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Voci A, Mazzone L, De Stefano D, Valeriani M, Bruni O, Moavero R. Restless sleep disorder in a sample of children and adolescents with autism spectrum disorder: preliminary results from a case series. J Clin Sleep Med 2024; 20:427-432. [PMID: 37909101 PMCID: PMC11019215 DOI: 10.5664/jcsm.10902] [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: 06/28/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/02/2023]
Abstract
STUDY OBJECTIVES Sleep disorders are a frequent comorbidity among children with autism spectrum disorder (ASD). Among sleep-related issues of ASD, restless sleep is a common complaint. In recent years, restless sleep disorder (RSD) has been proposed as a new clinical entity, characterized by agitated sleep as its predominant manifestation. Despite the high prevalence of sleep disorders and data reporting restless sleep among ASD patients, to date no study has yet characterized RSD within patients with ASD. Therefore, the aim of our study was to assess the occurrence of RSD in a sample of children and adolescents with ASD through clinical and polysomnographic assessment. METHODS Children and adolescents with ASD ages 6-18 years were recruited for the study. Through parental interviews, patients with a suspected RSD were selected and offered diagnostic investigation by video-polysomnography and blood tests to assess martial balance. RESULTS Among the 129 participants included, 16 patients (12.4%) were found to have a suspected RSD. Only 6 (4.7%) underwent video-polysomnography due to lack of compliance or family refusal. In 6/6 participants examined, the disorder was confirmed by video-polysomnography movement analysis (total movement index ≥ 5 events/h) and ferritin values were found in the normal range. CONCLUSIONS RSD does not appear to be particularly frequent among patients with ASD and that of iron metabolism may not be the main factor implicated in the pathogenesis of RSD within this population. Additional evaluation is needed to confirm the result and further investigate the etiological mechanisms underlying the disorder. CITATION Voci A, Mazzone L, De Stefano D, Valeriani M, Bruni O, Moavero R. Restless sleep disorder in a sample of children and adolescents with autism spectrum disorder: preliminary results from a case series. J Clin Sleep Med. 2024;20(3):427-432.
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Affiliation(s)
- Alessandra Voci
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Luigi Mazzone
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy
| | - Donata De Stefano
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Massimiliano Valeriani
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Center for Sensory Motor Interaction, Aalborg University, Aalborg, Denmark
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Rome, Italy
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, Italy
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, 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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Economou NT, Ferini-Strambi L, Steiropoulos P. Sleep-Related Drug Therapy in Special Conditions: Children. Sleep Med Clin 2022; 17:531-542. [PMID: 36150812 DOI: 10.1016/j.jsmc.2022.06.015] [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: 10/14/2022]
Abstract
Pharmacologic treatment of the most common pediatric sleep disorders lacks evidence, and alternative methods, which have been proved to alleviate the symptoms, are preferred in most cases. The implementation of specific guidelines is of great importance because sleep disorders in children are not rare and they can negatively affect children's development and their cognitive and social skills. This article summarizes the current therapeutic management of sleep disorders in children, bearing in mind the absence of evidence-based guidelines on this topic.
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Affiliation(s)
- Nicholas-Tiberio Economou
- Sleep Unit, Department of Psychiatry, University of Athens, 74 Vas Sofias Avenue, Athens 11528, Greece; Enypnion Sleep-Epilepsy Center, Bioclinic Hospital Athens, 15 M. Geroulanou Street, Athens 11524, Greece
| | - Luigi Ferini-Strambi
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Stamira d'Ancona 20, Milan 20127, Italy
| | - Paschalis Steiropoulos
- Department of Pulmonology, Medical School, Democritus University of Thrace, University Campus, Dragana, Alexandroupolis 68100, Greece.
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Pavkovic IM, Kothare SV. Pharmacologic Approaches to Insomnia and Other Sleep Disorders in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00712-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Clinical efficacy and safety of intravenous ferric carboxymaltose treatment of pediatric restless legs syndrome and periodic limb movement disorder. Sleep Med 2021; 87:114-118. [PMID: 34562823 DOI: 10.1016/j.sleep.2021.08.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/23/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Iron supplementation is the most commonly considered treatment option for children with restless legs syndrome (RLS) or periodic limb movement disorder (PLMD); however, there is a scarcity of evidence on the effectiveness of intravenous preparations. In this study, we evaluated the effectiveness and tolerability of intravenous ferric carboxymaltose (IV FCM) on clinical symptoms and iron indices in children with RLS or PLMD. METHODS This was a single-center retrospective data analysis. Children with a diagnosis of RLS or PLMD, who underwent a single infusion of IV FCM, were included. Clinical Global Impression (CGI) Scale scores, serum ferritin, and serum iron profile at baseline and after eight weeks post infusion were obtained. Adverse effects were assessed. RESULTS Thirty-nine children received IV FCM, 29 with RLS and 10 with PLMD. Pre-infusion CGI-Severity revealed moderate illness, with post-infusion CGI-Improvement between "very much improved" and "much improved". Ferritin increased from 14.6 μg/L±7.01 to 112.4 μg/L±65.86 (p < 0.00001), together with improvements in iron, total iron binding capacity, and transferrin levels from baseline to post-treatment. When compared to children with RLS, those with PLMD had a similar improvement in clinical symptoms and laboratory parameters. Seven subjects (14.3%) experienced one or two adverse events; all were mild. CONCLUSIONS Children with RLS and PLMD responded to IV iron supplementation with improvement in both clinical severity and laboratory parameters. Treatment was well tolerated. Although larger, randomized-controlled trials are needed, IV FCM appears to be a promising alternative to oral iron supplementation for the treatment of pediatric RLS or PLMD.
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DelRosso LM, Picchietti DL, Ferri R. Comparison between oral ferrous sulfate and intravenous ferric carboxymaltose in children with restless sleep disorder. Sleep 2021; 44:5897018. [PMID: 32840615 DOI: 10.1093/sleep/zsaa155] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/20/2020] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES Recent work has identified clinical and polysomnographic features of a newly defined pediatric sleep disorder, restless sleep disorder (RSD). One of these features is low serum ferritin. In this retrospective, pilot study, we assess the response to iron supplementation. Children were given oral ferrous sulfate (FS) or intravenous ferric carboxymaltose (IV FCM). METHODS Children 5-18 years old with a diagnosis of RSD were evaluated clinically. Serum ferritin, iron profile, and video-polysomnography were obtained at baseline. Oral or IV iron supplementation was offered as part of routine care. Oral FS was one 325 mg tablet daily or 3 mg/kg/day liquid for 3 months. IV FCM was 15 mg/kg, up to 750 mg as a single infusion. Adverse effects were assessed. Ferritin and iron profile were checked after 2-3 months. Eight weeks after FCM, the phosphorus level was checked. Clinical Global Impression (CGI) scale was obtained pre- and posttreatment. RESULTS A total of 15 children received oral FS and 15 IV FCM. Baseline RSD severity, age, gender, or pretreatment lab values did not differ significantly between groups. CGI-improvement median score was "minimally improved" after oral FS and "much improved" after IV FCM (effect size 1.008, p < 0.023). All iron parameters were found to be significantly higher after intravenous iron treatment than oral iron, especially ferritin (effect size 3.743, p < 0.00003). Adverse effects: constipation, three with FS; noncompliance, one with FS; syncope, one with FCM infusion; and hypophosphatemia, zero post-FCM. CONCLUSIONS In this retrospective, clinical case series, RSD responded to iron supplementation with improvement in both clinical and laboratory parameters. The response was greater with IV FCM than oral FS.
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Affiliation(s)
| | - Daniel L Picchietti
- University of Illinois School of Medicine, Carle Illinois College of Medicine, and Carle Foundation Hospital, University of Illinois School of Medicine, Urbana, IL
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute-IRCCS, Troina, Italy
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Ryan CS, Edlund W, Mandrekar J, Wong-Kisiel LC, Gavrilova RH, Kotagal S. Iron Deficiency and Its Role in Sleep Disruption in Patients With Angelman Syndrome. J Child Neurol 2020; 35:963-969. [PMID: 32713229 DOI: 10.1177/0883073820941755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine if Angelman syndrome patients with sleep complaints have an increased risk of iron deficiency, and if iron therapy improves their sleep difficulties. BACKGROUND About two-thirds of Angelman syndrome patients experience sleep difficulties, which are likely multifactorial. Because iron deficiency can contribute toward restlessness in sleep, we investigated whether it might be a contributing factor in this special population. METHODS This retrospective study involved medical record review of Angelman syndrome patients <18 years old who had attended our multidisciplinary Angelman syndrome clinic and had sleep complaints. Serum ferritin levels were compared to age- and sex-matched controls. Sleep history and nocturnal polysomnogram findings of the Angelman syndrome patients were also characterized. RESULTS Nineteen Angelman syndrome patients (9 female, mean age 6.2±4.4 years) were identified. All 19 reported sleep difficulties. The mean serum ferritin level was 19.9±8.5 μg/L, while that in controls was 27.8±17.8 μg/L (P value .13). The odds ratio of iron deficiency in Angelman syndrome compared to controls was 4.17 (95% confidence interval 1.23-14.10), using normal serum ferritin level of 24 μg/L based on literature. Fifteen Angelman syndrome patients underwent nocturnal polysomnogram with 9/15 showing an elevated periodic limb movement index (overall mean 9.8±10.4). Seventeen of 19 received iron therapy. Twelve had follow-up after iron therapy, with parents reporting improved sleep quality. Eight had serum ferritin levels rechecked after iron therapy, showing a mean increase of 24±5.1 μg/L. CONCLUSIONS Sleep difficulties in Angelman syndrome, though multifactorial, may in part be related to iron deficiency. Treatment with iron improved sleep to a modest degree in this population.
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Affiliation(s)
- Conor S Ryan
- Department of Neurology, 4352Mayo Clinic, Rochester, MN, USA
| | - Wendy Edlund
- Department of Neurology, 4352Mayo Clinic, Rochester, MN, USA
| | - Jay Mandrekar
- Department of Neurology, 4352Mayo Clinic, Rochester, MN, USA.,Department of Health Sciences Research, 4352Mayo Clinic, Rochester, MN, USA
| | | | - Ralitza H Gavrilova
- Department of Neurology, 4352Mayo Clinic, Rochester, MN, USA.,Department of Genetics, 4352Mayo Clinic, Rochester, MN, USA
| | - Suresh Kotagal
- Department of Neurology, 4352Mayo Clinic, Rochester, MN, USA
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Esposito D, Belli A, Ferri R, Bruni O. Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments. Brain Sci 2020; 10:brainsci10070441. [PMID: 32664572 PMCID: PMC7407189 DOI: 10.3390/brainsci10070441] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Dario Esposito
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (D.E.); (A.B.)
| | - Arianna Belli
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (D.E.); (A.B.)
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute–IRCCS, 94018 Troina, Italy;
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence:
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DelRosso LM, Yi T, Chan JHM, Wrede JE, Lockhart CT, Ferri R. Determinants of ferritin response to oral iron supplementation in children with sleep movement disorders. Sleep 2020; 43:5575974. [PMID: 31563958 DOI: 10.1093/sleep/zsz234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/18/2019] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Lourdes M DelRosso
- Seattle Children's Hospital, Seattle, WA.,University of Washington, Seattle, WA
| | - Troy Yi
- University of Washington, Seattle, WA
| | | | - Joanna E Wrede
- Seattle Children's Hospital, Seattle, WA.,University of Washington, Seattle, WA
| | - Carey T Lockhart
- Seattle Children's Hospital, Seattle, WA.,University of Washington, Seattle, WA
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DelRosso L, Bruni O. Treatment of pediatric restless legs syndrome. PHARMACOLOGY OF RESTLESS LEGS SYNDROME (RLS) 2019; 84:237-253. [DOI: 10.1016/bs.apha.2018.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Sleep disorders in children may lead to neurodevelopmental and neurocognitive deficits; it is important to diagnose and treat them properly. Apart from the existing challenges in diagnosis, another drawback is that few therapies are currently approved. In this article, a comprehensive summary of the most common pediatric sleep disorders, along with the various pharmacologic and nonpharmacologic approaches for their management, is presented. Special attention has been paid to the currently available treatment options for pediatric insomnia, obstructive sleep apnea, parasomnias, narcolepsy, and restless legs syndrome, and comparisons are made with the corresponding treatment options for sleep disorders in adults.
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DelRosso LM, Bruni O, Ferri R. Restless sleep disorder in children: a pilot study on a tentative new diagnostic category. Sleep 2018; 41:4996606. [DOI: 10.1093/sleep/zsy102] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/14/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lourdes M DelRosso
- Benioff Children’s Hospital Oakland, University of California, San Francisco, Oakland, CA
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, Sapienza University, Rome, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Department of Neurology IC, Oasi Research Institute – IRCCS, Troina, Italy
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