Treatment of pediatric restless legs syndrome

Risk of Suicidal Ideation and Behavior Following Early-Onset Idiopathic Restless Legs Syndrome Treatment

PURPOSE

To estimate incidence rates of suicidal ideation and behavior following treatment initiation with gabapentinoids or dopamine agonists (DAs) in patients with newly diagnosed early-onset idiopathic restless legs syndrome (RLS) and to examine suicidal behavior risk, comparing between those receiving gabapentinoids and DAs.

METHODS

A new user retrospective cohort study using MarketScan claims data from 2012 to 2019 was conducted. Exposures were monotherapy gabapentinoids or DAs initiated within 60 days of new RLS diagnosis. Three varying outcome measures of suicidality were examined and incidence rates were calculated for each. A log-binomial regression model the estimated relative risk (RR) of the outcomes with gabapentinoids. Propensity score weighting adjusted for baseline covariates, including age, substance use disorders, hyperlipidemia, antipsychotic use, hypnotic/sedative use, and mood stabilizer use, which were most imbalanced before weighting.

RESULTS

The cohort included 6672 patients, with 4986 (74.7%) initiating a DA and 1686 (25.3%) initiating a gabapentinoid. Incidence rates for all outcome measures were higher in the gabapentinoid group (suicidality: 21.6 vs. 10.7 per 1000 person-years; suicidality with self-harm: 23.0 vs. 11.1 per 1000 person-years; overdose- and suicide-related events: 30.0 vs. 15.5 person-years). Associated risk of suicidality (adjusted RR, 1.27 [95% CI, 0.86-1.88]); suicidality with self-harm (adjusted RR, 1.30 [95% CI, 0.89-1.90]); or overdose- and suicide-related events (adjusted RR, 1.30 [95% CI, 0.93-1.80]) was not significant with gabapentinoids.

CONCLUSIONS

Incidence rates for suicidal ideation and behavior were higher among the gabapentinoid group, although increased risk was not detected after adjustment. A possible signal cannot be ruled out given limitations of the data and rarity of the outcome.

Restless Legs Syndrome in Children and Adolescents

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.

Sleep Disorders in Childhood

OBJECTIVE

This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome.

LATEST DEVELOPMENTS

Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available.

ESSENTIAL POINTS

The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.

Restless Legs Syndrome and Restless Sleep Disorder in Children

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.

Restless sleep disorder, restless legs syndrome, and periodic limb movement disorder-Sleep in motion!

Sleep-related movement disorders (SRMDs) represent an important part of pediatric sleep disorders. The most common complaint in SRMD is restless sleep at night. Restless sleep is reported in up to 80% of children with restless legs syndrome (RLS) and children with periodic limb movements of sleep (PLMS) disorder (PLMD). However, restless sleep causing daytime behavioral consequences can be seen in children without another apparent condition and has recently been identified as a new independent primary pediatric sleep disorder, called restless sleep disorder (RSD). This study describes these three main SRMDs (RSD, RLS, and PLMD), explains the new consensus criteria for RSD, emphasizes the rapidly evolving areas of research in this field, and proposes recommendations for future research. In particular, the published data constitute convincing evidence that sleep-related movements are disruptors of sleep quality and continuity. However, while important advancements have recently been reported in adults, a detailed analysis of the phenomenology and consequences of sleep-related movements has just started in children. New approaches, standardized diagnostic methods, and specific guidelines are needed in the field of pediatric SRMD.

Restless Sleep Disorder (RSD): a New Sleep Disorder in Children. A Rapid Review

PURPOSE OF REVIEW

Restless sleep disorder (RSD) is a recently identified pediatric sleep disorder characterized by frequent movements during sleep associated with daytime symptoms. In this review we summarize the expanding evidence of the clinical presentation of RSD, potential pathophysiology, associated comorbidities, and current treatment options that will help the pediatrician identify children with RSD in a timely manner.

RECENT FINDINGS

RSD is diagnosed in 7.7% of children referred evaluated in a pediatric sleep center. Children with RSD present with frequent nightly movements during sleep for at least 3 months, and have daytime symptoms related to poor sleep quality including excessive sleepiness, hyperactivity, irritability among other symptoms. Current evidence shows an increased sympathetic predominance, increased NREM sleep instability, and iron deficiency, as well as increased prevalence in parasomnias and attention deficit hyperactivity disorder. Consensus diagnostic criteria were recently published to diagnose RSD and emergent evidence suggests that iron supplementation improves its nighttime and daytime symptoms.

Improved definition of growing pains: A common familial primary pain disorder of early childhood

Background

Commonly applied diagnostic criteria for growing pains (GP) have evolved without determination by an authoritative representative body. GP and restless legs syndrome (RLS) share anatomical, distributional, temporal, and other clinical features and are associated in individuals over time, in families, and in population samples. In this study, we tested the hypothesis that GP, diagnosed by widely used criteria, is confounded by cases of painful restless legs syndrome (RLS‐Painful).

Methods

A twin family study of genetic influence and associations of GP using questionnaires was administered by Twins Research Australia. Twins (3–18 years; monozygous 503, dizygous 513), their oldest siblings, mothers, and fathers were randomly selected from the twin registry. Family members completed the questionnaires assessing lifetime prevalence of GP by commonly applied criteria and covariates including the history of iron deficiency and pediatric pain disorders. A GP‐Specific phenotype was defined as GP without urge to move the legs. We determined similarities in twin pairs for the GP and GP‐Specific phenotypes, family associations, and estimated familial and individual‐specific associations for each phenotype.

Results

Lifetime prevalence was one‐third lower for GP‐Specific than for GP among the twin and family members. Monozygous twin pairs were more similar than dizygous twin pairs for GP and for the derived GP‐Specific phenotype by three methods, consistent with genetic influence. There were familial associations, but the essential evidence for genetic influence was the twin‐cotwin data. GP was associated, in multivariable analyses, with migraine, headaches, recurrent abdominal pain, and iron deficiency, while GP‐Specific associations were limited to migraine and headaches.

Conclusions

GP is hybrid, one‐third of cases having symptoms and associations of RLS, necessarily RLS‐Painful. GP‐Specific (without symptoms and associations of RLS) could have a genetic etiology. We propose new criteria to facilitate etiological and therapeutic research.

Growing pains, a highly prevalent primary pain disorder of childhood, has been associated with restless legs syndrome in individuals over time, in families and in population samples. This conundrum has been clarified by the evidence in this twin family study that growing pains, as previously defined, has been confounded by symptoms of restless legs syndrome. An exclusion clause of urge to move the legs has resulted in criteria for a purer phenotype which retains evidence of heritability.

The relationship between sleep disorders, anxiety, depression, and cognitive function with restless legs syndrome (RLS) in the elderly

OBJECTIVES

Restless legs syndrome (RLS) has a significant effect on sleep and quality of life. Delays in diagnosis and treatment are frequent due to a lack of awareness. In this study, a clinical analysis was performed to examine the relationship between sleep, mood, and cognitive function in RLS.

METHODS

According to the Pittsburgh Sleep Quality Index score (PSQI), patients with RLS were divided into a sleep disorders group (SD, PSQI > 7) and non-sleep disorders group (NSD, PSQI ≤ 7). Healthy controls were selected as a control group matched for age, cultural background, and marital status. We compared differences between the three groups using the Hamilton Anxiety Scale (HAMA), Hamilton Depression (HAMD), Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA). The SD and NSD groups were also assessed with the Restless Leg Syndrome Rating Scale (RLSRS) and the severity of RLS between the two groups was compared. The analysis used t-test, ANOVA, and Pearson correlation.

RESULTS

(1) Among the 54 RLS patients, 30 people in the control group, 35 patients with sleep disorders (SD, 65%), and 19 patients without sleep disorders (NSD, 35%), there were no significant differences in age, educational level, marital status, or trauma history. (2) The comparison results of the case group (SD and NSD) and the control group showed highly significant differences (P < 0.01) in the PSQI-HAMA-HAMD score but no significant differences between the NSD group, the SD group, and the control group in MMSE score. There was no difference between the NSD group and the control group in the MoCA, but a significant difference (P < 0.05) between the SD group and the control group was found. (3) The comparison between the NSD and the SD groups revealed significant differences in the RLSRS, HAMA, and HAMD scores (P < 0.05), but there were no statistical differences (P > 0.05) between two groups on MMSE and MoCA score. (4) Correlation and regression showed that there was a linear correlation between PSQI scores and RLSRS and HAMD scores in patients with RLS (P < 0.05). The regression equation was PSQI =  - 2.393 + 0.494 RLSRS + 0.170 HAMD.

CONCLUSIONS

RLS patients were prone to sleep disorders, anxiety, and depression. Sleep disorders increased with the severity of the RLS and had some influence on the patient's cognitive function. Sleep disorders were closely related to RLSRS and HAMD.

The Management of Restless Legs Syndrome: An Updated Algorithm

Restless legs syndrome (RLS) is a common disorder. The population prevalence is 1.5% to 2.7% in a subgroup of patients having more severe RLS with symptoms occurring 2 or more times a week and causing at least moderate distress. It is important for primary care physicians to be familiar with the disorder and its management. Much has changed in the management of RLS since our previous revised algorithm was published in 2013. This updated algorithm was written by members of the Scientific and Medical Advisory Board of the RLS Foundation based on scientific evidence and expert opinion. A literature search was performed using PubMed identifying all articles on RLS from 2012 to 2020. The management of RLS is considered under the following headings: General Considerations; Intermittent RLS; Chronic Persistent RLS; Refractory RLS; Special Circumstances; and Alternative, Investigative, and Potential Future Therapies. Nonpharmacologic approaches, including mental alerting activities, avoidance of substances or medications that may exacerbate RLS, and oral and intravenous iron supplementation, are outlined. The choice of an alpha₂-delta ligand as first-line therapy for chronic persistent RLS with dopamine agonists as a second-line option is explained. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS and describe management approaches, including combination therapy and the use of high-potency opioids. Treatment of RLS in pregnancy and childhood is discussed.

Rethinking bedtime resistance in children with autism: is restless legs syndrome to blame?

STUDY OBJECTIVES

In this study we investigated the clinical correlates of restless legs syndrome in children with autism and report on our experiences with response to treatment.

METHODS

A retrospective chart review of children seen in our sleep center from 2016-2019 was performed to identify children with autism and chronic insomnia. Patients underwent clinical assessments for restless legs symptomatology. Overnight polysomnogram, serum ferritin testing, and response to clinical treatment data were collected.

RESULTS

A total of 103 children with autism and chronic insomnia were identified (age range 2-19 years). Of these, 41 children (39%) were diagnosed with restless legs syndrome. The diagnosis of restless legs syndrome was associated with significantly lower serum ferritin levels (mean 29 ± 18.62 ng/mL vs non-restless legs syndrome 56.7 ± 17.59, P < .001) and higher periodic limb movements of sleep on polysomnogram (8.12 ± 6.6 vs non-restless legs syndrome 0.06 ± 0.17). The presence of leg kicking, body rocking, or any symptoms involving the legs was highly correlated with the diagnosis of restless legs syndrome. Positive treatment response was noted in nearly all treated patients, including those treated with oral iron supplementation alone (25 children, 23 responders), gabapentin alone (12 children, all responders), and combination therapy (3 children, all responders).

CONCLUSIONS

Our findings suggest restless legs syndrome may represent an under-recognized cause of insomnia in children with autism. Initial assessment should include a thorough query of behaviors related to nocturnal motor complaints, because restless legs syndrome may be a treatable cause of sleep disruption.

Pediatric Restless Legs Syndrome

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.

Restless Legs Syndrome in Children and Adolescents

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.

Nocturnal events in children: When and how to evaluate

Nocturnal events of wide variety and concern are frequently reported by patients and their caregivers. To evaluate suspected abnormal events, primary care physicians must first be familiar with normal behaviors, movements and breathing patterns. Abnormal nocturnal events can then be categorized as nocturnal seizure, parasomnia, sleep-related movement disorder or sleep-related breathing disorder. Diagnoses in the above categories can be made clinically; however, it is important to know when to refer for additional evaluation. Comprehensive literature review was undertaken of nocturnal and sleep-related disorders. This guide reviews nocturnal seizures, normal and abnormal nonepileptic movements and behaviors, discusses broad indications for referral for electroencephalography (EEG) or polysomnography (PSG), and guides counseling and management for patients and their families, ultimately aiding in interpretation of both findings and prognosis. Epilepsy syndromes can result in seizures during sleep or adjacent periods of wakefulness. Parasomnias and sleep-related movement disorders tend to also occur in childhood and may be distinguished clinically. Referral to additional specialists for specific studies including EEG or PSG can be necessary, while other times a knowledgeable and vigilant clinician can contribute to a prompt diagnosis based on clinical features. Nocturnal events often can be managed with parental reassurance and watchful waiting, but treatment or evaluation may be needed. Sleep-related breathing disorders are important to recognize as they present very differently in children than in adults and early intervention can be life-saving. This review should allow both primary and subspecialty non-neurologic pediatric and adolescent health care providers to better utilize EEG and PSG as part of a larger comprehensive clinical approach, distinguishing and managing both epileptic and nonepileptic nocturnal disorders of concern while fostering communication across providers to facilitate and coordinate better holistic long-term care of pediatric and adolescent patients.

Restless Legs Syndrome and Other Common Sleep-Related Movement Disorders

PURPOSE OF REVIEW

In this article, the different sleep-related movement disorders are discussed with special attention given to restless legs syndrome (RLS).

RECENT FINDINGS

The differential diagnosis of sleep-related movement disorders can often be challenging; therefore, it is essential to have accurate information to make a correct diagnosis. This article focuses on RLS, highlighting the change in the paradigm of initial treatment, the role played by iron (pathophysiologic and therapeutic), and how to approach possible complications occurring with long-term treatment.

SUMMARY

RLS is one of the most common neurologic conditions, and it is common in clinical practice to find patients experiencing symptoms suggestive of RLS. Neurologists must be careful and thorough in the diagnosis, excluding RLS mimics. The decisions regarding which specific sleep-related movement disorder is present and how it should be treated are important because in certain cases, especially in RLS, adverse effects and long-term complications are frequently reported with the use of certain drugs.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.

Neurodevelopmental Consequences of Pediatric Cancer and Its Treatment: The Role of Sleep

Cognitive impairment is frequent in pediatric cancer, and behavioral and psychological disturbances often also affect children who have survived cancer problems. Furthermore, pediatric tumors are also often associated with sleep disorders. The interrelationship between sleep disorders, neurodevelopmental disorders and pediatric cancer, however, is still largely unexplored. In this narrative review we approach this important aspect by first considering studies on pediatric cancer as a possible cause of neurodevelopmental disorders and then describing pediatric cancer occurring as a comorbid condition in children with neurodevelopmental disorders. Finally, we discuss the role of sleep disorders in children with cancer and neurodevelopmental disorders. Even if the specific literature approaching directly the topic of the role of sleep in the complex relationship between pediatric cancer and neurodevelopmental disorders was found to be scarce, the available evidence supports the idea that in-depth knowledge and correct management of sleep disorders can definitely improve the health and quality of life of children with cancer and of their families.

Diagnosis and management of iron deficiency in children with or without anemia: consensus recommendations of the SPOG Pediatric Hematology Working Group

Iron deficiency is the most prevalent nutritional deficiency affecting children and adolescents worldwide. A consistent body of epidemiological data demonstrates an increased incidence of iron deficiency at three timepoints: in the neonatal period, in preschool children, and in adolescents, where it particularly affects females.Conclusion: This narrative review focuses on the most suggestive symptoms of iron deficiency in childhood, describes the diagnostic procedures in situations with or without anemia, and provides Swiss expert-based management recommendations for the pediatric context.What is Known:• Iron deficiency (ID) is one of the most common challenges faced by pediatricians.• Significant progress in the diagnosis and therapy of ID has been made over the last decade.What is New:• Our expert panel provides ID management recommendations based on the best available evidence.• They include strategies for ID diagnosis and therapy, both oral and intravenous.

Determinants of ferritin response to oral iron supplementation in children with sleep movement disorders

STUDY OBJECTIVES

To identify children who respond to oral iron supplementation as evidenced by increased ferritin levels and to identify factors that correlate with improvement in ferritin levels in those who respond.

METHODS

A retrospective chart review of the PLMS/RLS/RSD database at Seattle Children's Hospital was carried out. Data collected included nocturnal polysomnography parameters, age, sex, initial and follow-up ferritin level and date of collection, and presence of restless legs syndrome (RLS), periodic limb movements of sleep (PLMS)/PLM disorder (PLMD), restless sleep disorder (RSD), obstructive sleep apnea (OSA), neurologic, psychiatric, neurodevelopmental, or medical comorbidity. Oral iron therapy was evaluated by side effects (none; constipation; bad taste/nausea), subjective outcome in symptoms (resolved, improved, no change), and adherence to therapy (poor, fair, good).

RESULTS

Seventy-seven children were included in this study of whom 42 were classified as responders (increase in ferritin of ≥10 µg/L) and 35 were nonresponders. Age and sex were not different between groups. Adherence was the only significant predictor of an increase in ferritin of ≥10 µg/L. Constipation was seen in 7.1% of responders vs. 45.8% of nonresponders. No change in symptoms was reported in 26.2% of responders vs. 71.4% in nonresponders. A significant correlation was found between treatment duration and ferritin level change in responders but not in nonresponders.

CONCLUSIONS

Side effects hinders adherence to oral iron supplementation in children. Responders to oral iron show improvement in ferritin levels and symptoms, while nonresponders show no improvement in ferritin levels despite a long-lasting treatment, at least in part of them.