Diagnosis and management of restless legs syndrome in children

Correlations between Sleep Features and Iron Status in Children with Neurodevelopmental Disorders: A Cross-Sectional Study

A high prevalence of sleep disturbances has been reported in children with neurodevelopmental disorders (NDDs), such as autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and intellectual disability (ID). The etiology of sleep disorders in these children is heterogeneous and, recently, iron deficiency has received increasing attention. This study aims to investigate sleep features in children with NDDs and to explore a possible correlation between serum iron status biomarkers and qualitative features of sleep. We included 4- to 12-year-old children with a diagnosis of ASD, ADHD, or ID and assessed their sleep features through the children's sleep habits questionnaire (CSHQ). Venous blood samples were collected to investigate ferritin, transferrin, and iron levels. The mean CSHQ total score exceeds the cut-off in all groups of children. In the ASD group, the Parasomnias subscale negatively correlated with serum ferritin levels (Rho = 0.354; p = 0.029). Our findings may suggest the existence of an association between iron status, sleep quality, and neurodevelopmental processes. In clinical practice, sleep assessment should be included in the routine assessment for patients with NDDs. Furthermore, a routine assessment of iron status biomarkers should be recommended for children with NDDs who have sleep disturbances.

[Pharmacotherapy of sleep disturbances in pre-school and elementary school children]

Sleep disturbance in pre-school and elementary school children is a common clinical situation. These disturbances may require pharmacotherapeutic approaches in certain cases. Major forms of sleep disturbances in children and data on known pharmacotherapeutic means of their treatment are considered.

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.

Sleep's role in memory consolidation: What can we learn from atypical development?

Research conducted over the last century has suggested a role for sleep in the processes guiding healthy cognition and development, including memory consolidation. Children with intellectual and developmental disabilities (IDDs) tend to have higher rates of sleep disturbances, which could relate to behavior issues, developmental delays, and learning difficulties. While several studies examine whether sleep exacerbates daytime difficulties and attention deficits in children with IDDs, this chapter focuses on the current state of knowledge regarding sleep and memory consolidation in typically developing (TD) groups and those at risk for learning difficulties. In particular, this chapter summarizes the current literature on sleep-dependent learning across developmental disabilities, including Down syndrome, Williams syndrome, Autism Spectrum Disorder, and Learning Disabilities (Attention-Deficit/Hyperactivity Disorder and Dyslexia). We also highlight the gaps in the current literature and identify challenges in studying sleep-dependent memory in children with different IDDs. This burgeoning new field highlights the importance of considering the role of sleep in memory retention across long delays when evaluating children's memory processes. Further, an understanding of typical and atypical development can mutually inform recent theories of sleep's role in memory.

[Pharmacotherapy of sleep disturbances in pre-school and elementary school children]

Sleep disturbance in pre-school and elementary school children is a common clinical situation. These disturbances may require pharmacotherapeutic approaches in certain cases. Major forms of sleep disturbances in children and data on known pharmacotherapeutic means of their corrections are considered.

Does Improvement of Low Serum Ferritin Improve Symptoms of Restless Legs Syndrome in a Cohort of Pediatric Patients?

STUDY OBJECTIVES

To determine whether an oral iron supplement improves restless leg/restless sleep symptoms in a pediatric population.

METHODS

In a cohort study, 47 patients (age 5-18 years) exhibiting restless legs/restless sleep symptoms and low serum ferritin levels (< 50 ng/mL) were given a daily oral iron supplement (ferrous sulfate + vitamin C) and re-evaluated 8 weeks later. A diagnosis of definite Restless Legs Syndrome (RLS) was determined based on criteria established by the International RLS Study Group. Using Wilcoxon signed-rank tests and Spearman rho, the change and association between the measures of Pediatric Restless Legs Syndrome Severity Scale and serum ferritin levels were also examined.

RESULTS

Overall, the median change and distribution of ferritin was statistically significantly different after 8 weeks of treatment (40.0 versus 23.0 ng/mL, P < .0001). Median RLS score was also statistically significantly lower from baseline to follow-up (4.0 versus 6.0, P = .0283). Sixteen patients met criteria for definite RLS; however, the change in RLS score was not determined to be significant in our population (9.5 versus 7.0, P = .0558), despite significant change in ferritin (25.0 versus 42.5 ng/mL, P < .0001). In addition, no correlation was observed between change in RLS score and ferritin level (rho = -.39, P = .1362).

CONCLUSIONS

In preliminary findings, we found a modest, yet nonsignificant improvement in children exhibiting restless sleep and RLS symptomatology, despite significant improvement in ferritin levels. Though not statistically significant, the findings can lend to the suggested benefit of iron supplementation in patients with RLS; however, clinical judgment and further research is necessary.

CITATION

Rosen GM, Morrissette S, Larson A, Stading P, Barnes TL. Does improvement of low serum ferritin improve symptoms of restless legs syndrome in a cohort of pediatric patients? J Clin Sleep Med. 2019;15(8):1149-1154.

Randomized, Placebo-Controlled Trial of Ferrous Sulfate to Treat Insomnia in Children With Autism Spectrum Disorders

BACKGROUND

Insomnia and low iron stores are common in children with autism spectrum disorders, and low iron stores have been associated with sleep disturbance.

METHODS

We performed a randomized placebo-controlled trial of oral ferrous sulfate to treat insomnia in children with autism spectrum disorders and low normal ferritin levels. Twenty participants who met inclusion criteria and whose insomnia did not respond to sleep education were randomized to 3 mg/kg/day of ferrous sulfate (n = 9) or placebo (n = 11) for three months.

RESULTS

Iron supplementation was well tolerated, and no serious adverse events were reported. Iron supplementation improved iron status (+18.4 ng/mL active versus -1.6 ng/mL placebo, P = 0.044) but did not significantly improve the primary outcome measures of sleep onset latency (-11.0 minutes versus placebo, 95% confidence interval -28.4 to 6.4 minutes, P = 0.22) and wake time after sleep onset (-7.7 minutes versus placebo, 95% confidence interval -22.1 to 6.6 min, P = 0.29) as measured by actigraphy. Iron supplementation was associated with improvement in the overall severity score from the Sleep Clinical Global Impression Scale (-1.5 points versus placebo, P = 0.047). Changes in measures of daytime behavior did not differ between groups.

CONCLUSION

This trial demonstrated no improvement in primary outcome measures of insomnia in subjects treated with ferrous sulfate compared with placebo. Interpretation was limited by low enrollment.

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

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.

A 15-Year-Old Girl With Sleep-Onset Insomnia and Poor Sleep Quality

CASE PRESENTATION

A 15-year-old girl was referred to us for sleep difficulties and restless sleep. The parent stated that she was always a poor sleeper, having difficulty falling asleep and frequent nocturnal awakenings since she was a very young child, but in the past 6 months the symptoms had worsened. She slept in her own room and in her own bed. Her bedtime was 10:30 pm, staying in bed anywhere from 2 to 5 h before she could fall asleep. During this time, she felt discomfort in her legs with the urge to move her legs and relief after movement. This sensation was worse at night or when sitting for prolonged periods of time. Once she fell asleep, she woke up 2 to 3 times a night. She started her day at 7 am but felt very sleepy and often would fall asleep again until 10 am. During the day she was exhausted and often took a nap from 3 to 5 pm. There was soft snoring and no parasomnias. Her medical history was significant for beta-thalassemia trait. She was not on any medications. Social history included no dietary restrictions and no caffeine use.

Restless legs syndrome in children with allergic rhinitis: A comparative study on frequency, severity and sleep quality

OBJECTIVES

This study aims to investigate the frequency and severity of restless legs syndrome (RLS) and its relationship with sleep quality in children with allergic rhinitis (AR) with the hypothesis that comorbid RLS may be an additional causative factor of sleep disturbances in pediatric AR.

PATIENTS AND METHODS

A total of 143 children with AR (aged 8-18 years) and 144 healthy control subjects (aged 8-18 years) were included. The diagnosis of AR was established on history, clinical examination and skin prick test according to the Allergic Rhinitis and its Impact on Asthma guidelines. Presence of RLS was determined using the International RLS study group (IRLSSG) criteria. The severity of RLS was assessed using the IRLSSG rating scale. Sleep quality was evaluated by Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Thirteen patients (9.1%) in AR group, and six children (4.2%) in control group had RLS (p=0.159). The frequency of RLS in AR group was higher than two folds when compared to the control group; however, the difference was not statistically significant. Restless legs syndrome severity score was significantly higher in AR group than control group (15.00 [11-20] and 11.00 [10-16] respectively, p=0.046). Total PSQI scores were similar between groups. Also, no significant differences were observed in total PSQI scores of AR patients with or without RLS.

CONCLUSION

Restless legs syndrome was not more common but was more severe in children with AR. There was no evidence that RLS has an obvious effect on sleep quality in children with AR.

The Pediatric Sleep Clinical Global Impressions Scale-A New Tool to Measure Pediatric Insomnia in Autism Spectrum Disorders

OBJECTIVE

To pilot a clinician-based outcome measure that provides complementary information to objective measures and parent-based questionnaires for insomnia in children with autism spectrum disorders (ASD).

METHOD

The authors developed a Pediatric Sleep Clinical Global Impressions Scale (CGI). Questions included (1) the child's ability to fall asleep and remain sleeping independently (i.e., apart from parents); (2) bedtime resistance; (3) sleep onset delay; (4) night awakening; (5) parental satisfaction with their child's current sleep patterns; (6) family functioning as affected by their child's current sleep patterns; and (7) clinician's overall concern with the child's sleep. After refining the instrument through the evaluation of vignettes by ASD and sleep experts, the authors piloted the Pediatric Sleep CGI in a 12-week randomized trial of iron supplementation in children with ASD. Clinicians completed Pediatric Sleep CGIs and structured sleep histories, parents completed the Children's Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches.

RESULTS

In repeated measures models, the Pediatric Sleep CGI and CSHQ were correlated for sleep onset delay (r = .66, p < .001), night wakings (r = .40, p < .001), and total score (r = .29, p < .001). The CGI-S sleep onset delay and actigraphy sleep onset delay scores (r = .75, p = .0095) were also correlated. The overall CGI-S showed improvement with therapy (p = .047).

CONCLUSION

The Pediatric Sleep CGI shows promise in measuring clinician-rated outcomes in pediatric insomnia in children with ASD. Larger samples will be necessary to examine reliability, validity, and measure to change, as well as applicability to other populations with pediatric insomnia.

Assessing the iron delivery efficacy of transferrin in clinical samples by native electrospray ionization mass spectrometry

Serum transferrin is a key player in iron homeostasis, and its ability to deliver iron to cells via the endosomal pathway critically depends on the presence of carbonate that binds this protein synergistically with ferric ion. Oxalate is another ubiquitous anionic species that can act as a synergistic anion, and in fact its interaction with transferrin is notably stronger compared to carbonate, preventing the protein from releasing the metal in the endosomal environment. While this raises concerns that high oxalate levels in plasma may interfere with iron delivery to tissues, concentration of free oxalate in blood appears to be a poor predictor of impeded availability of iron, as previous studies showed that it cannot displace carbonate from ferro-transferrin on a physiologically relevant time scale under the conditions mimicing plasma. In this work we present a new method that allows different forms of ferro-transferrin (carbonate- vs. oxalate-bound) to be distinguished from each other by removing this protein from plasma without altering the composition of the protein/metal/synergistic anion complexes, and determining their accurate masses using native electrospray ionization mass spectrometry (ESI MS). The new method has been validated using a mixture of recombinant proteins, followed by its application to the analysis of clinical samples of human plasma, demonstrating that native ESI MS can be used in clinical analysis.

Sleep in Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

Sleep problems are common in autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). Sleep problems in these disorders may not only worsen daytime behaviors and core symptoms of ASD and ADHD but also contribute to parental stress levels. Therefore, the presence of sleep problems in ASD and ADHD requires prompt attention and management. This article is presented in 2 sections, one each for ASD and ADHD. First, a detailed literature review about the burden and prevalence of different types of sleep disorders is presented, followed by the pathophysiology and etiology of the sleep problems and evaluation and management of sleep disorders in ASD and ADHD.

Sleep in Autism Spectrum Disorders

Autism spectrum disorders (ASD) are common neurodevelopmental conditions, affecting 1 in 68 children. Sleep disturbance, particularly insomnia, is very common in children diagnosed with ASD, with evidence supporting overlapping neurobiological and genetic underpinnings. Disturbed sleep exacerbates core and related ASD symptoms and has a substantial negative impact on the entire family. Treatment of sleep disturbance holds promise for ameliorating many of the challenging behavioral symptoms that children with ASD and their families face. Behavioral and pharmacological studies indicate promising approaches to treating sleep disturbances in this population. Awareness of treatment options is particularly important as parents and clinicians may believe that sleep disturbance is part of autism and refractory to therapy. In addition, autism symptoms refractory to treatment with conventional psychiatric medications may improve when sleep is addressed. Additional evidence-based studies are needed, including those that address the underlying biology of this condition.

Brazilian consensus on guidelines for diagnosis and treatment for restless legs syndrome

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.

Supporting a happy, healthy adolescence for young people with Down syndrome and other intellectual disabilities: recommendations for clinicians

PURPOSE OF REVIEW

To review clinical updates and current healthcare issues for adolescents with Down syndrome and intellectual disabilities, including behavioral, social, and emotional issues, health supervision recommendations, and recommendations for supporting the transition process.

RECENT FINDINGS

Several recent findings merit particular attention: low activity levels and implications for overweight and poor bone density; high prevalence of obstructive sleep apnea and its implications; prevalence of mental health and behavioral concerns; and need for appropriate transition services.

SUMMARY

In guiding adolescents with Down syndrome towards healthy productive adult lives, clinicians can make use of healthcare guidelines and should also take a broader, more interdisciplinary approach to ensure that social, educational, and vocational plans are in place to support physical and mental health and development during transition into adulthood. Many of these issues have broader applicability to any adolescent with an intellectual disability.

Growing pains and periodic limb movements of sleep in children

AIM

To investigate whether there was any association between growing pains (GP) and periodic limb movements of sleep (PLMS) in children referred for polysomnography (PSG), in light of the possible shared genetic determinants between GP and restless legs syndrome.

METHODS

Records of all 903 children who underwent PSG at a paediatric hospital between January 2009 and May 2010 were retrospectively reviewed. Children aged 3-16 years, without neuromuscular or neurological/developmental disorders who were seen by a single sleep physician were included in the analysis. Data extracted included: current GP, PLMS index, mixed obstructive apnoea/hypopnoea index and patient demographics. GP was diagnosed in the pre-PSG consultation.

RESULTS

GP was recorded in 43 of the eligible 230 children referred for PSG of whom 25.6% had a PLMS index ≥ 5/h, significantly higher than in the children without GP (10.2%) (odds ratio 3.04, χ(2) = 6.0, P = 0.014). The adjusted odds ratio for the association between GP and PLMS remained significant at 2.53 (95% CI 1.1-6.1, P < 0.05). A PLMS index ≥ 5/h was recorded in 30 of the 230 participants. GP and PLMS were also significantly multivariately associated with restlessness as the indication for PSG.

CONCLUSIONS

Children with GP were three times more likely to have a PLMS index ≥ 5/h than children without GP on PSG. These results suggest that GP may be associated with PLMS, giving greater support for the hypothesis that GP might lie on the phenotypic spectrum of restless legs syndrome.

Treatment of pediatric restless legs syndrome

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.

Early childhood-onset restless legs syndrome: symptoms and effect of oral iron treatment

AIM

To describe symptoms of restless legs syndrome (RLS) in early childhood and the effect of oral iron treatment.

METHODS

A study population comprising 22 children, 15 males and seven females referred for paediatric evaluation because of sleep disturbances. Presence of RLS was evaluated using the International RLS Study Group consensus criteria of RLS. In case of ferritin level below 50 ng/mL, oral iron treatment was initiated. Fourteen were examined by polysomnography as well, and periodic limb movement index during sleep (PLMSI) was calculated. Relief of symptoms was recorded by the parents and correlated with ferritin levels and PLMSI.

RESULTS

Median age at onset of symptoms was 7.5 months (0-40 months). The most striking single symptom was awakening after 1-3 h of sleep followed by screaming, crying, kicking or hitting the legs. Oral iron supplementation had a positive ferritin-concentration-dependent clinical effect. A relation between high PLMSI and low ferritin levels was demonstrated.

CONCLUSION

Symptoms of RLS may start as early as the first year of life, are accompanied by low ferritin levels and a high PLMSI and can be ameliorated by iron supplementation. An increased awareness and knowledge of RLS in early childhood are warranted.

Treatment of dyssomnias and parasomnias in childhood

OPINION STATEMENT

Dyssomnias are sleep disorders associated with complaints of insomnia or hypersomnia. The daytime sleepiness of narcolepsy is treated by a combination of planned daytime naps, regular exercise medications such as modafinil, or salts of methylphenidate, or amphetamine. Cataplexy that accompanies narcolepsy is treated with anticholinergic agents, selective serotonin reuptake inhibitors, or sodium oxybate. Children with neurodevelopmental disabilities such as autism have sleep initiation and maintenance difficulties on a multifactorial basis, with favorable response to melatonin in some patients. Childhood onset restless legs syndrome is often familial, associated with systemic iron deficiency, and responsive to iron supplementation and gabapentin. Parasomnias are episodic phenomena events which occur at the sleep -- wake transition or by intrusion on to sleep. Arousal parasomnias such as confusional arousals and sleep walking can sometimes be confused with seizures. A scheme for differentiating arousal parasomnias from nocturnal seizures is provided. Since arousal parasomnias are often triggered by sleep apnea, restless legs syndrome, or acid reflux, treatment measures directed specifically at these disorders often helps in resolution. Clonazepam provided in a low dose at bedtime can also alleviate sleep walking and confusional arousals. Obstructive sleep apnea affects about 2 percent of children. Adeno-tonsillar hypertrophy, cranio-facial anomalies, and obesity are common predisposing factors. Mild obstructive sleep apnea can be treated using a combination of nasal corticosteroids and a leukotriene antagonist. Moderate to severe obstructive sleep apnea are treated with adeno-tonsillectomy, positive airway pressure breathing devices, or weight reduction as indicated. This paper provides an overview of the topic, with an emphasis on management steps. Where possible, the level of evidence for treatment recommendations is indicated.

Iron status in children with autism spectrum disorder

BACKGROUND AND OBJECTIVES

Children with autism spectrum disorders (ASDs) often have food selectivity and restricted diets, putting them at risk for nutritional deficiencies. Previous studies have demonstrated a high prevalence of iron deficiency (ID) in children with ASDs living in Wales, Canada, and Turkey. The objectives of this study were to determine the prevalence of ID and the adequacy of iron intake in children with ASD in the United States.

METHODS

Participants (age 2-11 years recruited from the Autism Treatment Network Diet and Nutrition Study) completed a 3-day diet record (n = 368) and had laboratory measures of serum ferritin (SF), complete blood count, iron, total iron binding capacity, and transferrin saturation (TS) (n = 222).

RESULTS

Of the 222 participants with laboratory data, 18 (8%) had SF <12 µg/L and 2 (1%) had ID defined by both low SF and TS (3 children with low SF had missing TS data). One subject had iron deficiency anemia. Fewer than 2% of subjects had iron intake below the estimated average requirement.

CONCLUSIONS

Although the determination of iron status is complex, these data do not support previous reports that children with ASD are at greater risk for ID than the general population; however, 8% percent of the sample did demonstrate low SF despite <2% of the sample demonstrating iron intake below the estimated average requirement. The prevalence of low SF may be an underestimate, because SF is an acute phase reactant and the study included no measure of inflammation.

Current treatment of selected pediatric sleep disorders

While pediatric sleep disorders are relatively common, treatments are often not straightforward. There is often a paucity of gold standard studies and data available to guide clinicians, treatments may yield arguably incomplete results, interventions may require chronic use, and/ or involve multiple modalities including behavioral interventions that require high parental and family commitment. This review points out diagnostic differences compared to adults and focuses on current therapy for selected common pediatric sleep disorders including sleep disordered breathing/ obstructive sleep apnea, narcolepsy, and restless legs syndrome. Other common pediatric sleep disorders, such as insomnia and parasomnias, are not covered.

Iron deficiency anemia in infancy exerts long-term effects on the tibialis anterior motor activity during sleep in childhood

OBJECTIVES

To explore the eventual connection between iron deficiency anemia (IDA) in infancy and altered leg movements during sleep in a 10-year follow-up study in children who did or did not have IDA in infancy.

SUBJECTS AND METHODS

Polysomnographic studies were performed in 32 10-year-old children (13 females and 19 males) who had IDA in infancy and 26 peers (10 females and 16 males) who were nonanemic controls. The time structure of their polysomnographically recorded leg movements (LM) was analyzed by means of an approach particularly able to consider their quantity, periodicity, and distribution during the night.

RESULTS

All LM indexes and those related to periodic LM during sleep (PLMS) were slightly higher in the former IDA group than in the control group, but not always significant. The Periodicity index during NREM sleep was higher and was reflected by a small but significant increase in PLMS separated by 10-50s intervals. PLMS index tended to be higher in former IDA children than in controls throughout the whole night.

CONCLUSION

The association between IDA in infancy, despite iron therapy, and PLMS in childhood could lead to new research in this area. Indeed, transient infantile IDA, a common nutritional problem among human infants, may turn out to be important for understanding the mechanisms of PLMS or restless legs syndrome, which are common in adulthood.

Psychiatric comorbidity in children and adolescents with restless legs syndrome: a retrospective study

OBJECTIVE

Children and adolescents with restless legs syndrome (RLS) are commonly diagnosed with comorbid attention deficit hyperactivity disorder and behavioral disturbances. Uncertainty exists over the significance of other co-occurring psychiatric disorders and their pharmacologic management in children with RLS. The purpose of this study was to determine the prevalence and nature of psychiatric disorders in children with RLS and to describe the use of psychotropic medications in our study cohort.

METHODS

The electronic medical records of children younger than 18 years of age who had been diagnosed with RLS between January 1, 2003, and December 31, 2009, were reviewed. Only those patients whose findings were consistent with the 2003 NIH workshop diagnostic criteria for probable or definite restless legs syndrome were included in this study. The medical records were cross-referenced for encounters with a child psychiatrist or psychologist. Likewise, only psychiatric diagnoses whose medical records explicitly reflected DSM-IV diagnostic criteria for psychiatric disorder(s) were included. Demographic data, serum ferritin, psychotropic medications, and in some cases, the results of pharmacogenomic testing were included in the data analysis in an ad hoc fashion.

RESULTS

We found 374/922 patients who met diagnostic criteria for childhood onset RLS. The mean age of the subjects was 10.6 years (range 0 to 18) and the male to female ratio was approximately 1:1. Overall, 239/374 (64%) patients with RLS had one or more comorbid psychiatric disorders. Attention deficit hyperactivity disorder was found in 94/374 (25%) patients, mood disturbances were found in 109/374 (29.1%) patients, anxiety disorders in 43/374 (11.5%) patients, and behavioral disturbances in 40/374 (10.9%) patients. Attention deficit hyperactivity disorder and disruptive behavior disorders were more common in males (OR = 1.94 for both), whereas mood disturbances and anxiety disorders were more common in females (OR = 1.6 and 1.26, respectively). Mean serum ferritin levels derived from all patients without any psychiatric disorder were compared to all patients with one or more psychiatric disorder. No differences were found. The number of new psychotropic medication trials increased significantly with increase in patient age. Stimulants and antidepressant medications were the most commonly prescribed agents. As a part of clinical care, 15 of these patients underwent pharmacogenomic testing. Metabolic abnormalities were predicted by genotyping in 12/15 (80%) patients.

CONCLUSION

Comorbid psychiatric conditions occurred in two-thirds of children with RLS, underscoring the need for multidisciplinary management of this condition. An important relationship might exist between psychotropic medication, and possibly pharmacogenomic factors, in children and adolescents with symptoms of restless legs syndrome. These findings are consistent and build on those reported in the adult literature.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

In this article, we advocate the need for better understanding and treatment of children exhibiting inattentive, hyperactive, impulsive behaviors, by in-depth questioning on sleepiness, sleep-disordered breathing or problematic behaviors at bedtime, during the night and upon awakening, as well as night-to-night sleep duration variability. The relationships between sleep and attention-deficit/hyperactivity disorder (ADHD) are complex and are routinely overlooked by practitioners. Motricity and somnolence, the most consistent complaints and objectively measured sleep problems in children with ADHD, may develop as a consequence of multidirectional and multifactorial pathways. Therefore, subjectively perceived or reported restless sleep should be evaluated with specific attention to restless legs syndrome or periodic limb movement disorder, and awakenings should be queried with regard to parasomnias, dyssomnias and sleep-disordered breathing. Sleep hygiene logs detailing sleep onset and offset quantitatively, as well as qualitatively, are required. More studies in children with ADHD are needed to reveal the 24-h phenotype, or its sleep comorbidities.

Pediatric restless legs syndrome: analysis of symptom descriptions and drawings

The specific aims of this study were to collect and analyze detailed symptom descriptions from patients with pediatric restless legs syndrome, ages 6 to 17 years, as well as assess symptom impact and the usefulness of drawings. Trained qualitative interviewers conducted face-to-face audio-recorded interviews of children and adolescents who met criteria for definite restless legs syndrome. Thirty-three patients in 3 age groups used 16 different categories of descriptors for restless legs sensations, with a mean of 3 or more categories used per patient in each age group. "Need to move/kick," "pain/hurts," "uncomfortable/cannot get comfortable," and "like bugs or ants/crawling" were the most common descriptors. Two-thirds reported daytime sensations, and nearly half had arm involvement. They described impact on sleep, cognitive function, and affect. Drawings provided useful diagnostic information. These detailed empirical data will be useful in clinical practice, as well as in the development of formal diagnostic tools and severity measures.

Sleep and autism spectrum disorders

Sleep disorders are common in children with autism spectrum disorders and have a significant effect on daytime function and parental stress. The cornerstone of treatment is to establish the cause of the sleep concern, which is often multifactorial. Identifying and treating sleep disorders may result not only in more consolidated sleep, more rapid time to fall asleep, and avoidance of night waking but also favorably affect daytime behavior and parental stress. Targeting effective treatment strategies is dependent on understanding the underlying causes of sleep problems in children with Autism spectrum disorders, therefore further research is paramount.

Restless Leg Syndrome in ADHD children: levetiracetam as a reasonable therapeutic option

The comorbidity of Attention Deficit Hyperactivity Disorder (ADHD) with sleep disorders has been extensively studied. In particular, Restless Legs Syndrome (RLS) appears to be consistently more frequent in children with ADHD. Several papers also draw attention to the frequent occurrence of epileptic seizures and EEG abnormalities in ADHD children. We performed a preliminary open label study to evaluate the efficacy of Levetiracetam (LEV) to ameliorate the sleep pattern and reduce RLS symptoms in children with a complex comorbidity between Attention Deficit Hyperactivity Disorder (ADHD), RLS and focal interictal epileptic discharges (IEDs) on EEG. We recruited seven children (all males, aged between 5 and 12years) who fulfilled the following criteria: ADHD diagnosis combined subtype; presence of idiopathic RLS; and presence of focal IEDs on EEG. All children were given LEV at a starting dose of approximately 10-20mg/kg/day followed by 10mg/kg/day incrementing at 1-week intervals up to 50-60mg/kg/day given in two separate doses. At a 3 and 6month follow-up, all children showed significant improvement (p<0.05) in global International RLS Rating Scale (IRLS-RS). Parents' reports revealed improved sleep quality with fewer awakenings and restorative sleep in their children. LEV was well tolerated and no major side effects were reported. With an accessory report we observed the reduction of epileptiform EEG activity during sleep. In most patients (6 on 7) the discharges completely disappeared; in the last patient epileptiform EEG activity was significantly reduced. These children may represent a subgroup of ADHD patients in which the hyperactivity and attention difficulties might be aggravated by sleep disturbances and by IEDs. LEV could represent a therapeutic option for these comorbid conditions.

Differential Diagnosis and Treatment of Obsessive-Compulsive, Inattentive, and Sleep Symptoms in a 7-Year-Old With PDD-NOS

The overlap in symptoms among autism spectrum disorders (ASDs), anxiety disorders, and attention-deficit/hyperactivity disorder (ADHD) in youth can present diagnostic challenges for clinicians and researchers. Accurate diagnosis and comprehensive treatment can be facilitated by ongoing assessment and close collaboration among members of a multidisciplinary team. Specific treatment guidelines for reducing anxiety and/or inattentive behaviors in children with a primary ASD diagnosis are currently lacking. This case provides an example of how an empirically supported treatment for anxiety, exposure with response prevention (E/RP), in conjunction with pharmacotherapy, can be effective in reducing anxiety and ritualistic/compulsive behaviors in ASDs. This case also exemplifies how attention to and treatment of sleep problems can improve inattentive symptoms and overall functioning.

Development of the Pediatric Restless Legs Syndrome Severity Scale (P-RLS-SS): a patient-reported outcome measure of pediatric RLS symptoms and impact

OBJECTIVE

To develop a questionnaire to measure Pediatric Restless Legs Syndrome (P-RLS) symptoms and impact for use in clinical research.

METHODS

Questionnaire items were developed based on open-ended, qualitative interviews of 33 children and adolescents diagnosed with definite RLS (ages 6-17 years) and their parents. The draft questionnaire was then tested through cognitive debriefing interviews with 21 of the same children/adolescents and 15 of their parents. This involved the children and parents answering the draft items and then interviewing them about the child's ability to understand and interpret the questionnaire. Expert clinicians provided clinical guidance throughout.

RESULTS

Draft severity questions were generated to measure the four-symptom and four-impact domains identified from the concept elicitation interviews: RLS sensations, move/rub due to RLS, relief from move/rub, pain, and impact of RLS on sleep, awake activities, emotions, and tiredness. RLS descriptions, symptoms, and impact were compared between those who had comorbid attention-deficit/hyperactivity disorder and those who did not. Revisions to several questions were made based on the cognitive debriefing interviews and expert clinician review, resulting in a severity scale with 17 morning and 24 evening items. Caution regarding self-administration in children ages 6-8 years is recommended. To complement the child/adolescent measures, a separate parent questionnaire was also developed.

CONCLUSIONS

The P-RLS-SS was constructed based on detailed input from children and adolescents with RLS, their parents, and clinical experts, thus providing a scale with strong content validity that is intended to be comprehensive, clinically relevant, and important to patients. Validation of this scale is recommended.

Ropinirole in restless legs syndrome and periodic limb movement disorder

Restless legs syndrome and periodic limb movement disorder of sleep are now recognized as prevalent, distinct, yet overlapping disorders affecting all age groups. Although delineation of the mechanisms underlying these disorders continues to be the focus of very intense research efforts, it has become apparent that there is a prominent role for dopaminergic agents in the clinical management of these patients. Among the various dopaminergic drugs, ropinirole has undergone relatively intense and critical scrutiny, and appears to provide a safe and efficacious treatment option for patients with these two conditions. The more recent development of a controlled formulation for this drug is likely to yield additional benefits such as improved adherence and reduced fluctuations in daytime and nighttime symptoms. However, there is not enough evidence at this time to support such assumption.

Update on the management of restless legs syndrome: existing and emerging treatment options

Restless legs syndrome (RLS) is a sensorimotor disorder, characterized by a circadian variation of symptoms involving an urge to move the limbs (usually the legs) as well as paresthesias. There is a primary (familial) and a secondary (acquired) form, which affects a wide variety of individuals, such as pregnant women, patients with end-stage renal disease, iron deficiency, rheumatic disease, and persons taking medications. The symptoms reflect a circadian fluctuation of dopamine in the substantia nigra. RLS patients have lower dopamine and iron levels in the substantia nigra and respond to both dopaminergic therapy and iron administration. Iron, as a cofactor of dopamine production and a regulator of the expression of dopamine type 2-receptor, has an important role in the RLS etiology. In the management of the disease, the first step is to investigate possible secondary causes and their treatment. Dopaminergic agents are considered as the first-line therapy for moderate to severe RLS. If dopaminergic drugs are contraindicated or not efficacious, or if symptoms are resistant and unremitting, gabapentin or other antiepileptic agents, benzodiazepines, or opioids can be used for RLS therapy. Undiagnosed, wrongly diagnosed, and untreated RLS is associated with a significant impairment of the quality of life.

[Sleep disorders in children and adolescents]

BACKGROUND

Pediatric sleep is a rapidly developing area, and understanding of sleep disorders in children and adolescents is improving. The article aims to present new knowledge to Norwegian physicians.

MATERIAL AND METHODS

The article is based on review articles and clinical guidelines identified through non-systematic searches in PubMed, limited to the period 2007-2009.

RESULTS

Primary and secondary sleep disorders in children and adolescents are common, but underdiagnosed. Sleep disorders may occur as early as infancy and the clinical presentation often differs from that in adults. These disorders may have serious consequences in the short and long run. Information about sleep and circadian rhythm, positive routines and good sleep hygiene may prevent sleep disorders and form natural constituents of treatment of all such disorders in youngsters. A non-pharmacological approach with cognitive behavioural interventions is the most important treatment of insomnia. Randomized studies and guidelines for pharmacological therapy are needed.

INTERPRETATION

Sleep disorders in children and adolescents demand special knowledge and attention. Norway needs an increase in capacity and competent experts to evaluate sleep disorders in children and adolescents.