Kids and RLS

[Guest guest]

Dear Anita,

You're right, very little has been written or is even known about RLS and

children. In the 1996 publication in Neurology, " A questionnaire study of

138 patients with restless legs syndrome: the 'Night-s' survey, " the

authors found that more than a third of the patients experienced their

first symptoms before the age of 10, and for those who had an " early onset "

of RLS, the family history was more often positive for RLS. Dr. Picchietti,

who wrote the chapter on children in Sleep Thief, is probably the " expert "

on RLS in children. He recently wrote a short pediatric update for the RLS

Foundation's medical bulletin and I will copy what he gave me at the end of

this message.

Good luck,

Cate Murray

RLS Foundation

Until recently, reference to childhood RLS and PLMD in the medical

literature was infrequent and often incidental (1-3). However, newer

reports have now documented multiple childhood and adolescent cases (4-14).

Onset of RLS prior to age 21was found in about 40% of adults in two recent

retrospective studies (15,16). Recognizing that RLS and PLMD are frequent

(albeit vastly underdiagnosed) disorders in adults, this research suggests

that childhood cases may not be a rare occurrence.

Given current data, diagnosis of RLS in childhood is often difficult.

Child-specific criteria that take into account the limited language and

conceptual skills of a young child have yet to be developed. Often helpful

in diagnosing childhood cases is the autosomal dominant mode of inheritance

of RLS that has been suggested by genetic studies (1,17-19). Diagnosis in a

biologic parent substantially increases the likelihood of the child having

RLS, as is seen in other disorders such as childhood migraine and

dominantly inherited epilepsy syndromes. Another important consideration is

the recognition that children can have moderate to severe PLMD, without

diagnosable RLS, even in families where RLS has been found (14).

Polysomnography is an important tool in this situation to confirm PLMD and

assess the severity of the sleep disruption.

As in adults, the symptomatology of RLS and PLMD includes leg dysesthesias

(usually mild and intermittent but sometimes misdiagnosed as growing

pains), sleep-onset problems, and sleep-maintenance problems. In addition,

it is typical for these untreated children to get less than the normal

amount of sleep for their age. Recent research suggests that cognitive,

behavioral, and affective problems, especially attention problems (ADHD)

and oppositional behaviors (oppositional defiant disorder) (8,9,11,13,20),

may be more common in these children. Further work is needed to delineate

the association of these symptoms with RLS and PLMD, as well as to

determine whether sleep disturbance or other factors may mediate the

effect.

Beyond a few case reports, there are no treatment studies specific to

children. These case reports have indicated individual responses to strict

limit-setting in enforcing the child's sleep schedule, restricting caffeine

consumption, and using medications such as clonazepam, levodopa/carbidopa,

pergolide, and clonidine (6-9,12,14,20). Benzodiazepines, anticonvulsants,

alpha-adrenergic agents (21), and opioids have been extensively used in

children with disorders other than RLS, as has chronic use of levodopa for

dopa-responsive dystonia (22). In general, it is probably best to start

with behavioral, sleep-schedule, and sleep-hygiene interventions before

considering pharmacologic treatments.

References

1. Ekbom KA. Growing pains and restless legs. Acta Paediatr Scand

1975;64:264-266

2. Boghen D, Peyronnard J. Myoclonus in familial restless legs syndrome.

Arch Neurol 1976;33:368-370

3. Montplaisir J, Godbout R, Boghen D, DeChamplain J, Young SN, Lapierre G.

Familial restless legs with periodic movements: electrophysiologic,

biochemical, and pharmacological study. Neurology 1985;35:130-134

4. Kotagal S, Rathnow SR, Chu JK, O'Connor DM, Cross J, Sterneck RL.

Nocturnal myoclonus- a sleep disturbance with leukemia (letter). Dev Med

Child Neurol 1985;27:124-126

5. Walters AS, Picchietti DL, Hening W, Lazzarini A. Variable expressivity

in familial restless legs syndrome. Arch Neurol 1990;47:1219-1220

6. Sheldon SH, Levy HB. Periodic limb movements in childhood (abstract).

Sleep Res 1993;22:70

7. Walters AS, Picchietti DL, Ehrenberg BL, Wagner ML. Restless legs

syndrome in childhood and adolescence. Pediatr Neurol 1994;11:241-245

8. Picchietti DL, Walters AS. Restless legs syndrome and periodic limb

movement disorder in children and adolescents: comorbidity with

attention-deficit hyperactivity disorder. Child Adoles Clin North Am

1996;5:729-740

9. Picchietti DL, VN. Growing pains: restless legs syndrome in

children. In: VN with Walters AS, editor. Sleep thief: restless legs

syndrome. Orange Park, FL: Galaxy Books, 1996:82-94

10. Wise M, Gillespie S. Autosomal dominant restless legs syndrome in a

young girl with symptom onset at 12 months [abstract]. Sleep Res

1996;25:391

11. Picchietti D, Walters A, Underwood D, Farris W, Dahl R, Trubnick L,

Bertocci M. Periodic limb movement disorder in attention-deficit

hyperactivity disorder children [abstract]. Sleep Res 1997;26:496

12. Arens R, B, Elliott J, Zhao H, Wang PP, Brown LW, Kaplan P.

Periodic limb movements in sleep in children with syndrome. J

Pediatr 1998;133:670-674

13. Picchietti DL, England SJ, Walters AS, Willis K, Verrico T. Periodic

limb movement disorder and restless legs syndrome in children with

attention-deficit hyperactivity disorder. J Child Neurol 1998; 13:588-594

14. Picchietti DL, Walters AS. Moderate to severe periodic limb movement

disorder in childhood and adolescence. Sleep, 1999;22: In press.

15. Walters AS, Hickey K, Maltzman J, et al. A questionnaire study of 138

patients with restless legs syndrome: the " night-walkers " survey. Neurol

1996;46:92-95

16. Montplaisir J, Boucher S, Poirier G, Lavigne G, Lapierre O, Lesperance

P. Clinical, polysomnographic, and genetic characteristics of restless legs

syndrome: a study of 133 patients diagnosed with new standard criteria. Mov

Disord 1997;12:61-65

17. Montagna P, Coccagna G, Cirignotta F, Lugaresi E. Familial restless

legs syndrome: long-term follow-up. In: Guilleminault C, Lugaresi E, eds.

Sleep/wake disorders: natural history, epidemiology, and long-term

evolution. New York: Raven Press, 1983:231-235

18. RP, LaBuda MC, Becker PM, Early CJ. Family history study of RLS

patients from two clinical populations [abstract]. Sleep Res 1997;26:537

19. Lazzarini A, Walters AS, Hickey K, Coccagna G, Lugaresi E, Ehrenberg

BL, Picchietti DL, Brin MF, Stenroos ES, Verrico T, WG. Studies of

penetrance and anticipation in five autosomal-dominant restless legs

syndrome pedigrees. Mov Disord 1999;14:111-116

20. Walters AS, Kugler S, Saperstein E, Lewin D, Willis K, Burack G,

England S, Mandelbaum D, Shah M, Thai O, Wagner M. Therapy with

dopaminergic agents in children with both restless legs syndrome/periodic

limb movements of sleep and attention deficit hyperactivity disorder

[abstract]. Sleep 1998;21 Suppl 1:147

21. Wilens TE, Biederman J, Spencer T. Clonidine for sleep disturbances

associated with attention-deficit hyperactivity disorder. J Am Acad Child

Adolesc Psychiatr 1994;33:424-426

22. Nygaard TG, Marsden D, Fahn S. Dopa-responsive dystonia: long-term

treatment response and prognosis. Neurology 1991;41:174-181