Faculty, Department of Pediatrics, Kayseri, Turkey.
| | - Sevda Ismailogullari
- Erciyes University Medical Faculty, Department of Neurology, Division of Sleep Medicine, Kayseri, Turkey.
| | - Didem Behice Oztop
- Erciyes University Medical Faculty, Department of Child Psychiatry, Kayseri, Turkey.
| | - Osman Gunay
- Erciyes University Medical Faculty, Department of Public Health, Kayseri, Turkey.
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Simakajornboon N, Dye TJ, Walters AS. Restless Legs Syndrome/Willis-Ekbom Disease and Growing Pains in Children and Adolescents. Sleep Med Clin 2015; 10:311-22, xiv. [PMID: 26329441 DOI: 10.1016/j.jsmc.2015.05.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Recent studies have shown that restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common in pediatric population. The diagnostic criteria for Pediatric RLS have recently been updated to simplify and integrate with newly revised adult RLS criteria. Management of RLS and PLMD involves pharmacologic and nonpharmacologic interventions. Children with low iron storage are likely to benefit from iron therapy. Although, there is limited information on pharmacologic therapy, there are emerging literatures showing the effectiveness of dopaminergic medications in the management of RLS and PLMD in children. This article covers clinical evaluation of RLS and PLMD in children and the relationship with growing pains.
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Affiliation(s)
| | - Thomas J Dye
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Arthur S Walters
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
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14
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Fröhlich AC, Eckeli AL, Bacelar A, Poyares D, Pachito DV, Stelzer FG, Coelho FMS, Rizzo GNV, Prado GFD, Sander HH, Goulart LI, Lucchesi LM, Gitai LLG, Prado LBFD, Ataíde-Junior L, Bezerra MLDS, Lopes MC, Trentin MM, Rodrigues RND, Hasan R, Alves RSC, Schönwald SV, Moraes WADS. Brazilian consensus on guidelines for diagnosis and treatment for restless legs syndrome. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:260-280. [PMID: 25807136 DOI: 10.1590/0004-282x20140239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
The Consensus on restless legs syndrome is an effort of neurologists from several Brazilian states, which tirelessly reviewed the literature of recent years in search of evidence, both in regard to diagnosis and treatment, according to the Oxford Centre for Evidence-based Medicine.
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Affiliation(s)
| | - Alan Luiz Eckeli
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | - Heidi Haueisen Sander
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | | | | | | | | | | | - Maria Cecília Lopes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
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15
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Bruni O, Ferri R. The Emergence of Pediatric Sleep Medicine. Sleep Med 2015. [DOI: 10.1007/978-1-4939-2089-1_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Scholle S, Scholle HC. Leg movements and periodic leg movements during sleep in the development across childhood and adolescence from 1 to 18 years. Sleep Med 2014; 15:1068-74. [DOI: 10.1016/j.sleep.2014.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/15/2014] [Accepted: 04/19/2014] [Indexed: 10/25/2022]
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Silva GE, Goodwin JL, Vana KD, Vasquez MM, Wilcox PG, Quan SF. Restless legs syndrome, sleep, and quality of life among adolescents and young adults. J Clin Sleep Med 2014; 10:779-86. [PMID: 25024656 DOI: 10.5664/jcsm.3872] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Clinical reports in children implicate restless legs syndrome (RLS) with sleep and behavior problems. However, population-based studies on this association in adolescents and young adults are limited. Furthermore, few studies have evaluated the association between symptoms consistent with RLS and quality of life (QoL). STUDY DESIGN This cross-sectional study included 214 Caucasian and Hispanic adolescents and young adults aged 12-20 years. Symptoms consistent with RLS were based on four essential criteria and if the symptoms occurred ≥ 5 days/ month. Trouble falling asleep was present if reported "yes, still have the problem." Quality of life (QoL) was assessed using the Pediatric QoL Inventory. Three summary QoL scores ranging from 0-100 were evaluated; higher scores indicated better QoL. RESULTS Participants were 50% male and 68.1% Caucasian. Prevalence of RLS was 8.4% (n = 18). RLS was associated with trouble falling asleep (OR = 3.1, p = 0.049), and trouble falling asleep was associated with worse Psychosocial Health scores (Coeff. -5.6, p = 0.004) and Total Scale scores for quality of life (Coeff. -4.6, p = 0.007). CONCLUSIONS The prevalence of symptoms consistent with RLS in this community-based sample of adolescents and young adults, aged 12-20, is comparable to rates reported in older cohorts. Symptoms consistent with RLS may be associated with trouble falling asleep and psychosocial distress that may contribute to a lower health-related quality of life.
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Affiliation(s)
| | - James L Goodwin
- Arizona Respiratory Center, University of Arizona, Tucson, AZ ; College of Medicine, University of Arizona, Tucson, AZ ; Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Kimberly D Vana
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
| | | | - Peter G Wilcox
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
| | - Stuart F Quan
- Arizona Respiratory Center, University of Arizona, Tucson, AZ ; College of Medicine, University of Arizona, Tucson, AZ ; Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Amos LB, Grekowicz ML, Kuhn EM, Olstad JD, Collins MM, Norins NA, D'Andrea LA. Treatment of pediatric restless legs syndrome. Clin Pediatr (Phila) 2014; 53:331-6. [PMID: 24198314 DOI: 10.1177/0009922813507997] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The primary aim was to determine if iron supplementation effectively treats children with restless legs syndrome (RLS), the time to improvement or resolution of symptoms, and patient characteristics (family history of RLS, secondary sleep disorders, medical diagnoses, and/or mental health diagnoses) that may affect outcome. METHODS.: This was a retrospective chart review of children between 5 and 18 years old who were diagnosed with RLS at the pediatric sleep disorders clinic at Children's Hospital of Wisconsin in Milwaukee, Wisconsin. Documented RLS treatment approaches included supplemental iron, nonpharmacologic interventions, melatonin, gabapentin, clonidine, and dopamine agonists (pramipexole and ropinirole). RESULTS Ninety-seven children were diagnosed with RLS; 60.8% of children were between 5 and 11 years old. Most children (65%) received iron either as monotherapy or in combination with other treatments. Approximately 80% of the children who received iron and had follow-up had improvement or resolution of their symptoms. The median baseline ferritin level was 22.7 ng/mL, and 71% of children had a ferritin level less than 30 ng/mL. The median time to improvement or resolution of symptoms was 3.8 months. CONCLUSIONS Supplemental iron as monotherapy or in combination with other treatments is effective in treating pediatric RLS. A prospective study could help determine if the initial ferritin level and degree of change in the ferritin level impact response to iron treatment. It is also important to study the long-term outcomes in these patients.
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Pai V, Khatwa U, Ramgopal S, Singh K, Fitzgerald R, Kothare SV. Prevalence of pediatric periodic leg movements of sleep after initiation of PAP therapy. Pediatr Pulmonol 2014; 49:252-6. [PMID: 23818327 DOI: 10.1002/ppul.22802] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 02/27/2013] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Positive-airway-pressure (PAP) is a treatment for obstructive-sleep-apnea (OSA). In adults, initiation of PAP-therapy may unmask periodic-limb movements-of-sleep (PLMS). We present a series of children in whom PLMS was aggravated or induced following initiation of PAP therapy. METHODS Retrospective analysis was performed on children who had PAP-studies performed over a 3-year period. Children with OSA without significant PLMS on baseline studies and who then showed a periodic-limb-movement-index (PLMI) (>5/hr) during titration with PAP-therapy were identified. Charts were reviewed for demographics, OSA severity based on apnea hypopnea index (AHI), PLMI, PLM-arousal-index (PLMAI) and pressures titrated. RESULTS Two hundred fourteen PAP-titration studies (151 on continuous positive airway pressure [CPAP] and 63 on bilevel positive airway pressure [BiPAP]) were done. Eleven (10 on CPAP, 1 on BiPAP) met study criteria. Eight patients were boys. The median age was 12 years (range 6 months-18 years). On baseline studies, median AHI was 5/hr (range 1.5-32/hr), median PLMI was 1/hr (range 0-4/hr) and median PLMAI 0.3/Hr (range 0-2/hr). On titration studies, pressures ranged from 4 to 14 cm of water, median AHI was 0.5/hr (range 0-1), median PLMI was 12/hr (range 5-55/hr) and median PLMAI 9/hr (range 0-25). PLMS were seen predominantly during N1, N2 sleep and on PAP of >7 cm of water. One patient had resolution of PLMS at 1-year follow-up. CONCLUSION PLMS were seen in 5.1% of children after initiation of PAP. OSA may mask PLMS, which appears as breathing improves. Alternatively, PAP may unmask or induce PLMS. PLMS may potentially be a cause of treatment failure in children on recent-onset PAP therapy.
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Affiliation(s)
- Vidya Pai
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Pediatric Sleep Disorders, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Walters AS, Gabelia D, Frauscher B. Restless legs syndrome (Willis-Ekbom disease) and growing pains: are they the same thing? A side-by-side comparison of the diagnostic criteria for both and recommendations for future research. Sleep Med 2013; 14:1247-52. [PMID: 24157095 DOI: 10.1016/j.sleep.2013.07.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 12/12/2022]
Abstract
There has been no previous side-by-side comparison of the diagnostic criteria for restless legs syndrome (RLS) (Willis-Ekbom disease) and growing pains. In our review, we explore this comparison emphasizing overlaps and disconnects, summarize recent literature exploring the relationship between the 2 entities, and make suggestions for future research. There is considerable overlap in the diagnostic criteria for childhood RLS and growing pains. The literature also indicates that RLS and growing pains more commonly occur together than one would expect based on chance alone, and the family histories of RLS and growing pains often are overlapping. Leg rubbing to obtain relief from leg discomfort is common to both disorders, though walking to obtain relief seems unique to RLS. Childhood RLS also has been reported to be painful in up to 45% of cases. The development of standard diagnostic criteria is necessary to move forward in the field of growing pains research. A quantitative and validated rating scale for growing pains severity already exists. Because of the clinical and genetic similarity between RLS and growing pains, studies that parallel those previously performed in RLS patients are recommended for growing pains patients. For example, a genome wide association study in growing pains patients of all possible genes with particular attention to those identified as related to RLS and a therapeutic trial of medications known to be effective in RLS would be welcome. Abnormalities in vitamin D metabolism also may be common to both disorders.
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Affiliation(s)
- Arthur S Walters
- Department of Neurology, Sleep Division, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Molfese DL, Ivanenko A, Key AF, Roman A, Molfese VJ, O'Brien LM, Gozal D, Kota S, Hudac CM. A one-hour sleep restriction impacts brain processing in young children across tasks: evidence from event-related potentials. Dev Neuropsychol 2013; 38:317-36. [PMID: 23862635 PMCID: PMC4361951 DOI: 10.1080/87565641.2013.799169] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The effect of mild sleep restriction on cognitive functioning in young children is unclear, yet sleep loss may impact children's abilities to attend to tasks with high processing demands. In a preliminary investigation, six children (6.6-8.3 years of age) with normal sleep patterns performed three tasks: attention ("Oddball"), speech perception (consonant-vowel syllables), and executive function (Directional Stroop). Event-related potentials (ERPs) responses were recorded before (Control) and following 1 week of 1-hour per day of sleep restriction. Brain activity across all tasks following Sleep Restriction differed from activity during Control Sleep, indicating that minor sleep restriction impacts children's neurocognitive functioning.
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Affiliation(s)
- Dennis L Molfese
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska 68588-0308, USA.
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Acute and non-acute lower extremity pain in the pediatric population: part II. J Pediatr Health Care 2012; 26:216-30. [PMID: 22526001 DOI: 10.1016/j.pedhc.2012.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 01/27/2012] [Accepted: 01/30/2012] [Indexed: 11/21/2022]
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Durmer JS, Quraishi GH. Restless legs syndrome, periodic leg movements, and periodic limb movement disorder in children. Pediatr Clin North Am 2011; 58:591-620. [PMID: 21600344 DOI: 10.1016/j.pcl.2011.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The characteristic symptoms of restless legs syndrome (RLS) have been known for hundreds of years and were first reported in medicine in the 1600s. Clinicians must consider potential mimics, comorbid, and associated conditions when evaluating children with RLS symptoms. The traditional differentiation of RLS from periodic limb movement disorder (PLMD) is noted in children as well as adults. Because current pediatric RLS research is sparse, this article provides the most up-to-date evidence-based as well as consensus opinion-based information on the subject of childhood RLS and PLMD. Prevalence, pathophysiology, diagnosis, treatment, and clinical associations are discussed.
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A prevalence study of restless legs syndrome in Turkish children and adolescents. Sleep Med 2011; 12:315-21. [DOI: 10.1016/j.sleep.2010.08.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/26/2010] [Accepted: 08/29/2010] [Indexed: 10/18/2022]
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Advances in pediatric restless legs syndrome: Iron, genetics, diagnosis and treatment. Sleep Med 2010; 11:643-51. [DOI: 10.1016/j.sleep.2009.11.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 11/12/2009] [Accepted: 11/18/2009] [Indexed: 11/22/2022]
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Affiliation(s)
- Robin Slover
- Department of Anesthaseology, University of Colorado Denver, 12401 East 17th Avenue, Aurora, CO 80045, USA.
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Abstract
Sleep deprivation is associated with considerable social, financial, and health-related costs, in large measure because it produces impaired cognitive performance due to increasing sleep propensity and instability of waking neurobehavioral functions. Cognitive functions particularly affected by sleep loss include psychomotor and cognitive speed, vigilant and executive attention, working memory, and higher cognitive abilities. Chronic sleep-restriction experiments--which model the kind of sleep loss experienced by many individuals with sleep fragmentation and premature sleep curtailment due to disorders and lifestyle--demonstrate that cognitive deficits accumulate to severe levels over time without full awareness by the affected individual. Functional neuroimaging has revealed that frequent and progressively longer cognitive lapses, which are a hallmark of sleep deprivation, involve distributed changes in brain regions including frontal and parietal control areas, secondary sensory processing areas, and thalamic areas. There are robust differences among individuals in the degree of their cognitive vulnerability to sleep loss that may involve differences in prefrontal and parietal cortices, and that may have a basis in genes regulating sleep homeostasis and circadian rhythms. Thus, cognitive deficits believed to be a function of the severity of clinical sleep disturbance may be a product of genetic alleles associated with differential cognitive vulnerability to sleep loss.
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Affiliation(s)
- Namni Goel
- Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Hengyi Rao
- Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - David F. Dinges
- Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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[Epidemiology of restless legs syndrome]. Rev Neurol (Paris) 2009; 165:641-9. [PMID: 19345965 DOI: 10.1016/j.neurol.2009.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 01/26/2009] [Accepted: 02/08/2009] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Restless legs syndrome (RLS) is a chronic sensorimotor disorder where patients complain of an almost irresistible urge to move their legs. This urge can often be accompanied by pain or other unpleasant sensations, it either occurs or worsens with rest particularly at night, and improves with activity. The International Restless Legs Syndrome Study Group has established four essential criteria for clinical diagnosis of RLS. STATE OF ART Affecting an estimated 7.2 to 11.5% of the adult population, the symptoms of RLS may be associated with significant sleep disturbance and may have a negative impact on quality of life. The prevalence of RLS increases with age, and women are more frequently affected than men. In France, the estimated prevalence is 8.5%. Among sufferers, 4.4% complain of very severe symptoms. Although RLS is mainly idiopathic, several clinical conditions have been associated with it, especially iron deficiency with or without anemia, end-stage renal disease and pregnancy. These conditions may share a common pathophysiological mechanism involving a disorder of iron metabolism. By contrast, controversy persists as to whether polyneuropathy, particularly when associated with diabetes, is to be considered as an important cause of secondary RLS. This association is difficult to demonstrate as conventional electromyography is not adequate to detect small fiber neuropathy often associated with diabetes. CONCLUSION AND PERSPECTIVES RLS is often underdiagnosed and few subjects receive recommended RLS drug treatment. There is a clear need for complementary education to improve the accurate diagnosis of RLS. Indeed, better knowledge of this syndrome is a prerequisite to prompt an appropriate therapeutic management.
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Pediatric restless legs syndrome and periodic limb movement disorder: parent-child pairs. Sleep Med 2009; 10:925-31. [PMID: 19332386 DOI: 10.1016/j.sleep.2008.10.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 09/28/2008] [Accepted: 10/03/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Although recent publications have reported the occurrence of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) in children and adolescents, the literature is relatively limited. The goals of this retrospective study were to (1) apply the recent International Classification of Sleep Disorders 2nd edition (ICSD-2) diagnostic criteria for RLS and PLMD in pediatric cases where periodic limb movements in sleep (PLMS) 5 per hour were found; (2) review parental history of RLS; and (3) further define the clinical characteristics of RLS and PLMD in a pediatric subgroup where each child had a parent with clinically assessed RLS. METHODS This was a retrospective analysis of consecutive polysomnograms (PSGs) with PLMS >5 per hour in patients 19 years of age from a single pediatric sleep/neurology practice over 11 years. Excluded were cases with sleep apnea, narcolepsy, or medication that might induce or aggravate PLMS or RLS. ICSD-2 diagnostic criteria for definite RLS and PLMD were applied to the pediatric cases, and parental history for RLS was assessed. A subset of cases was included for detailed review if the child or adolescent had RLS or PLMD and a biological parent met RLS criteria and had a formal sleep evaluation. RESULTS There were 204 cases that met the initial inclusion criteria. A positive parental history of RLS was found in 53% of pediatric RLS cases and in 52% of pediatric PLMD cases. A subset of 37 children or adolescents and 36 biological parents, from 33 different families, met full inclusion criteria and are presented in detail. Of these 37, 10 had a diagnosis of RLS and 27 a diagnosis of PLMD. Over this same period of time, PLMS >5 per hour were found in 74% of pediatric definite RLS cases assessed by PSG. CONCLUSIONS This case series adds to the growing literature describing RLS and PLMD in children and adolescents using recently revised diagnostic criteria. The similar prevalence of parental RLS in both pediatric RLS and pediatric PLMD cases suggests a close association between PLMD and RLS in some cases. This supports the emerging view that PLMS may be a marker or endophenotype for a specific, common RLS genotype.
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Early manifestations of restless legs syndrome in childhood and adolescence. Sleep Med 2008; 9:770-81. [DOI: 10.1016/j.sleep.2007.08.012] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2007] [Revised: 08/20/2007] [Accepted: 08/20/2007] [Indexed: 11/23/2022]
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Abstract
Restless legs syndrome (RLS) is clinically defined by the presence of (i) an urge to move the legs with or without an actual paraesthesia; (ii) a worsening of symptoms with inactivity; (iii) improvement with activity; and (iv) a worsening of symptoms in the evening and at night. Patients may use a variety of semantic phrases to describe their symptoms but all must have an urge to move. Most people with RLS also have periodic limb movements during sleep, although this is not part of the clinical diagnostic criteria. RLS is very common. About 10% of all Caucasian populations have RLS, although it may be mild in the majority of cases. Women generally outnumber men by about 2:1. As a general rule, RLS severity worsens through the first seven to eight decades of life, but may actually lessen in old age. The aetiology of RLS is only partly understood. There is a strong genetic component, and several genetic linkages and three causative genes have been identified worldwide. Several medical conditions, including renal failure, systemic iron deficiency and pregnancy, and possibly neuropathy, essential tremor and some genetic ataxias, are also associated with high rates of RLS. In all cases to date, the actual CNS pathology of RLS demonstrates reduced iron stores, in a pattern that suggests that the homeostatic control of iron is altered, not just that there is not enough iron entering the brain. The relationship between reduced CNS iron levels and the clinical phenotype or treatment response to dopaminergics is not known but generates promising speculation. Treatment of RLS is usually rewarding. Most patients respond robustly to dopamine receptor agonists. Over time, response may lessen, or the patients may develop 'augmentation', whereby they have a worsening of symptoms, usually in the form of an earlier onset. Other treatment options include gabapentin, or similar antiepileptic drugs, and opioids. High-dose intravenous iron is a promising but still experimental approach.
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Affiliation(s)
- Pankaj Satija
- Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA
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Growing pains: a noninflammatory pain syndrome of early childhood. ACTA ACUST UNITED AC 2008; 4:542-9. [PMID: 18762787 DOI: 10.1038/ncprheum0903] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 07/28/2008] [Indexed: 01/15/2023]
Abstract
The term 'growing pains' has been used for almost 200 years to refer to the often severe, generally bilateral lower-extremity nocturnal pains experienced by up to one-third of all children at some time during early childhood. No clear mechanism has yet been identified that explains these pains, but there is an increasing body of evidence indicating that several factors, individually or in combination, might be responsible for this phenomenon. These include mechanical factors, such as joint hypermobility and flat feet, decreased pain thresholds, reduced bone strength, and emotional factors involving the patient's family and other social stressors. Correct diagnosis of growing pains requires a thorough patient history and physical examination. The diagnosis can be safely established without unnecessary laboratory investigations or imaging; however, identification of one or more clinical cautionary signs, such as unilateral pain, morning stiffness, joint swelling and systemic symptoms (e.g. fever, weight loss and malaise), should trigger an extended evaluation to exclude other more serious conditions that might also present with limb pain. Once the diagnosis has been established, conservative management, using symptomatic pain medications, massage and other supportive measures, should be employed until the syndrome self-resolves with time.
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Mohri I, Kato-Nishimura K, Tachibana N, Ozono K, Taniike M. Restless legs syndrome (RLS): An unrecognized cause for bedtime problems and insomnia in children. Sleep Med 2008; 9:701-2. [DOI: 10.1016/j.sleep.2007.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 08/09/2007] [Accepted: 08/11/2007] [Indexed: 10/22/2022]
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Muhle H, Neumann A, Lohmann-Hedrich K, Lohnau T, Lu Y, Winkler S, Waltz S, Fischenbeck A, Kramer PL, Klein C, Stephani U. Childhood-onset restless legs syndrome: Clinical and genetic features of 22 families. Mov Disord 2008; 23:1113-21; quiz 1203. [DOI: 10.1002/mds.22016] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Picchietti MA, Picchietti DL. Restless legs syndrome and periodic limb movement disorder in children and adolescents. Semin Pediatr Neurol 2008; 15:91-9. [PMID: 18555195 DOI: 10.1016/j.spen.2008.03.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Restless Legs Syndrome (RLS) has been recognized as a common and treatable neurologic disorder in adults for some time, but the occurrence of RLS in children and adolescents has seen relatively delayed acceptance. A large, population-based study has recently reported a 1.9% and 2% prevalence of RLS in children and adolescents, respectively. RLS in children is closely associated with periodic limb movement disorder (PLMD), and symptoms of both may range from mild to severe. An early, accurate diagnosis of RLS or PLMD provides substantial benefits to an individual's quality of life, especially in cases of poor-sleep related intellectual or emotional dysfunction. Treatment plans should use emerging knowledge of how RLS and PLMD affect children and adolescents to correctly identify these disorders and aim to reduce or eliminate symptoms. Best-fitting therapy will consider severity of symptoms, comorbid conditions, and phenotypic variables. Promising progress has been made in understanding the genetic components of RLS as well as the role of iron deficiency in exacerbating symptoms. A review of current research on RLS and PLMD in children and adolescents is presented.
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Konofal E, Cortese S, Marchand M, Mouren MC, Arnulf I, Lecendreux M. Impact of restless legs syndrome and iron deficiency on attention-deficit/hyperactivity disorder in children. Sleep Med 2007; 8:711-5. [PMID: 17644481 DOI: 10.1016/j.sleep.2007.04.022] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2007] [Revised: 04/10/2007] [Accepted: 04/24/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Increasing evidence suggests a significant comorbidity between attention-deficit/hyperactivity disorder (ADHD) and restless legs syndrome (RLS). Iron deficiency may underlie common pathophysiological mechanisms in subjects with ADHD plus RLS (ADHD+RLS). To date, the impact of iron deficiency, RLS and familial history of RLS on ADHD severity has been scarcely examined in children. These issues are addressed in the present study. METHODS Serum ferritin levels, familial history of RLS (diagnosed using National Institutes of Health (NIH) criteria) and previous iron supplementation in infancy were assessed in 12 ADHD+RLS children, 10 ADHD children and 10 controls. RLS was diagnosed using NIH-specific pediatric criteria, and ADHD severity was assessed using the Conners' Parent Rating scale. RESULTS ADHD symptom severity was higher, although not significantly, in children with ADHD+RLS compared to ADHD. The mean serum ferritin levels were significantly lower in children with ADHD than in the control group (p<0.0005). There was a trend for lower ferritin levels in ADHD+RLS subjects versus ADHD. Both a positive family history of RLS and previous iron supplementation in infancy were associated with more severe ADHD scores. CONCLUSIONS Children with ADHD and a positive family history of RLS appear to represent a subgroup particularly at risk for severe ADHD symptoms. Iron deficiency may contribute to the severity of symptoms. We suggest that clinicians consider assessing children with ADHD for RLS, a family history of RLS, and iron deficiency.
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Affiliation(s)
- Eric Konofal
- Service de Psychopathologie de l'Enfant et de l'Adolescent, Hôpital Robert Debré, 48 boulevard Sérurier, 75019 Paris, France.
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Martin CM. The mysteries of restless legs syndrome. THE CONSULTANT PHARMACIST : THE JOURNAL OF THE AMERICAN SOCIETY OF CONSULTANT PHARMACISTS 2007; 22:907-924. [PMID: 18198978 DOI: 10.4140/tcp.n.2007.907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Restless legs syndrome (RLS) is a sensorimotor disorder characterized by the uncontrollable urge to move the legs. This urge can often be accompanied by pain or other unpleasant sensations, and it either occurs or worsens with rest. Affecting an estimated 6% to 15% of the adult population, RLS compromises the patient's ability to sleep and can significantly decrease quality of life. Because diagnosis currently relies solely on patient (or caregiver) interview, recognizing the symptoms of RLS and knowing what medications treat this condition--as well as the many that exacerbate it--is important for all health care practitioners.
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Síndrome das pernas inquietas: diagnóstico e tratamento. Opinião de especialistas brasileiros. ARQUIVOS DE NEURO-PSIQUIATRIA 2007. [DOI: 10.1590/s0004-282x2007000400035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Este artigo contém as conclusões de reunião de 17-18 de novembro de 2006 do Grupo Brasileiro de Estudo em Síndrome das Pernas Inquietas (GBE-SPI) sobre diagnóstico e tratamento de SPI. Reiterou-se que se trata de condição de diagnóstico exclusivamente clínico, caracterizada por sensação anormal localizada, sobretudo, mas não exclusivamente, em membros inferiores, com piora noturna e alívio por movimentação da parte envolvida. Agentes terapêuticos com eficácia comprovada por estudos classe I são agonistas dopaminérgicos, levodopa e gabapentina enquanto que ácido valpróico de liberação lenta, clonazepam, oxicodona e reposição de ferro têm eficácia sugerida por estudos classe II. As recomendações do GBE-SPI para manejo de SPI primária são medidas de higiene do sono, suspensão de agentes agravantes de SPI, tratamento de comorbidades e agentes farmacológicos. Para estes as drogas de primeira escolha são agentes dopaminérgicos; segunda escolha são gabapentina ou oxicodona; e terceira escolha são clonazepam ou ácido valpróico de liberação lenta.
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Simple Sleep-Related Movement Disorders of Childhood Including Benign Sleep Myoclonus of Infancy, Rhythmic Movement Disorder, and Childhood Restless Legs Syndrome and Periodic Limb Movements in Sleep. Sleep Med Clin 2007. [DOI: 10.1016/j.jsmc.2007.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Affiliation(s)
- Nathan J Blum
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Picchietti D, Allen RP, Walters AS, Davidson JE, Myers A, Ferini-Strambi L. Restless legs syndrome: prevalence and impact in children and adolescents--the Peds REST study. Pediatrics 2007; 120:253-66. [PMID: 17671050 DOI: 10.1542/peds.2006-2767] [Citation(s) in RCA: 231] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Restless legs syndrome, a common neurologic sleep disorder, occurs in 5% to 10% of adults in the United States and Western Europe. Although approximately 25% of adults with restless legs syndrome report onset of symptoms between the ages of 10 and 20 years, there is very little literature looking directly at the prevalence in children and adolescents. In this first population-based study to use specific pediatric diagnostic criteria, we examined the prevalence and impact of restless legs syndrome in 2 age groups: 8 to 11 and 12 to 17 years. METHODS Initially blinded to survey topic, families were recruited from a large, volunteer research panel in the United Kingdom and United States. Administration was via the Internet, and results were stratified by age and gender. National Institutes of Health pediatric restless legs syndrome diagnostic criteria (2003) were used, and questions were specifically constructed to exclude positional discomfort, leg cramps, arthralgias, and sore muscles being counted as restless legs syndrome. RESULTS Data were collected from 10,523 families. Criteria for definite restless legs syndrome were met by 1.9% of 8- to 11-year-olds and 2.0% of 12- to 17-year-olds. Moderately or severely distressing restless legs syndrome symptoms were reported to occur > or = 2 times per week in 0.5% and 1.0% of children, respectively. Convincing descriptions of restless legs syndrome symptoms were provided. No significant gender differences were found. At least 1 biological parent reported having restless legs syndrome symptoms in > 70% of the families, with both parents affected in 16% of the families. Sleep disturbance was significantly more common in children and adolescents with restless legs syndrome than in controls (69.4% vs 39.6%), as was a history of "growing pains" (80.6% vs 63.2%). Various consequences were attributed to restless legs syndrome, including 49.5% endorsing a "negative effect on mood." Data were also collected on comorbid conditions and restless legs diagnosis rates. CONCLUSIONS These population-based data suggest that restless legs syndrome is prevalent and troublesome in children and adolescents, occurring more commonly than epilepsy or diabetes.
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Affiliation(s)
- Daniel Picchietti
- University of Illinois School of Medicine and Carle Clinic Association, Department of Pediatrics, 602 W University Ave, Urbana, IL 61801, USA.
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Benbir G, Guilleminault C. Pramipexole: new use for an old drug - the potential use of pramipexole in the treatment of restless legs syndrome. Neuropsychiatr Dis Treat 2006; 2:393-405. [PMID: 19412489 PMCID: PMC2671938 DOI: 10.2147/nedt.2006.2.4.393] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Restless legs syndrome (RLS) is characterized by paraesthesias-dysesthesias and motor restlessness worsening at rest-in the evening, with at least temporary relief by activity. Its etiology is unknown, though it could be secondary to various conditions. It is well known, however, that dopamine plays a crucial role in the pathophysiology of RLS, as dopaminergic agonists achieve marked improvement. Pramipexole is a nonergoline compound with selectivity for D3 dopamine receptors. This drug is very effective in the treatment of idiopathic and secondary RLS and in treatment-resistant patients, as shown by double-blind, placebo-controlled studies in adults. In children, studies are much more limited, and RLS is often misdiagnosed as "growing pain" or attention deficit hyperactivity disorder. Pramipexole has been successful in open studies, eliminating clinical symptoms. This medication has the advantage of being free of the frequently encountered problems seen with ergot derivatives. The side-effects are limited, particularly at the dosages usually prescribed for RLS treatment: They are much lower than in Parkinson's disease, and inappropriate sleepiness and sleep attacks, particularly while driving, or compulsive behavior have not been seen. Compared with the adverse reactions of levodopa, including tolerance, rebound, and augmentation phenomena in RLS, which led to usage of dopamine agonists as first line of treatment for RLS, pramipexole has had one of the best profiles. Augmentation can still be noted with the drug, but after longer usage time compared with many other dopamine agonists. Although excessive daytime sleepiness has been noted, sleep attacks have not been encountered in RLS patients treated with pramipexole.
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Affiliation(s)
- Gulcin Benbir
- Sleep Medicine Program, Stanford University, CA, USA.
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Abstract
Periodic limb movement disorder (PLMD) has been reported in children and is more prevalent in certain conditions such as attention deficit hyperactivity disorder. The International Restless Legs Syndrome Group has recently developed the criteria for diagnosis of PLMD in children. These criteria include both specific clinical features and polysomnographic findings. Exclusion of other causes especially sleep-disordered breathing is essential. Several medications including benzodiazepine and dopaminergic medication have been used in children, although these medications have not been adequately studied in this age group. Some PLMD children have evidence of low iron storage and response favorably to iron therapy.
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Affiliation(s)
- Narong Simakajornboon
- Section of Pediatric Pulmonology, Department of Pediatrics, Tulane University School of Medicine, Tulane University Hospital and Clinics, SL-37, New Orleans, LA 70112, USA.
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Abstract
Sleep problems are extremely common during childhood, from infancy to adolescence. Despite the prevalence of sleep problems, childhood sleep disorders are often underrecognized and undiagnosed, despite being either preventable or treatable. Sleep impacts almost all aspects of a child's functioning, and thus the increased recognition and treatment of sleep disorders will positively affect a child's well-being. Children experience the same broad range of sleep disturbances encountered in adults, including sleep apnea, insomnia, parasomnia, delayed sleep phase, narcolepsy, and restless legs, but their clinical presentation, evaluation, and management may differ. Although snoring and sleep apnea may be the most common indication for an overnight sleep study in a child, one quarter of children presenting to a sleep clinic for evaluation will have a second sleep diagnosis, which is often nonrespiratory in nature. Especially in children, ruling out sleep apnea is rarely the end point of the sleep evaluation. Clinicians involved in sleep medicine must be prepared to recognize, evaluate, and manage plans for sleep disorders across the lifespan of the patient. This article will provide an updated review of nonrespiratory pediatric sleep disorders within a developmental framework.
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Affiliation(s)
- Melisa Moore
- Case Western Reserve University, Department of Psychology, Mather Memorial Building, No. 109, 10900 Euclid Ave, Cleveland, OH 44106, USA.
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Abstract
Is treatable but under-recognised
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Engel JM, Kartin D, Jaffe KM. Exploring Chronic Pain in Youths with Duchenne Muscular Dystrophy: A Model for Pediatric Neuromuscular Disease. Phys Med Rehabil Clin N Am 2005; 16:1113-24, xii. [PMID: 16214064 DOI: 10.1016/j.pmr.2005.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Joyce M Engel
- Department of Rehabilitation Medicine, Box 356490, Division of Occupational Therapy, University of Washington, Seattle, WA 98195-6490, USA.
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Barrière G, Cazalets JR, Bioulac B, Tison F, Ghorayeb I. The restless legs syndrome. Prog Neurobiol 2005; 77:139-65. [PMID: 16300874 DOI: 10.1016/j.pneurobio.2005.10.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Revised: 10/19/2005] [Accepted: 10/21/2005] [Indexed: 10/25/2022]
Abstract
The restless legs syndrome (RLS) is one of the commonest neurological sensorimotor disorders at least in the Western countries and is often associated with periodic limb movements (PLM) during sleep leading to severe insomnia. However, it remains largely underdiagnosed and its underlying pathogenesis is presently unknown. Women are more affected than men and early-onset disease is associated with familial cases. A genetic origin has been suggested but the mode of inheritance is unknown. Secondary causes of RLS may share a common underlying pathophysiology implicating iron deficiency or misuse. The excellent response to dopaminegic drugs points to a central role of dopamine in the pathophysiology of RLS. Iron may also represent a primary factor in the development of RLS, as suggested by recent pathological and brain imaging studies. However, the way dopamine and iron, and probably other compounds, interact to generate the circadian pattern in the occurrence of RLS and PLM symptoms remains unknown. The same is also the case for the level of interaction of the two compounds within the central nervous system (CNS). Recent electrophysiological and animals studies suggest that complex spinal mechanisms are involved in the generation of RLS and PLM symptomatology. Dopamine modulation of spinal reflexes through dopamine D3 receptors was recently highlighted in animal models. The present review suggests that RLS is a complex disorder that may result from a complex dysfunction of interacting neuronal networks at one or several levels of the CNS and involving numerous neurotransmitter systems.
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Affiliation(s)
- G Barrière
- Laboratoire de Neurophysiologie, UMR-CNRS 5543, Université Bordeaux 2, Bordeaux, France
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Abstract
The restless legs syndrome is a common disorder that encompasses an idiopathic form of genetic or unknown origin and symptomatic forms associated with many causes. Symptomatic forms occur during pregnancy and are coincident with uraemia, iron depletion, polyneuropathy, spinal disorders, and rheumatoid arthritis. For the hereditary forms, at least three gene loci, located on chromosomes 12, 14, and 9, have been traced so far. Prevalence in the general population is between 3% and 9%, increases with age, and is higher in women than in men. Treatment is needed only in the moderate to severe forms of the disorder and mostly in elderly people. Pathophysiology and treatment may be closely linked to the dopaminergic system and iron metabolism. Dopaminergic treatment with levodopa and dopamine agonists is the first choice in idiopathic restless legs syndrome, but augmentation and rebound should be monitored in long-term treatment. Various other drugs, such as opioids, gabapentin, and benzodiazepines, provide alternative treatment possibilities.
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Affiliation(s)
- Claudia Trenkwalder
- Paracelsus Elena Klinik, Centre of Parkinsonism and Movement Disorders, Kassel, Germany.
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Millman RP. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics 2005; 115:1774-86. [PMID: 15930245 DOI: 10.1542/peds.2005-0772] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Adolescents and young adults are often excessively sleepy. This excessive sleepiness can have a profound negative effect on school performance, cognitive function, and mood and has been associated with other serious consequences such as increased incidence of automobile crashes. In this article we review available scientific knowledge about normal sleep changes in adolescents (13-22 years of age), the factors associated with chronic insufficient sleep, the effect of insufficient sleep on a variety of systems and functions, and the primary sleep disorders or organic dysfunctions that, if untreated, can cause excessive daytime sleepiness in this population.
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