Restless sleep disorder in children …

Sleep Disorders

Updated 05.27.2024
Released 12.18.2021
Expires For CME 05.27.2027

Restless sleep disorder in children

Authors: Lourdes M DelRosso MD PhD, Gulcin Benbir Senel MD

See Contributor Disclosures

Editor: Antonio Culebras MD FAAN FAHA FAASM

Restless sleep disorder in children

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Introduction

Overview

Restless sleep disorder is a relatively new pediatric sleep disorder characterized by frequent body movements during sleep and daytime impairment. Since its characterization, potential pathophysiologic mechanisms have been identified, particularly the association with iron deficiency. Alteration in cyclic alternating pattern and heart rate variability brings to light some of the possible contributing mechanisms. Treatment with oral or intravenous iron supplementation has been highly effective. Comorbid parasomnias or other disorders can further contribute to sleep disruption and daytime symptoms. One study has identified that restless sleep disorder may also be present in adults.

Key points

	• Large muscle group movements during sleep characterize restless sleep disorder.
	• Restless sleep disorder presents with significant daytime symptoms, such as sleepiness, hyperactivity, inattention, and cognitive deficits.
	• Children with attention deficit hyperactivity, seizure disorder, or parasomnias may be at higher risk of restless sleep disorder.
	• Children with restless sleep disorder have low ferritin levels.
	• Iron supplementation improves sleep in children with restless sleep disorder.

Historical note and terminology

Sleep medicine is a medical specialty dedicated to identifying, diagnosing, and treating sleep disorders (39). It is well established that sleep is essential for healthy development, growth, cognition, executive function, and emotional regulation, among other important areas of health in children and adults (26). Decades of research have demonstrated the importance of an appropriate amount of sleep. In fact, the American Academy of Sleep Medicine has published an expert consensus position statement that details the number of hours that children of various ages should sleep to avoid consequences of sleep deprivation, which include excessive daytime sleepiness, hyperactivity, and attention deficit (36; 34). Although the recommended total amount of sleep has been determined, assessment of sleep quality has not been equally studied. Sleep interruption can potentially affect sleep quality in a similar manner as sleep deprivation.

According to symptoms, pathophysiology, and presentation, sleep disorders are divided into six main groups: circadian rhythm disorders, insomnia, hypersomnia, sleep-related breathing disorders, parasomnias, and sleep-related movement disorders (37). A large body of literature proves the consequences of sleep disorders in adults, including cardiovascular and neurologic consequences (20; 30; 43), but studies in children are sparse, in particular studies that assess the consequences of sleep-related movement disorders in children (33; 32). Sleep-related movement disorders include restless legs syndrome, periodic limb movements of sleep, rhythmic movement disorders, bruxism, and the recently identified restless sleep disorder (14). Although restless sleep disorder has been identified and characterized in the past couple of years, restless sleep has been described since the early 1980s. In fact, the very first International Classification Of Sleep Disorders published in 1979 defined restless sleep as repetitive and persistent movements during sleep (04). This definition was later removed, but restless sleep has continued to be studied in the setting of poor sleep quality in various medical and sleep disorders (29).

A systematic review of the literature performed by the International Restless Legs Study Group demonstrated that several medical and sleep disorders that presented with restless sleep in children were reported in the literature (16). Obstructive sleep apnea, restless legs syndrome, eczema, pain, and headaches, among others, were some of the most common conditions associated with restless sleep (31; 44; 24). Besides presenting as a symptom of another disorder, the systematic review also demonstrated that restless sleep could be a primary sleep disorder. The International Restless Legs Study Group task force then established consensus diagnostic criteria for restless sleep disorder.

Since then, advances in the literature have demonstrated the presence of restless sleep disorder in other groups, including children with attention deficit hyperactivity disorder (28), epilepsy (06), autism spectrum disorder, and children with parasomnia (38).

Clinical manifestations

Presentation and course

	• Children with restless sleep disorder appear to have an adequate amount of sleep at night.
	• Parents describe sleep as “constant movements through the night.”
	• Daytime symptoms must be present for the diagnosis of restless sleep disorder and can include sleepiness, inattention, behavioral problems, or poor academic performance.
	• Polysomnography is required for the diagnosis of restless sleep disorder.
	• The body movement index should be five or more per hour of sleep.

The most characteristic symptom of restless sleep disorder is frequent movements during sleep.

Frequent movements during sleep (polysomnography)

Polysomnographic finding of large muscle group movement in a child with restless sleep disorder. (A) Beginning of the movement; (B) middle of the movement; (C) end of the movement with repositioning from lateral decubitus to su...

Parents usually describe these movements in various forms, for example, “moves like a helicopter,” “sleeps like a fish,” or “fights in his sleep.” In some cases, children have fallen out of bed and ended up sleeping on a mattress on the floor. These descriptions by the parents have been corroborated by video polysomnography analysis. In fact, in the very first restless sleep disorder descriptive study, video polysomnographic characterization of restless sleep disorder demonstrated that these children move through the night at a rate of approximately five large body movements or repositionings per hour (13). Restless sleep disorder is also a chronic disorder occurring at least three times a week and for at least 3 months. The chronicity of restless sleep disorder is an important consideration, particularly because restless sleep has also been associated with other disorders, and it is important to rule out temporary causes, such as eczema exacerbation, infection, or effect of the surrounding environment (eg, temperature). Parents are also concerned about daytime symptoms because children with restless sleep disorder can present with poor academic performance, excessive daytime sleepiness, behavioral problems, mood disorders, or difficulty with attention or hyperactivity (09). A study assessed cognitive and executive functions in children with restless sleep disorder and showed that selective attention was the most affected area (18).

Early studies compared children with restless sleep disorder to children with restless legs syndrome and identified a lack of leg kicks during sleep in children with restless sleep disorder, whereas children with restless legs syndrome are known to have an increased index of periodic limb movements of sleep in 70% of cases (21). Children with restless legs syndrome tend to present with symptoms of insomnia and the classic “urge to move the legs,” whereas children with restless sleep disorder do not typically present with concerns for insomnia (41). Another important consideration in the differential diagnosis is periodic limb movement disorder; however, identifying periodic limb movement disorder requires an index of periodic limb movements of at least five per hour. Periodic limb movements are characteristic movements that are excluded when counting the large body movements of restless sleep disorder (14).

Although the natural course of restless sleep disorder is unknown, one study suggests that adults could also present with restless sleep disorder (01).

Table 1 summarizes the diagnostic criteria for restless sleep disorder.

Table 1. Diagnostic Criteria for Restless Sleep Disorder (A to H must be met)

A. Complaint of “restless sleep” reported by the patient’s parent, caregiver, or by the patient.

B. Restless sleep involves large muscle groups.

C. The movements occur during sleep.

D. Video-polysomnography shows a total movement index of five or more per hour of sleep.

E. Restless sleep occurs at least three times per week.

F. Restless sleep has been present for at least 3 months.

G. Restless sleep causes clinically significant daytime impairment (sleepiness, irritability, fatigue, mood disturbance, impaired concentration, or impulsivity).

H. The condition is not better explained by another sleep disorder, medical disorder, mental disorder, behavior disorder, environmental factor, or the physiological effects of a substance.

(12)

Prognosis and complications

The long-term consequences of restless sleep disorder are unknown. Parents of children with restless sleep disorder report that the children present with excessive sleepiness, inattention, and behavioral problems. Restless sleep disorder is proposed to exist in adults, but further research is needed.

Biological basis

Etiology and pathogenesis

	• The pathophysiology of restless sleep disorder is unknown.
	• There is evidence suggesting an association between restless sleep disorder and low ferritin levels in children.
	• Children with restless sleep disorder demonstrate changes in cyclic alternating pattern, which can be a marker of sleep instability.
	• Children with restless sleep disorder have increased sympathetic activation during sleep.

Although the pathophysiology of restless sleep disorder is unknown, current research points towards iron deficiency as a main contributing mechanism. Other important findings that help elucidate the underlying mechanism include changes in cyclic alternating pattern and heart rate variability.

Early studies demonstrated that children with restless sleep disorder had low ferritin levels. On average, children with restless sleep disorder were found to have ferritin levels around 20 ng/dl; this finding was lower than the ferritin levels in children with restless legs syndrome (09). Nonanemic brain iron deficiency in patients with restless legs syndrome has been identified and defined as ferritin levels lower than 50 ng/dl. Low iron level represented by low ferritin level is a known contributor to sleep-related movement disorders, mainly by altering dopaminergic pathways involved in motor activity at night (03). Children with restless sleep disorder not only have low ferritin levels at presentation but also demonstrate improvement in sleep patterns and daytime symptoms after supplementation with iron, supporting the pathophysiologic mechanism of iron deficiency (17; 27).

Sleep instability was studied by analyzing a physiological electroencephalographic pattern detected in polysomnography during NREM sleep called cyclic alternating pattern, which is a marker of NREM sleep instability (13). Cyclic alternating pattern cycles include two subtypes (A3 and B). Children with restless sleep disorder had abnormal cyclic alternating pattern characterized by a lower percentage of A3 subtypes than controls, shorter duration of the B phase of the cyclic alternating pattern cycle, and shorter cyclic alternating pattern cycle suggesting abnormalities in sleep stability. Another interesting finding was that movements in children with restless sleep disorder occurred mainly during NCAP periods interrupting the sleep period (35), confirming that the large muscle group movements seen in children with restless sleep disorder during sleep are associated with significant sleep disruption.

During sleep, in particular, during NREM sleep, there is a predominance of parasympathetic activity responsible for slowing the heart rate and lowering blood pressure (42). Increased sympathetic activation has been demonstrated in sleep disorders that disrupt NREM, such as obstructive sleep apnea (19). Heart rate variability is a marker of sympathetic-to-parasympathetic balance (25). Children with restless sleep disorder have demonstrated subtle abnormalities in heart rate variability consistent with increased sympathetic activation during sleep compared to controls (23; 38).

Differential diagnosis

Confusing conditions

It is important to identify restless sleep disorder from other sleep-related movement disorders that present with parental perception of restless sleep (Table 2). The most common disorders that present with restless sleep are obstructive sleep apnea and restless legs syndrome. Video polysomnography is, therefore, indicated to rule out obstructive sleep apnea, periodic leg movement disorder, and nocturnal seizures (45).

Restless legs syndrome can be easily differentiated in children who can express in their own words the urge to move the legs and the improvement in symptoms with the movement of the legs. The other two key diagnostic features of restless legs syndrome include worsening of symptoms in the evening and during rest periods.

Sleep-related rhythmic movement disorders are repetitive, rhythmic movements that usually start early in infancy and rarely persist in children older than 5 years of age. These movements are quite typical and hard to miss. For example, the child rolls back and forth or bangs his head against the pillow repetitively. The movements are also more common during periods of sleep-wake transition and are postulated to be associated with self-soothing mechanisms before sleep (10).

Bruxism is another sleep-related movement disorder equally difficult to miss. The hallmark of bruxism is teeth grinding. A characteristic “grinding” sound is often heard.

Nocturnal epilepsy can present with dystonia, stereotypical movements, and myoclonic movements. These movements occur during the seizure and can be correlated with electroencephalographic findings. Although seizures can occur several times a night, they are usually rare during REM sleep (40).

Children with restless sleep disorder move through the night and in every sleep stage, including REM sleep, with an index of at least five movements per hour. Children with restless sleep disorder do not have leg movements characteristic of periodic leg movement disorder, and the prevalence of comorbid bruxism in other sleep-related movement disorders has not been studied.

Consider evaluation of adults with symptoms of restless sleep and daytime impairment.

Table 2. Differential Diagnosis of Restless Sleep Disorder

	Restless sleep disorder	Restless leg syndrome	Periodic leg movement disorder	Rhythmic movement disorder	Bruxism
Symptoms	Large body movements during sleep	Urge to move legs or leg discomfort in the evening	Sleep disruption	Repetitive rhythmic movements	Tooth grinding
Polysomnography	Body movement index > 5	Increased leg movements	PLMI>5	Rhythmic movements	Increased masseter muscle activity
Treatment	Iron supplementation	Iron supplementation Others	Iron supplementation Others	None	Mouthguard
Family history	Unknown	Often positive	Suspected	Rare	20% to 30% familial pattern
Comorbidities	Epilepsy Parasomnias ADHD	Attention deficit hyperactivity disorder, renal disease, hypothyroidism (02)	Narcolepsy Attention deficit hyperactivity disorder	Restless leg syndrome, obstructive sleep apnea, narcolepsy, attention deficit hyperactivity disorder	Upper airway resistance

Associated or underlying disorders

Iron deficiency is the only disorder that has been associated with restless sleep disorder.

Diagnostic workup

	• All children with restless sleep should have a full physical examination and sleep history.
	• Secondary causes of restless sleep disorder need to be ruled out.
	• Primary restless sleep disorder is diagnosed with polysomnography and diagnostic criteria.
	• Absence of insomnia symptoms and movements through the night are supportive of restless sleep disorder.

Restless sleep in children evaluation algorithm

Suggested algorithm for evaluating children with restless sleep. (Contributed by Dr. Lourdes M DelRosso.)

The evaluation of restless sleep in children should start with a complete medical and sleep history and physical examination. Often conditions or medications that can contribute to restless sleep can be identified at this step, and appropriate measures to improve the disorder can be prescribed. A clear example is eczema. A skin evaluation can identify the typical lesions, and treatment recommendations can be prescribed. Follow-up should be established to ensure improvement in sleep after treatment of a primary medical, psychiatric, or sleep disorder. If a primary cause is not identified, a sleep study or polysomnogram should be ordered. At this stage, other sleep disorders can be identified, such as obstructive sleep apnea and periodic limb movement disorder. Large body movement index can be identified in polysomnography, and the International Restless Legs Study Group criteria should be used to score large muscle group movements (22). A large muscle group movement index of five or more is diagnostic of restless sleep disorder. A single case series report using actigraphy before and after intravenous iron administration in children with restless sleep disorder showed inconsistent results (08). Therefore, actigraphy or other home sleep monitors are currently not recommended for diagnosis of restless sleep disorder.

References

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Authors

Lourdes M DelRosso MD PhD

Dr. DelRosso University of Washington School of Medicine has no relevant financial relationships to disclose.
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Gulcin Benbir Senel MD

Dr. Senel of Istanbul University-Cerrahpasa has no relevant financial relationships to disclose.
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Editor

Antonio Culebras MD FAAN FAHA FAASM

Dr. Culebras of SUNY Upstate Medical University at Syracuse has no relevant financial relationships to disclose.
See Profile

Patient Profile

Age range of presentation: 6 to 18 years
Sex preponderance: No known sex preponderance
Heredity: Unknown heredity
Population groups selectively affected: No population group selectively affected
Occupation groups selectively affected: No occupation group selectively affected

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Restless sleep disorder in children

Associated Disorders

Iron deficiency

Differential Diagnosis

Sleep-disordered breathing
Restless legs syndrome
Periodic limb movement disorder
Sleep-related rhythmic movement disorder
Sleep-related bruxism
- Chronic insomnia disorder
- Asthma (especially if poorly controlled)
- Acute otitis media
- Atopic dermatitis (eczema)
- Pain
- Physiologic effect of a substance (eg, caffeine)

Also Relevant

Drug-induced parasomnias, sleep apnea, and restless legs syndrome
Environmental and behavioral sleep disorders
Obstructive sleep apnea
Restless legs syndrome
Sleep disorders
- Sleep-related rhythmic movement disorder

Clinical Categories

Sleep Disorders

	• Iron supplementation has been effective in treating restless sleep disorder.
	• Oral iron supplementation at 1 to 3 mg/kg per day has been used.
	• Intravenous iron supplementation with ferric carboxymaltose has been effective.
	• Side effects to oral iron include constipation and teeth staining.
	• Side effects to intravenous ferric carboxymaltose include malaise.

Restless sleep disorder in children …

Restless sleep disorder in children

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Diagnostic Criteria for Restless Sleep Disorder (A to H must be met)

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Table 2. Differential Diagnosis of Restless Sleep Disorder

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Media

References

Contributors

Authors

Editor

Patient Profile

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Hypersomnolence

Fatal familial insomnia

Sleep and mental disorders

Sleep paralysis

Sleep and epilepsy

Narcolepsy

Confusional arousal

Restless legs syndrome

	• In a sleep center, the prevalence of restless sleep disorder is 7.7%.
	• Even though other sleep disorders that mimic restless sleep disorder need to be ruled out, restless sleep disorder can coexist with some disorders, particularly attention deficit hyperactivity disorder and parasomnias.

	• Consider education on the consequences of nonanemic iron deficiency.
	• Ensure that children are not iron deficient.
	• Screen for sleep quality and restless sleep.

Restless sleep disorder in children

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Diagnostic Criteria for Restless Sleep Disorder (A to H must be met)

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Table 2. Differential Diagnosis of Restless Sleep Disorder

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Media

References

Contributors

Authors

Editor

Patient Profile

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Hypersomnolence

Fatal familial insomnia

Sleep and mental disorders

Sleep paralysis

Sleep and epilepsy

Narcolepsy

Confusional arousal

Restless legs syndrome

This is an article preview.
Start a Free Account
to access the full version.