PEDIATRICS Vol. 120 No. 2 August 2007, pp. 438-439 (doi:10.1542/10.1542/peds.2007-1235)
COMMENTARY |
Restless Legs Syndrome: What Is a Pediatrician to Do?
a Departments of Pediatrics
c Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
b Section of Behavioral Pediatrics, Division of Child Development, Rehabilitation, Metabolic Disease
d Sleep Center, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Abbreviations: RLS, restless legs syndrome • NIH, National Institutes of Health
Over the last 15 years there has been increasing recognition that restless legs syndrome (RLS) occurs in children. Adults with the diagnosis often report having had symptoms as children, and case series have described children as young as 18 months of age with features of RLS.1 In 2003, a report from a National Institutes of Health (NIH) consensus conference outlined the essential diagnostic criteria for RLS in children,2 and these criteria are summarized in detail in Table 1 of the Picchietti et al article in this issue of Pediatrics.3
Picchietti et al developed a survey that was based on the NIH criteria and used to screen >10000 members of a volunteer research panel in the United States and United Kingdom who had children between 8 and 17 years of age for symptoms of RLS. Before agreeing to participate, those surveyed were blind to the topic and content of the survey. Only 14% of those in the research panel expressed an interest in completing the study, but of those who expressed an interest, 91% of the eligible families completed the survey. An expert panel of 4 authors developed an algorithm for scoring and interpreting the questionnaire. On the basis of this questionnaire and algorithm, the researchers found a prevalence of definite RLS of 1.9% for 8- to 11-year-olds and 2.0% for 12- to 17-year-olds.3
Despite many strengths of the study (eg, large sample size, use of NIH consensus diagnostic criteria), there are reasons to be cautious in interpreting these prevalence estimates. Most problematic is that the authors did not provide data to allow one to assess the validity or reliability of the survey. For example, we do not know how often the survey and clinical evaluation agreed on the presence or absence of RLS. We do not know whether families who completed the survey a second time received the same diagnosis as the first time (test-retest reliability), and we do not know how often different experts using the algorithm come to the same conclusions about the diagnosis (interrater reliability). Also of concern is the fact that very little information was given about the volunteer research panel or those who volunteered for this study. Given this limited information, we do not know what group was really surveyed and, thus, to whom the calculated prevalence rates apply.
Additional research will be needed to better define prevalence estimates, but the Picchietti et al article highlights some important findings: symptoms of RLS are more prevalent than most physicians would have expected; most individuals with symptoms have not had the condition diagnosed; and the symptoms cause significant distress for a subset of those with the disorder.3 The article challenges primary care physicians to consider what role they might play in the detection and treatment of RLS.
Picchietti et al provided some information that should be very helpful to primary care physicians in the detection of RLS. Table 5 from their article provides an excellent list of the myriad ways in which children describe the discomfort associated with RLS.3 The authors also commented that they found asking about "growing pains" to be a useful "lead-in" question, but here their data were more mixed. Of the 206 individuals with definite RLS, they found that for 166 (80.6%) of them, parents reported the presence of growing pains. However, growing pains are very common and were reported by 6661 of the families surveyed. Thus, only 166 (2.5%) of 6661 of individuals with growing pains had definite RLS, a prevalence that is not much greater than the 
2% prevalence found in the entire population surveyed.3 Thus, growing pains had a very low positive predictive value in the sample surveyed, although the negative predictive value of 99% suggests that most children who do not have growing pains do not have RLS. Future studies should investigate how best to identify children with RLS in a primary care setting.
If a primary care physician does identify a child with RLS, there are no current guidelines as to what the physician should do next. Not every child encountered with RLS will need treatment; in particular, those with infrequent, mild symptoms may not require intervention. The patient's history and examination can be used to exclude secondary causes of RLS, including neurologic disorders (eg, polyneuropathies, lumbosacral radiculopathies), medical disorders (such as anemia and hypothyroidism), and effects of medications that can provoke or aggravate RLS (including neuroleptics, antihistamines, and many antidepressants).4,5
For children with significant RLS, treatment can be a challenge, because there have been no randomized, controlled medication trials in the pediatric population and no currently Food and Drug Administration–approved therapies for use in children. Therefore, management of children with idiopathic RLS should begin nonpharmacologically. Case histories and anecdotal reports have suggested that good sleep hygiene, cognitive behavioral therapy, and relaxation therapies may be helpful for some patients.4 One small randomized trial suggested that an exercise program could decrease symptoms in adults with RLS.6 It would also be reasonable to restrict caffeinated beverages, which may exacerbate RLS.5 If these measures are ineffective, screening for anemia and checking the patient's serum ferritin level makes sense, because some adults with relatively low body iron stores (ferritin levels of <50 µg/L) have responded favorably to iron supplementation.7 For children, elemental iron in doses of 3 mg/kg per day given in a 3-month trial was shown to improve periodic limb movements in sleep and clinical symptoms,8 but more data are needed to determine effectiveness in pediatric RLS. If symptoms persist despite behavioral interventions and possible iron repletion, then referral to a pediatric sleep center would be appropriate. Classes of medications that have been used to treat RLS successfully in adults include dopaminergic agents, benzodiazepines, opiates, and anticonvulsants.4,5 Medications that have been reportedly helpful in children include pergolide, carbidopa/levodopa, and pramipexole.9,10
In summary, Picchietti et al have conducted the largest assessment of RLS in children and adolescents to date, and their important study should serve to increase physicians' awareness of this relatively common and underdiagnosed disorder. When concerns about growing pains and/or sleep problems arise, pediatricians should consider RLS as a potential cause while recognizing that most children with sleep problems or growing pains do not have RLS.
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FOOTNOTES |
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Accepted Apr 30, 2007.
Address correspondence to Nathan J. Blum, MD, Section of Behavioral Pediatrics, Division of Child Development, Rehabilitation, Metabolic Disease, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: blum{at}email.chop.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
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REFERENCES |
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 TOP REFERENCES |
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- Walters AS, Picchietti DL, Ehrenberg BL, Wagner ML. Restless legs syndrome in childhood and adolescence. Pediatr Neurol. 1994;11 :241 –245[CrossRef][Web of Science][Medline]
- Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology—a report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med. 2003;4 :101 –119[CrossRef][Web of Science][Medline]
- Picchietti D, Allen RP, Walters AS, Davidson JE, Myers A, Ferini-Strambi L. Restless legs syndrome: prevalence and impact in children and adolescents—the Peds REST Study.
Pediatrics. 2007;120
:253
–266
[Abstract/Free Full Text] - Hening W, Allen R, Earley C, Kushida C, Picchietti D, Silber M. The treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Review. Sleep. 1999;22 :970 –999[Web of Science][Medline]
- Hening WA. Current guidelines and standards of practice for restless legs syndrome. Am J Med. 2007;120(1 suppl 1) :S22 –S27
- Aukerman MM, Aukerman D, Bayard M, Tudiver F, Thorp L, Bailey B. Exercise and restless legs syndrome: a randomized controlled trial.
J Am Board Fam Med. 2006;19
:487
–493
[Abstract/Free Full Text] - Chesson AL Jr, Wise M, Davila D, et al. Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999;22 :961 –968[Web of Science][Medline]
- Simakajornboon N, Gozal D, Vlasic V, Mack C, Sharon D, McGinley BM. Periodic limb movements in sleep and iron status in children. Sleep. 2003;26 :735 –738[Web of Science][Medline]
- Walters AS, Mandelbaum DE, Lewin DS, Kugler S, England SJ, Miller M. Dopaminergic therapy in children with restless legs/periodic limb movements in sleep and ADHD. Dopaminergic Therapy Study Group. Pediatr Neurol. 2000;22 :182 –186[CrossRef][Web of Science][Medline]
- Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and sleep terrors in prepubertal children: what triggers them? Pediatrics. 2003;111(1) . Available at: www.pediatrics.org/cgi/content/full/111/1/e17
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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