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DOI: 10.1542/peds.2006-27672007;120;253Pediatrics
Myers and Luigi Ferini-StrambiDaniel Picchietti, Richard P. Allen, Arthur S. Walters, Julie E. Davidson, Andrew
The Peds REST StudyRestless Legs Syndrome: Prevalence and Impact in Children and Adolescents
http://pediatrics.aappublications.org/content/120/2/253.full.html
located on the World Wide Web at:The online version of this article, along with updated information and services, is
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
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ARTICLE
Restless Legs Syndrome: Prevalence and Impact inChildren and AdolescentsThe Peds REST Study
Daniel Picchietti, MDa, Richard P. Allen,PhDb, Arthur S.Walters,MDc, Julie E. Davidson, MPHd, AndrewMyers,PhDe, LuigiFerini-Strambi,MDf
aUniversity of Illinois and Carle Clinic Association, Urbana, Illinois; bDepartment of Neurology, Johns Hopkins University, Baltimore, Maryland; cSeton Hall University
School of Graduate Medical Education and New Jersey Neuroscience Institute at JFK Medical Center, Edison, New Jersey; dWorldwide Epidemiology, GlaxoSmithKline
R&D, Harlow, United Kingdom; ePremark Services, Crawley Down, United Kingdom; fSleep Disorders Center, Universita Vita-Salute and IRCCS H San Raffaele, Milan, Italy
Financial Disclosure: This project was su pported by GlaxoSmithKline Research and Development. Dr Picchietti receives grant support from the Carle Foundation.
ABSTRACT
OBJECTIVES. Restless legs syndrome, a common neurologic sleep disorder, occurs in
5% to 10% of adults in the United States and Western Europe. Although 25%
of adults with restless legs syndrome report onset of symptoms between the ages
of 10 and 20 years, there is very little literature looking directly at the prevalence
in children and adolescents. In this first population-based study to use specific
pediatric diagnostic criteria, we examined the prevalence and impact of restless
legs syndrome in 2 age groups: 8 to 11 and 12 to 17 years.METHODS. Initially blinded to survey topic, families were recruited from a large,
volunteer research panel in the United Kingdom and United States. Administra-
tion was via the Internet, and results were stratified by age and gender. National
Institutes of Health pediatric restless legs syndrome diagnostic criteria (2003) were
used, and questions were specifically constructed to exclude positional discomfort,
leg cramps, arthralgias, and sore muscles being counted as restless legs syndrome.
RESULTS. Data were collected from 10 523 families. Criteria for definite restless legs
syndrome were met by 1.9% of 8- to 11-year-olds and 2.0% of 12- to 17-year-
olds. Moderately or severely distressing restless legs syndrome symptoms were
reported to occur 2 times per week in 0.5% and 1.0% of children, respectively.
Convincing descriptions of restless legs syndrome symptoms were provided. No
significant gender differences were found. At least 1 biological parent reported
having restless legs syndrome symptoms in 70% of the families, with both
parents affected in 16% of the families. Sleep disturbance was significantly more
common in children and adolescents with restless legs syndrome than in controls
(69.4% vs 39.6%), as was a history of growing pains (80.6% vs 63.2%). Various
consequences were attributed to restless legs syndrome, including 49.5% endors-
ing a negative effect on mood. Data were also collected on comorbid conditions
and restless legs diagnosis rates.
CONCLUSIONS. These population-based data suggest that restless legs syndrome is
prevalent and troublesome in children and adolescents, occurring more commonly
than epilepsy or diabetes.
www.pediatrics.org/cgi/doi/10.1542/
peds.2006-2767
doi:10.1542/peds.2006-2767
This study was presented at the SLEEP
2006 meeting; June 1722, 2006; Salt Lake
City, UT.
KeyWords
restless legs syndrome, prevalence, sleep
disorder, growing pains, attention-deficit/
hyperactivity disorder, depression, anxiety,
children, adolescents
Abbreviations
RLSrestless legs syndrome
NIHNational Institutes of Health
ADHDattention-deficit/hyperactivity
disorder
Accepted for publication Apr 3, 2007
Address correspondence to Daniel Picchietti,
MD, University of Illinois School of Medicine
and Carle Clinic Association, Department of
Pediatrics, 602 W University Ave, Urbana, IL
61801. E-mail: [email protected]
PEDIATRICS (ISSNNumbers:Print, 0031-4005;
Online, 1098-4275). Copyright 2007by the
AmericanAcademy of Pediatrics
PEDIATRICS Volume 120, Number 2, August 2007 253by guest on November 28, 2011pediatrics.aappublications.orgDownloaded from
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RESTLESS LEGS SYNDROME (RLS) is a common neuro-logic sleep disorder in adults characterized by thefollowing diagnostic criteria: an urge to move that is
usually associated with unpleasant sensations, and
symptoms that are worse at rest, relieved by movement,
and most severe at night.1,2 Population-based studies in
adults using these 4 essential diagnostic criteria for RLS
found a prevalence of 5% to 10% in the United Statesand Western Europe.39 In 2 studies, the prevalence of
moderately to severely affected adults, with 2 to 3 days
per week or more of symptoms and a significant impact
on the quality of life, was 2.5%.3,10 Less extensive
studies have found lower prevalence in Asian popula-
tions1113 and in India.14,15 The impact of RLS can be quite
severe, with significant adverse effects in adults on
sleep,16 cognitive function,17,18 mood,19 and quality of
life.3,20 Nonetheless, the condition continues to be signif-
icantly underdiagnosed.10,21
Although Ekbom22,23 reported RLS symptomatology
in childhood as early as the 1940s, it was not until themid-1990s that detailed pediatric case reports with poly-
somnography appeared in the literature.24,25 Other case
reports and case series have followed.2635 Consensus
criteria for the diagnosis of RLS in children and adoles-
cents were published in 2003 after a workshop at the
National Institutes of Health (NIH)2 and are summarized
in Fig 1. The pediatric criteria evolved out of the adults
RLS criteria and 2 previous versions of pediatric crite-
ria.25,36 Two major concepts were incorporated, more
difficult to achieve criteria than in adults for a definitive
diagnosis in children and separate research categories for
less definitive cases. The first was agreed on to avoidoverdiagnosis in children and the second to try and
capture a broader spectrum of RLS in childhood for
research purposes. On the basis of clinical experience
and the development of better language skills in adoles-
cents than in young children, the NIH committee de-
cided to use the adult criteria for adolescents, although
the categories of probable and possible RLS were left
open as an option for research. These new pediatric RLS
criteria were subsequently included in the International
Classification of Sleep Disorders Diagnostic Manual (second
edition).37 Work on pediatric RLS in the past 12 years has
emphasized the familial occurrence of RLS, the associa-
tion with periodic limb movements in sleep, and the
relationship to attention-deficit/hyperactivity disorder
(ADHD) in some cases.38
Studies have indicated that many adults with RLS
retrospectively recall that their symptoms started in
childhood or adolescence. Two such reports noted onset
of RLS for 25% in the 10- to 20-year-old age range.39,40
A pediatric RLS prevalence of 5.9% was found at the
Mayo Clinic pediatric sleep disorders clinic,27 and an-
other study found a prevalence of 1.3% in 12 pediatric
practices.41 In addition, a study that included a question
about leg restlessness at bedtime found this in 6.1% of
Canadian children 11 to 13 years old.42 However, no
published studies have used the essential adult criteria or
the pediatric consensus criteria to assess the prevalence
of RLS in children and adolescents in the general popu-
lation.
The aims of the Peds RLS Epidemiology, Symptoms,
and Treatment (Peds REST) study were to characterize
the epidemiology of pediatric RLS in 2 general popula-tions, in the United Kingdom and United States, as well
as collect data on symptoms, severity, family history,
impact, diagnosis rates, treatments, and comorbidities.
METHODS
Study Population
A random selection of households identified from a
large, volunteer market-research panel in the United
Kingdom and United States were invited to participate in
this survey. Respondents were blinded to the content of
the survey before accepting the invitation, and only 1
survey was permitted per household. Those enrolled
into the survey were households with 1 child in the
eligible age range (817 years inclusive), where the
eligible child was the biological child of the responding
adult and where informed consent was given. When1
child was eligible in a household, the survey child was
selected randomly by using the last-birthday method.43
Figure 2 depicts the selection and enrollment process.
The volunteer market-research panel consisted of
163 000 respondents in the United Kingdom and
128 000 in the United States. Members were originally
enrolled into the panel through an online invitation and
agreed to participate in surveys on a variety of topics
such as leisure, consumer products, and health. Respon-
dents were paid a sum equivalent to approximately $12
or 10 Euros for completing each survey.
Survey Design
The survey consisted of questions about RLS symptoms,
the impact of symptoms on sleep and daytime function,
treatment-seeking behavior, diagnoses, treatments re-
ceived, comorbidities, and family history of RLS (Table
1). The survey consisted of 4 sections with the last 2
sections containing detailed questions for those who
responded positively to earlier questions indicative of
RLS. We stratified by age into 2 groups: 8 through 11
years, inclusive, and 12 through 17 years, inclusive. This
follows US Food and Drug Administration age group-
ings, which are slightly different from NIH age groupings
that have a break point at 13 years rather than 12 years.
In the complete survey, there were 48 total questions
about the 8- to 11-year-olds and 49 about the 12- to
17-year-olds. The surveys were field tested by 6 families,
each with a child or adolescent patient known to have
RLS by expert evaluation. Half were in the younger age
group and half in the older group. The surveys were
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FIGURE 1
NIH Workshop diagnostic criteria for RLS in children (2003). PLMS indicates periodic limb movements in sleep.
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found to perform well in this sample. Where the eligible
child was age 8 to 11 years old, the responding parent
was asked to complete the survey with the child present
for the section that contained questions about leg sen-
sations. Where the eligible child was age 12 to 17, the
sections referring to symptoms experienced, distress, and
consequences were completed by the adolescent. The
survey was administered online and respondents were
routed automatically to relevant questions on the basis
of their responses. The research was conducted from
April 11 to 25, 2005.
RLSCase Definition
On the basis of the pediatric NIH criteria2 (Fig 1), a
survey response-based algorithm for definite and prob-
able RLS, appropriate to each of the 2 age groups, was
developed by an expert panel (Drs Picchietti, Allen,
Walters, and Ferini-Strambi). Case status was evaluated
sequentially, with respondents being assessed first for
definite RLS and then for probable RLS. Where verbatim
descriptors were used in the RLS definitions, the descrip-
tors were reviewed by 3 experts (Drs Picchietti, Allen,
and Walters) in a blinded fashion. The focus of this
article is definite RLS. Although extensive data for prob-
able RLS were collected, probable RLS was only included
in the prevalence analysis, and there as a separate table.
Additional work is planned to assess the role of probable
RLS in the pediatric diagnostic scheme. Moderate-to-
severe RLS was defined as RLS with symptom frequency
of at least twice per week and at least moderate distress
reported (on a 4-point scale: extremely, moderately, a
little, or not at all).
FIGURE 2
Entry of participants into the study.
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There were specific survey questions to exclude sim-
ple positional discomfort, leg cramps, arthralgias, and
sore muscles from being counted as RLS.
Analysis
Analysis was conducted by using the Statistical Package
for the Social Sciences software (SPSS, Inc, Chicago, IL).
When appropriate, differences between groups were
tested by using descriptive tests (eg, 2 test statistic,
Students t statistic) and confidence intervals.
RESULTS
Survey Population
Entry of participants into the study is depicted in Fig 2.
Of 266 686 households invited to participate, 38 548responded in the time frame needed to obtain an ade-
quate sample size. Of those, 12 874 families had a child
in the valid age range, 11 815 consented to participate,
and 11 582 were eligible on the basis of the requirement
that a biological parent complete the survey. A total of
10 523 completed the detailed survey. Thus, 4% of the
total pool was sampled, and of those meeting all eligi-
bility screens, 91% completed the survey. Of the 10 523
children and adolescents, there were 2133 girls and 2192
boys in the 8- to 11-year age range, and in the 12- to
17-year age range there were 2981 girls and 3217 boys.
Of 4325 participants in the 8- to 11-year age range,2092 were from the United Kingdom and 2233 from the
United States. Of 6198 participants in the 12- to 17-year
age range, 2707 were from the United Kingdom and
3491 from the United States. Because prevalence rates
were not significantly different between the United
Kingdom and the United States, data were combined in
each age range for analysis, except for comorbidity data,
which did show significantly different rates of comorbid
diagnoses between countries.
Prevalence of RLSSymptoms
A total of 206 children and adolescents met the diag-
nostic criteria for definite RLS (Table 2). This corre-
sponds with a prevalence of 1.9% for ages 8 to 11
years and 2.0% for ages 12 to 17 years. Of these, 27%
(22 of 81) and 52% (65 of 125), respectively, reported
moderate-to-severe RLS, corresponding with preva-
lence estimates of 0.5% and 1.0%. Criteria for prob-
able 1 RLS were met by an additional 0.7% of 8- to
11-year-olds and 0.3% of 12- to 17-years-olds (Table
3).
No significant gender differences were found in either
age group for definite or probable RLS. See Table 4 for a
TABLE 1 Questionnaire Summary
Section Questions Included
Eligibility screen Presence of child age18 y and childs birth date
Informed consent to participate
Is responding parent the biological parent?
Is child/adolescent currently present in person?
Household demographics
Primary RLS screen Has child or adolescent:
ever experienced uncomfortable feelings or sensations
in their legs and a strong urge to move the legs while
sitting or lying down?a
ever experienced growing painsa
experienced difficulty in falling asleep or staying asleep
at night?a
RLS characteristics Does child or adolescent have difficulties sitting or lying
still in the evening or night?a
Does leg movement seem to make the leg discomfort
better or worse?a
When do these uncomfortable feelings and the need to
move to relieve them seem worst?a
Are symptoms almost always caused by positional
discomfort or muscle cramp?a
Frequency of symptomsa
Parental history of RLS
Additional questions Time of day of symptomsa
Symptoms experienced (from list of 11)a
Most troublesome symptoms (from list of 11)a
Words the child has used to describe the symptoms
(children only)
Effect of symptoms including distress, impact on sleep,
activities, etca
History of medical diagnosis for . . . (from list of 17
conditions)
Age at onset of symptoms
Consulted a healthcare professional in previous 12
months for symptoms? Diagnosis received
Treatments taken
For age 8 to 11 years, all questions answered by biological parent with input from child.a For age 12 to 17 years, questions were answered by the adolescent directly and other ques-
tions answered by biological parent.
TABLE 2 Prevalence ofDefinite RLS: Ages 8 to 17Years
Age, y Survey
Participants
At Least Once per Month At Least 3 Times per
Month
At Least Twice per Week At Least Twice per Week
and Moderate-to-Severe
Distressa
n Prevalence
(95% CI)
n Prevalence
(95% CI)
n Prevalence
(95% CI)
n Prevalence
(95% CI)
811 4325 81 1.9% (1.52.3) 64 1.5% (1.11.8) 40 0.9% (0.61.2) 22 0.5% (0.30.7)
1217 6198 125 2.0% (1.72.4) 119 1.9% (1.62.3) 89 1.4% (1.11.7) 65 1.0% (0.81.3)
Total 10 523 206 2.0% (1.72.2) 183 1.7% (1.52.0) 129 1.2% (1.01.4) 87 0.8% (0.71.0)
CI indicates confidence interval.a Moderate-to-severe RLS.
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detailed analysis of gender data for the definite RLS
groups.
Parents of children 8 to 11 years reported the age at
which uncomfortable feelings in the legs first appeared
in their child as: 5 years old for 15%, 5 to 7 years old
for 63%, and 8 years old for 22%.
Symptoms Reported andPerceived Impactof RLS
Descriptions of RLS
For the children 8 to 11 years old, detailed descriptions
of the RLS feelings were obtained because in this age
range urge and a description in the childs own words,
consistent with leg discomfort are required for the def-
inite 1 category (Fig 1). Examples of the descriptions
provided by participants are in Table 5.
Growing Pains
Children and adolescents with definite RLS were signif-
icantly more likely to report experience of growing
pains compared with those who did not meet the cri-
teria for definite or probable RLS (overall 80.6% vs
63.2%; P .001). Table 6 lists percent with a history of
growing pains by age category.
Distress
When asked how distressing the RLS symptoms were
(extremely, moderately, a little, or not at all), 22.2% (18
of 81) of responding parents of the 81 children who met
definite RLS criteria reported that the symptoms were
extremely distressing to their children, 32.1% (26 of 81)
reported moderate distress, 39.5% (32 of 81) reported a
little distress, and 6.2% (5 of 81) stated the symptomswere not at all distressing. Adolescents meeting definite
RLS criteria (n 125) were asked directly about their
level of distress, and 23.2% (29 of 125) reported extreme
distress, 40.8% (51 of 125) moderate distress, 31.2% (39
of 125) a little distress, and 4.8% (6 of 125) no distress.
Respondents were asked to select from a list the RLS
symptoms that they experienced. See Fig 3A for the
proportions of respondents reporting each symptom. In
response to a question about which symptoms were
most troublesome, adolescents with RLS reported inabil-
ity to get comfortable (32.0%) and inability to stay still/
urge to move (29.6%), whereas parents of children with
RLS reported inability to get comfortable (30.9%) and
pain (22.2%) to be the most bothersome to their child.
Figure 3B provides symptom rates for children and ad-
olescents with moderate-to-severe RLS, which were typ-
ically higher than all with RLS. For most symptoms there
were not significant differences between children and
adolescents (Fig 3).
Sleep Disturbance
Children and adolescents with definite RLS were signif-
icantly more likely to have a history of difficulty falling
asleep or staying asleep at night, compared with those
who did not meet the criteria for definite or probable
RLS (overall: 69.4% vs 39.6%; P .001). Table 7 lists
the percentage with difficulty falling asleep or staying
asleep by age category. Adolescents with definite RLS
reported sleeping for a mean of 7.1 (median: 7) hours on
a school night. Hours of reported sleep was not available
for the 8- to 11-year-olds. Parents of 8- to 11-year-olds
with definite RLS reported a mean of 2.1 (median: 2)nights of disturbed sleep per week for their children,
whereas adolescents with definite RLS reported dis-
turbed sleep with a mean frequency of 3.2 (median: 3)
nights per week. This figure for adolescents is signifi-
cantly higher on average (t 4.0529; df 204; P .001)
than it is for the children. A total of 83.9% of parents of
children with definite RLS reported that their child,
when suffering from RLS symptoms, took 30 minutes
to fall asleep and would wake up on average 1.9 (SD:
1.5) times per night. A total of 77.6% of adolescents with
definite RLS reported taking 30 minutes on average to
TABLE 3 Prevalence of ProbableRLS: Age8 to 17Years
Age, y Survey
Participants
At Least Once per Month At Least 3 Times per
Month
At Least Twice per Week At Least Twice per Week
and Moderate-to-Severe
Distressa
n Prevalence
(95% CI)
n Prevalence
(95% CI)
n Prevalence
(95% CI)
n Prevalence
(95% CI)
811 4325 29 0.7% (0.40.9) 22 0.5% (0.30.7) 14 0.3% (0.20.5) 6 0.1% (0.00.2)
1217 6198 18 0.3% (0.20.4) 17 0.3% (0.10.4) 14 0.2% (0.10.3) 7 0.1% (0.00.2)
Total 10 523 47 0.4% (0.30.6) 39 0.4% (0.30.5) 28 0.3% (0.20.4) 13 0.1% (0.10.2)
CI indicates confidence interval.a Moderate-to-severe RLS; met probable 1 RLS criteria.
TABLE 4 Definite RLS:Gender Analysis
Age, y n (%)
RLS Moderate-to-Severe RLS
Male Female Male Female
811 39 (48.1) 42 (51.9) 13 (59.1) 9 (40.9)
1217 72 (57.6) 53 (42.4) 39 (60.0) 26 (40.0)
Total 111 (53.9) 95 (46.1) 52 (59.8) 35 (40.2)
Percentages are percent of male-female total.Moderate-to-severeRLS: at least twiceper week
andmoderate-to-severe distress. Allmale-femaledifferencesare nonsignificant by Pearson2.
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get to sleep when suffering from RLS symptoms and
would wake a mean of 2.5 (SD: 1.8) times a night.
Daytime sleepiness was reported in 21.0% of 8- to
11-year-olds and 33.6% of 12- to 17-year-olds with
definite RLS.
Perceived Consequences
Respondents were asked to select from a list of potential
correlates that they thought were related to their leg
discomfort (Fig 4A). For children with definite RLS, the
most commonly reported consequence of RLS symptoms
listed by parents was a negative influence on the childs
mood (53.1%), followed by an inability to sit still in the
afternoon or evening (46.9%), and next a lack of energy(29.6%). The most frequent effect of RLS symptoms
listed by adolescents with RLS was an inability to sit still
in the late afternoon or evening (60.8%), followed by a
negative influence on mood (47.2%), a lack of energy
(40.8%), and an inability to concentrate on schoolwork/
work (40.0%). For those with moderate-to-severe RLS,
many of the reported consequences were more preva-
lent, including a negative influence on mood and a lack
of energy (Fig 4B). For most perceived consequences,
there were not significant differences between children
and adolescents (Fig 4).
RLSDiagnoses, Treatment, FamilyHistory, andComorbid
Conditions
RLS Diagnoses
Consulting patterns for all children and adolescents with
definite RLS were investigated. Of the 81 children with
definite RLS, 38 (46.9%) were reported to have had 1
medical consultation for RLS symptoms in the 12
months before the survey and of 125 adolescents with
definite RLS, 64 (51.2%) reported a consultation. In
response to the question What diagnosis, if any, has
your child been given for these symptoms? the mostcommon medical explanation reported as given for the
RLS symptoms was the same for both children (16 of 38
consulting) and adolescents with definite RLS (29 of 64
consulting), namely that the symptoms were part of
normal development (44.1%). The percentage of those
whose medical consultation for RLS symptoms produced
a diagnosis of RLS was 23.7% (9 of 38) for children with
definite RLS and 21.9% (14 of 64) for adolescents with
definite RLS. The overall rates of a medical diagnosis of
RLS for all of those with definite RLS was, therefore,
11.1% (9 of 81) of children and 11.2% (14 of 125) of
adolescents.
Of the 22 children meeting the criteria for moderate-
to-severe RLS, 11 (50.0%) parents reported medical
consultation about the childs symptoms in the last 12
months, and of these, 3 (27.3%) reported that the child
received a diagnosis of RLS. Correspondingly, the par-
ents of 41 of 65 adolescents (63.1%) with moderate-to-
severe RLS reported that health care had been sought for
the RLS symptoms in the last 12 months, with 10
(24.4%) of 41 reporting a subsequent RLS diagnosis.
Thus, overall rates of medical diagnosis of RLS in the
moderate-to-severe groups were: 13.6% (3 of 22) for
children and 15.4% (10 of 65) for adolescents.
TABLE 5 Descriptionsof Sensory Complaints: Age8 to 11Years
Legs need to stretch
Ouchie
Too much energy, I really have to move
Ants crawling and aching feeling
Twitchy, jerky
My legs need a walk/jog
Legs feel full of energy; funny feelings in the legs, aching
Throbbing-ache; have the need to want to run; blood racing through legsI have to keep moving
It hurts, I cant sleep; when I try my legs tingle and I hurt
Legs hurt, cant go to sleep
Legs hurt and feel funny
She screams It hurts at bedtime
Nervous, need to be jiggled
Runaway legs, tweaky legs
At night my legs tingle and tickle; I want to be still but if I do they hurt my feet;
that is why I kick myself at night
Tingly, fuzzy, pressure
Tickly inside the leg
Crampy, uncomfortable
Fidgety, restless, too much energy
My legs cant get comfortable, they want to move around on their own
I feel like my legs wont be still
Legs feeling giggly or jumpy
They ache and feel awful
He says it feels like therere bugs in his bones
My legs feel funny; I want to move them; I feel frustrated; I cant sleep
That her legs felt creepy crawly
Like electricity flowing
I have a hard time falling asleep when my legs want to keep going; they feel
jumpy
Antsy, excited, exploding
My legs feel funny, they kinda hurt and I want to move them; I cant get
comfortable
Feel like they want to jump off my body; make me want to run and run until I
cant run any more
Ticklish legs, like jumping beansI feel like I need to shake my legs like my dad does
Fizzy legs; need to kick out, stretch out legs
Spider in her legs
Statements are in response to question 15: What words has your child used to describe the
discomfort in their legs?
TABLE 6 History of GrowingPains
RLS Status Age 811 y (N 4296) Age 1217 y (N 6180)
n % n %
No RLS 2571/4215 61.0 3924/6055 64.8
Definite RLS 69/81 85.2a 97/125 77.6b
Data are from question 2: Do they, or have they, experienced growing pains? answered by
parent. Note: percentages in Table 8 are for a medical diagnosis of growing pains rather than a
simple history of growing pains.a Pearson 2 for 8 to 11 years 27.214 (P .001).b Pearson 2 for 12 to 17 years 16.213 (P .001).
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Treatment
Ongoing treatment with prescription medication for
children and adolescents with definite RLS was reported
low, but similar: 6.2% (5 of 81) and 6.4% (8 of 125),
respectively. However, in only 3 cases total (1.5%) were
the medications listed those that might be considered
appropriate in the adult RLS literature44,45: ropinirole
(n 1) and codeine (n 2). Others listed for RLS
treatment were amitriptyline, celecoxib, methylpheni-
date, amphetamine/dextroamphetamine, atomoxetine,
coproxamol, and a topical antiinflammatory agent.
Clonidine and clonazepam were not mentioned.
FIGURE 3
A, Symptoms reported: childrenand adolescents with definiteRLS. B, Symptoms reported: children and adolescentswith moderate-to-severe RLS.a Significantdifference 8 to 11 vs12
to 17 years at the P .05 level.
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Family History of RLS
A family history of RLS was common in the definite 1
RLS group for children (n 70) and the definite RLS
group for adolescents (n 125). The definite 2 RLS
group for children (n 11) was not included for this
analysis because the presence of a first-degree relative
with RLS is part of entry criteria for this group (Fig 1). At
least 1 parent responding positively to the RLS question
was found in 71.4% (50 of 70) of the definite 1 RLSchildren and in 80.0% (100 of 125) of the definite RLS
adolescents. Both parents responding positively to the
RLS question was found in 17.1% (12 of 70) and 16.0%
(20 of 125) of families, respectively. Gender analysis of
parental RLS found 44 mothers and 18 fathers positive
for RLS of definite 1 RLS 8- to 11-year-olds, and 83
mothers and 37 fathers of definite RLS 12- to 17-year-
olds, resulting in parental female to male ratios of 2.4:1
and 2.2:1, respectively.
We compared children and adolescents meeting the
diagnostic criteria for RLS and having a positive family
history of RLS to those meeting the diagnostic criteria
but having no family history RLS. There were no signif-
icant differences for sleep disturbance (question 3) or for
any of the perceived consequences listed in Fig 4A (P
.05).
Comorbidity
A question on medical history was included in the sur-
vey, and respondents were asked to select from a list
which, if any, diagnoses had been received. The list
consisted of diagnoses that might potentially confound,
mimic, or interact with RLS (Table 8). As expected, a
medical diagnosis of growing pains (29.6% of children
and 36.8% of adolescents with RLS) was the most com-
mon diagnosis reported. These data on a medical diag-
nosis of growing pains should not be confused with the
data in Table 6, which refer to a history of growing pains
in response to the question Do they, or have they,
experienced growing pains? answered by the parent.
Other common medical diagnoses were attention-deficit
disorders (14.8% and 17.6%, respectively), depression
(3.7% and 14.4%, respectively), and anxiety disorders
(4.9% and 8.0%, respectively). Children or adolescents
with RLS in the United States were more likely to have
received a diagnosis for an attention-deficit disorder,
depression, or an anxiety disorder than children or ad-
olescents with RLS in the United Kingdom.
DISCUSSION
To our knowledge, this is the first large-scale, popula-
tion-based study of RLS prevalence and impact in chil-
dren and adolescents and is the first to use specific
pediatric RLS definitions in a general population survey.The most important finding in this study was the high
prevalence of definite RLS, 1.9% of children 8 to 11
years old and 2.0% of adolescents 12 to 17 years old. In
addition, about one quarter of the children and one half
of the adolescents with definite RLS met criteria for
moderate-to-severe RLS. The approximate 2% preva-
lence in 8- to 17-year-olds exceeds that of nonfebrile
seizure disorders (0.5%) and diabetes type 1 and 2
combined (1%) in this same age range, and is similar
to estimates of pediatric obstructive sleep apnea
(2%).37,46 This RLS prevalence is consistent with 7 large
epidemiologic studies in adults, which have found a 5%to 10% prevalence in the United States and Western
Europe,39 when adjusted for the fact that 25% of adult
RLS patients reported in 2 different studies onset of RLS
between 10 to 20 years old.39,40 This would give a pre-
dicted prevalence of 1.25% to 2.5%, surprisingly close
to the results from this survey. The only other pediatric
population-based study related to RLS that we are aware
of is a longitudinal study of French-Canadian children
that included a question about leg restlessness at bed-
time and found 6.1% of 1353 children ages 11 to 13
years to consistently have this complaint.42 Adding in the
other RLS diagnostic criteria would be expected to re-duce this number appreciably. Also, it should be noted
that the French-Canadian population has one of the
highest reported general-population RLS prevalence
rates, estimated at 15% to 20%.47,48
We found the prevalence of RLS in boys and adoles-
cent males similar to girls and adolescent females, which
is in sharp contrast to adult RLS studies that have con-
sistently reported a 2:1 female to male ratio. 4 Although
our survey emphasized current symptoms, parents re-
ported recall of onset of RLS in the 8 to 11-year-olds at
5 years of age in 15% and 5 to 7 years old in 63%,
indicating that children younger than those included in
our study may be affected by RLS.
The descriptions of RLS feelings reported by the 8- to
11-year-olds (Table 5) provided convincing data to us
that this survey did successfully measure restless legs
symptomatology. Themes of bug-like sensations, ticklish
feelings, electricity, jumpiness, and energy were com-
mon and are consistent with our extensive clinical ex-
perience diagnosing RLS in children and adolescents. A
history consistent with RLS was reported by more than
two thirds of parents of the definite RLS children and
adolescents, supporting this aspect as helpful in the di-
agnostic criteria for RLS in children and adolescents. 49 Of
TABLE 7 DifficultyFalling Asleep or Staying Asleep atNight
RLS Status Age 811 y (N 4296) Age 1217 y (N 6180)
n % n %
No RLS 1427/4215 33.9 2639/6055 43.6
Definite RLS 55/81 67.9a 88/125 70.4b
Data are from question 3: Does your child have difficulty falling asleep or staying asleep?
answered by parent.a
Pearson 2
for 8 to 11 y 45.944 (P .001).b Pearson 2 for 12 to 17 y 35.680 (P .001).
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note, there were a remarkable number of families in
which both parents reported RLS symptoms (1 of 6
families). This extra genetic load may play a role in the
age of onset and severity of RLS in childhood. The in-
creased prevalence of RLS symptoms in mothers com-
pared with fathers is consistent with adult prevalence
studies, which have shown an approximate 2:1 ratio of
females to males.4 Parity is considered a major factor in
explaining this gender difference.4
It is likely that primary and secondary RLS cases are
included in our data. Although Table 8 lists 17 medical
diagnoses that we asked about, we did not include a
question about all active medical conditions, we did not
ask about all current medications, and this large survey
FIGURE 4
A, Perceived consequences: childrenand adolescentswith definiteRLS. B, Perceived consequences:children and adolescentswith moderate-to-severeRLS.a Significant difference 8 to
11 vs 12 to 17 years at the P .001 level; b significant difference 8 to 11 vs 12 to 17 years at the P .05 level.
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did not include screening laboratory tests. Known causes
of secondary RLS include renal failure, pregnancy, pe-
ripheral neuropathy, and some medications.50,51 None-
theless, it is probable that the majority of our cases are
primary RLS given the relatively low occurrence of these
factors in the age range studied and the predominance of
primary RLS in cases with onset before age 45.52 We did
find self-reported medical diagnoses of anemia or irondeficiency, which are known aggravating factors for
RLS, in 2.5% children 8- to 11-year- olds and 4.8% 12-
to 17-year-olds.
Growing Pains
Beginning with Ekboms work on RLS in the 1940s to
1970s, there has been controversy over the relationship
of growing pains to childhood RLS.23,35,53 We believe our
data shed some light on this issue. A history of growing
pains was common in 8- to 17-year-olds with RLS (over
three quarters), but it was also common in those withoutRLS (almost two thirds). Although statistically signifi-
cant and useful for group data, this difference is not
likely to be a key factor in the decision as to whether an
individual patient has RLS. However, we have found
growing pains to be a clinically useful lead-in question
to a more specific discussion of RLS symptoms. Perhaps
more relevant is the disparately high medical diagnosis
rate of growing pains in children with RLS compared
with a low medical diagnosis of RLS (Table 8), suggesting
that the much more specific diagnosis of RLS was missed
and that an opportunity for treatment was also missed.
Impact
The impact of RLS in children and adolescents seems to
be substantial. The frequency and severity of RLS feel-
ings were reported as moderate-to-severe in about one
quarter of the 8- to 11-year-olds and about half of the
12- to 17-year-olds (at least twice per week and moder-
ately or extremely distressing). Sleep disturbance was
very commonly reported in the children and adolescentsmeeting criteria for definite RLS, exceeding two thirds,
and much more than in those without RLS (Table 7).
Perceived consequences of RLS were common, with dif-
ficulty sitting in the late afternoon or evening, a negative
effect on mood, a lack of energy, and an inability to
concentrate frequently reported in the definite RLS
groups, and even more pronounced in the moderate-to-
severe RLS groups (Fig 4). Given the emerging literature
on the effect of sleep disturbance on cognitive and af-
fective function in children and adolescents, these as-
pects are of notable concern.5460 It has been our experi-
ence that in more severe cases of pediatric RLS,treatment can be of benefit. However, it should be noted
that there are currently no US Food and Drug Adminis-
trationapproved treatments for RLS in children and
adolescents.
Diagnosis and Treatment
Our data indicate that RLS is uncommonly diagnosed in
children and adolescents, even for those who reported
that they sought medical care for the symptoms. Less
than 1 in 4 who sought medical care received an RLS
diagnosis, with diagnosis rates only marginally better for
TABLE 8 Self-ReportedMedical Diagnoses: Children andAdolescentsWithDefinite RLS
%
United Kingdom
(N 90)
United States
(N 116)
United Kingdom and United States
(N 206)
811 y
(n 35)
1217 y
(n 55)
811 y
(n 46)
1217 y
(n 70)
811 y
(n 81)
1217 y
(n 125)
Growing painsa 22.9 29.1 34.8 42.9 29.6 36.8
ADD/ADHD 2.9 3.6 23.9 28.6 14.8 17.6
Depression 0.0 12.7 6.5 15.7 3.7 14.4
Restless legs 2.9 10.9 15.2 12.9 9.9 12.0
Anxiety disorder 0.0 1.8 8.7 12.9 4.9 8.0
Insomnia 0.0 3.6 2.2 11.4 1.2 8.0
Sleep disorder 5.7 3.6 4.3 7.1 4.9 5.6
Anemia/iron deficiency 2.9 3.6 2.2 5.7 2.5 4.8
Mental disability 2.9 1.8 0.0 7.8 1.2 4.8
Sleep apnea 0.0 3.6 2.2 5.7 1.2 4.8
Seizures/epilepsy 0.0 5.5 0.0 2.9 0.0 4.0
Nighttime cramps 2.9 3.6 2.2 2.9 2.5 3.2
Spinal injury/disk problems/sciatic pain 0.0 1.8 0.0 2.9 0.0 2.4
Tourettes syndrome 0.0 0.0 0.0 2.9 0.0 1.6
Rheumatoid arthritis 0.0 1.8 0.0 0.0 0.0 0.8
Periodic limb movement disorder 0.0 0.0 0.0 0.0 0.0 0.0Diabetes 0.0 0.0 0.0 0.0 0.0 0.0
aThese data report a medical diagnosis of growing pains compared with the simple history of growing pains reported in Table 6.
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those moderately to severely affected. Most often a med-
ical explanation of normal development was reported.
Because RLS is not generally recognized as a medically
significant disorder, there may be a tendency to discount
these symptoms as unimportant or interpret them as an
expression of more familiar medical conditions. In cases
where medication was prescribed, only 1 of the medica-
tions reported would be considered first-line treatmentfor RLS in the adult literature.1,45
Because this was a survey and not a clinical evalua-
tion, it is possible that other diagnoses could explain the
symptoms of the children and adolescents who met def-
inite RLS criteria in our study. However, the extensive
inclusion and exclusion criteria used in this study, as
well as rigorous application of NIH criteria, make this
unlikely in our opinion. It should be noted that the NIH
definite RLS criteria in those 12 years old requires
more symptoms than are required for a diagnosis in
adults. This was devised to avoid overdiagnosis in chil-
dren. More likely, the low medical diagnosis rates of RLSreflect a lack of awareness among those providing med-
ical care for children and adolescents. In 2 major US
pediatric textbooks RLS is mentioned sparingly, a total of
2 paragraphs.46,61 Low awareness of RLS has been docu-
mented for those who provide health care for adults,
although there is evidence that awareness is improv-
ing.3,21,62
Comorbidity
Comorbidity of definite RLS with medically diagnosed
ADHD, depression, and anxiety disorders in our study is
of interest. These all were found at rates higher thandiagnosis rates reported in the general pediatric popula-
tion,63,64 but caution regarding these findings is war-
ranted given the small sample size in some of the cells. In
addition, there were much lower diagnosis rates in the
United Kingdom than in the United States, perhaps re-
flecting lower occurrence but more likely because of
higher diagnosis and treatment rates of some behavioral
conditions in the United States than in the United King-
dom and Europe.65,66 There is considered to be a complex
relationship between ADHD and sleep disorders in chil-
dren, and a substantial literature exists.38,58,67,68 In adults
with RLS, there are increased rates of depression,19 anx-
iety,69,70 and ADHD71 compared with the general popu-
lation. Although various theories exist, there is some
evidence that RLS and these conditions have a negative
interactive effect with each other, and that their associ-
ation may reflect some shared common pathology.19,67
Limitations
Methodologic issues should be considered in the inter-
pretation of our results. First, the ascertainment of RLS
status was by self-report via the parents or adolescents,
not by clinical interview. Although it is possible that
other conditions could have been reported as RLS symp-
tomatology, a detailed set of questions to exclude known
mimics of RLS was part of the survey. It is reassuring that
there were low rates of diabetes, arthritis, and sciatic
problems in the RLS cases found, because these are
known confounders of the diagnosis in adults. Also, in
the clinical setting the diagnosis of RLS is based on
history, not requiring physical examination for a positive
diagnosis. Second, our survey was conducted in a con-venience sample of Internet users. United Kingdom cen-
sus data suggest that 55% of households in the United
Kingdom had Internet access in July 2005.72 US census
data from October 2003 provided by the US Department
of Commerce indicated that 55% of households in the
United States had Internet access and that access was
strongly associated with income.73 However, by spring
2004 the Internet usage rate was measured at 63% for
adults in the United States, and the income gap was
closing.74 To the extent that the prevalence of RLS, par-
ent observation of symptoms, and health care utilization
are associated with factors influencing Internet use orpropensity to volunteer in research surveys, our results,
like those from all similar population studies, may be
biased. Third, the 10 523 participating households rep-
resents a 4% subset of the initially invited households,
which itself is a subset of the total United Kingdom and
US households. To limit enrollment bias we did not
disclose the specific survey topic until all eligibility cri-
teria were met and enrollment was terminated after the
2 weeks it took to obtain an adequate sample size.
Fourth, although the NIH pediatric RLS diagnostic crite-
ria are a consensus of expert opinion, these criteria have
not been validated extensively in the clinical setting.Fifth, in families where there was a parent with RLS, it
is possible that those parents would have been more
likely to identify the symptoms in their children influ-
encing the prevalence rates in familial cases. Having the
adolescents complete the RLS questions directly and
having the younger children present when the parent
completed the questions about sensory symptoms
should have reduced this type of bias.
CONCLUSIONS
This large, population-based study found restless legs to
be quite prevalent in children and adolescents aged 8 to
17 years. Many of these children and adolescents hadmoderately to severely distressing symptoms and re-
ported that RLS adversely affected both sleep and day-
time function. Medical diagnosis rates of RLS were low,
and treatment was uncommon.
ACKNOWLEDGMENT
We thank Trevor Brown of Premark, Inc, for assistance
in organizing this project.
REFERENCES
1. Earley CJ. Clinical practice. Restless legs syndrome. N Engl
J Med. 2003;348:21032109
264 PICCHIETTI et alby guest on November 28, 2011pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/7/30/2019 The PEDS Rest Study: Restless Legs Syndrome
14/16
2. Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS,
Montplaisir J. Restless legs syndrome: diagnostic criteria, spe-
cial considerations, and epidemiology: a report from the rest-
less legs syndrome diagnosis and epidemiology workshop at
the National Institutes of Health. Sleep Med. 2003;4:101119
3. Allen RP, Walters AS, Montplaisir J, et al. Restless legs syn-
drome prevalence and impact: REST general population study.
Arch Intern Med. 2005;165:12861292
4. Berger K, Luedemann J, Trenkwalder C, John U, Kessler C. Sex
and the risk of restless legs syndrome in the general population.
Arch Intern Med. 2004;164:196 202
5. Bjorvatn B, Leissner L, Ulfberg J, et al. Prevalence, severity and
risk factors of restless legs syndrome in the general adult pop-
ulation in two Scandinavian countries. Sleep Med. 2005;6:
307312
6. Hogl B, Kiechl S, Willeit J, et al. Restless legs syndrome: a
community-based study of prevalence, severity, and risk fac-
tors. Neurology. 2005;64:19201924
7. Tison F, Crochard A, Leger D, Bouee S, Lainey E, El Hasnaoui
A. Epidemiology of restless legs syndrome in French adults: a
nationwide surveythe INSTANT Study. Neurology. 2005;65:
239246
8. Ulfberg J, Nystrom B, Carter N, Edling C. Prevalence of restless
legs syndrome among men aged 18 to 64 years: an associationwith somatic disease and neuropsychiatric symptoms. Mov Dis-
ord. 2001;16:1159 1163
9. Ulfberg J, Nystrom B, Carter N, Edling C. Restless legs syn-
drome among working-aged women. Eur Neurol. 2001;46:
1719
10. Hening W, Walters AS, Allen RP, Montplaisir J, Myers A,
Ferini-Strambi L. Impact, diagnosis and treatment of restless
legs syndrome (RLS) in a primary care population: the REST
(RLS epidemiology, symptoms, and treatment) primary care
study. Sleep Med. 2004;5:237246
11. Mizuno S, Miyaoka T, Inagaki T, Horiguchi J. Prevalence of
restless legs syndrome in non-institutionalized Japanese el-
derly. Psychiatry Clin Neurosci. 2005;59:461 465
12. Sevim S, Dogu O, Camdeviren H, et al. Unexpectedly low
prevalence and unusual characteristics of RLS in Mersin, Tur-
key. Neurology. 2003;61:15621569
13. Tan EK, Seah A, See SJ, Lim E, Wong MC, Koh KK. Restless
legs syndrome in an Asian population: a study in Singapore.
Mov Disord. 2001;16:577579
14. Bhowmik D, Bhatia M, Tiwari S, et al. Low prevalence of
restless legs syndrome in patients with advanced chronic renal
failure in the Indian population: a case controlled study. Ren
Fail. 2004;26:6972
15. Krishnan PR, Bhatia M, Behari M. Restless legs syndrome in
Parkinsons disease: a case-controlled study. Mov Disord. 2003;
18:181185
16. Allen RP, Earley CJ. Validation of the Johns Hopkins restless
legs severity scale. Sleep Med. 2001;2:239242
17. Pearson VE, Allen RP, Dean T, Gamaldo CE, Lesage SR, EarleyCJ. Cognitive deficits associated with restless legs syndrome
(RLS). Sleep Med. 2006;7:2530
18. Abetz L, Allen R, Washburn T, Early C. The impact of restless
legs syndrome (RLS) on sleep and cognitive function. Eur
J Neurol. 2004;9(suppl 2):50
19. Picchietti D, Winkelman JW. Restless legs syndrome, periodic
limb movements in sleep, and depression. Sleep. 2005;28:
891898
20. Abetz L, Allen R, Follet A, et al. Evaluating the quality of life of
patients with restless legs syndrome. Clin Ther. 2004;26:
925935
21. Van De Vijver DA, Walley T, Petri H. Epidemiology of restless
legs syndrome as diagnosed in UK primary care. Sleep Med.
2004;5:435440
22. Ekbom KA. Restless legs: a clinical study. Acta Med Scand
(Suppl). 1945;158:1122
23. Ekbom KA. Growing pains and restless legs. Acta Paediatr Scand.
1975;64:264266
24. Walters AS, Picchietti DL, Ehrenberg BL, Wagner ML. Restless
legs syndrome in childhood and adolescence. Pediatr Neurol.
1994;11:241245
25. Picchietti DL, Walters AS. Restless legs syndrome and periodic
limb movement disorder in children and adolescents: comor-
bidity with attention-deficit hyperactivity disorder. Child Ado-
lesc Psychol Clin North Am. 1996;5:729740
26. Chervin RD, Archbold KH, Dillon JE, et al. Associations be-
tween symptoms of inattention, hyperactivity, restless legs,
and periodic leg movements. Sleep. 2002;25:213218
27. Kotagal S, Silber MH. Childhood-onset restless legs syndrome.
Ann Neurol. 2004;56:803807
28. Konofal E, Arnulf I, Lecendreux M, Mouren MC. Ropinirole in
a child with attention-deficit hyperactivity disorder and restless
legs syndrome. Pediatr Neurol. 2005;32:350351
29. Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleep-
walking and sleep terrors in prepubertal children: what triggers
them? Pediatrics. 2003;111(1). Available at: www.pediatrics.
org/cgi/content/full/111/1/e17
30. Happe S, Treptau N, Ziegler R, Harms E. Restless legs syndromeand sleep problems in children and adolescents with insulin-
dependent diabetes mellitus type 1. Neuropediatrics. 2005;36:
98103
31. Kryger MH, Otake K, Foerster J. Low body stores of iron and
restless legs syndrome: a correctable cause of insomnia in
adolescents and teenagers. Sleep Med. 2002;3:127132
32. 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;13:588594
33. Picchietti DL, Underwood DJ, Farris WA, et al. Further studies
on periodic limb movement disorder and restless legs syn-
drome in children with attention-deficit hyperactivity disorder.
Mov Disord. 1999;14:10001007
34. Picchietti DL, Walters AS. Moderate to severe periodic limb
movement disorder in childhood and adolescence. Sleep. 1999;
22:297300
35. Rajaram SS, Walters AS, England SJ, Mehta D, Nizam F. Some
children with growing pains may actually have restless legs
syndrome. Sleep. 2004;27:767773
36. Hornyak M, Happe S, Trenkwalder C, Scholle S, Schluter B,
Kinkelbur J. Restless legs syndrome in childhood: a consensus
proposal for diagnostic criteria. Somnologie. 2002;6:133137
37. American Academy of Sleep Medicine. International Classifica-
tion of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed.
Westchester, IL: American Academy of Sleep Medicine; 2005
38. Cortese S, Konofal E, Lecendreux M, et al. Restless legs syn-
drome and attention-deficit/hyperactivity disorder: a review of
the literature. Sleep. 2005;28:1007101339. Walters AS, Hickey K, Maltzman J, et al. A questionnaire study
of 138 patients with restless legs syndrome: the Night-
Walkers survey. Neurology. 1996;46:9295
40. Montplaisir J, Boucher S, Poirier G, Lavigne G, Lapierre O,
Lesperance P. Clinical, polysomnographic, and genetic charac-
teristics of restless legs syndrome: a study of 133 patients
diagnosed with new standard criteria. Mov Disord. 1997;12:
6165
41. Kinkelbur J, Hellwig J, Hellwig M. Frequency of RLS symp-
toms in childhood. Somnologie. 2003;7(suppl 1):34
42. Laberge L, Tremblay RE, Vitaro F, Montplaisir J. Development
of parasomnias from childhood to early adolescence. Pediatrics.
2000;106:6774
43. Oldendick RW, Bishop GF, Sorenson SB, Tuchfarber AJ. A
PEDIATRICS Volume 120, Number 2, August 2007 265by guest on November 28, 2011pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/7/30/2019 The PEDS Rest Study: Restless Legs Syndrome
15/16
comparison of the Kish and last birthday methods of respon-
dent selection in telephone surveys. J Off Stat. 1988;4:307318
44. 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;22:970999
45. Silber MH, Ehrenberg BL, Allen RP, et al. An algorithm for the
management of restless legs syndrome. Mayo Clin Proc. 2004;
79:916922
46. Behrman RE, Kliegman R, Jenson HB. Nelson Textbook of Pedi-
atrics. Philadelphia, PA: Saunders; 2004
47. Lavigne GJ, Montplaisir JY. Restless legs syndrome and sleep
bruxism: prevalence and association among Canadians. Sleep.
1994;17:739743
48. Auger C, Montplaisir J, Duquette P. Increased frequency of
restless legs syndrome in a French-Canadian population with
multiple sclerosis. Neurology. 2005;65:16521653
49. Guttmacher AE, Collins FS, Carmona RH. The family history:
more important than ever. N Engl J Med. 2004;351:23332336
50. Gamaldo CE, Earley CJ. Restless legs syndrome: a clinical up-
date. Chest. 2006;130:1596 1604
51. Davis ID, Baron J, ORiordan M A, Rosen CL. Sleep distur-
bances in pediatric dialysis patients. Pediatr Nephrol. 2005;20:
697552. Allen RP, Earley CJ. Defining the phenotype of the restless legs
syndrome (RLS) using age-of-symptom-onset. Sleep Med. 2000;
1:1119
53. Walters AS. Is there a subpopulation of children with growing
pains who really have restless legs syndrome? A review of the
literature. Sleep Med. 2002;3:9398
54. Dahl RE. The impact of inadequate sleep on childrens daytime
cognitive function. Semin Pediatr Neurol. 1996;3:4450
55. Randazzo AC, Muehlbach MJ, Schweitzer PK, Walsh JK. Cog-
nitive function following acute sleep restriction in children
ages 1014. Sleep. 1998;21:861868
56. Roberts RE, Roberts CR, Chen IG. Impact of insomnia on
future functioning of adolescents. J Psychosom Res. 2002;53:
561569
57. Durmer JS, Dinges DF. Neurocognitive consequences of sleep
deprivation. Semin Neurol. 2005;25:117129
58. Fallone G, Acebo C, Seifer R, Carskadon MA. Experimental
restriction of sleep opportunity in children: effects on teacher
ratings. Sleep. 2005;28:15611567
59. Dahl RE. Sleep, learning, and the developing brain: early-to-
bed as a healthy and wise choice for school aged children. Sleep.
2005;28:1498 1499
60. Beebe DW. Neurobehavioral morbidity associated with disor-
dered breathing during sleep in children: a comprehensive
review. Sleep. 2006;29:11151134
61. Rudolph CD. Rudolphs Pediatrics. New York, NY: McGraw-Hill,
Medical Publications Division; 2003
62. Hening WA. Restless legs syndrome: the most common and
least diagnosed sleep disorder. Sleep Med. 2004;5:429 430
63. Pastor PN, Reuben CA. Attention deficit disorder and learning
disability: United States, 199798. Vital Health Stat. 2002;10:112
64. American Psychiatric Association. Diagnostic and Statistical Man-
ual of Mental Disorders. 4th ed, text revision. Washington, DC:
American Psychiatric Association, 2000
65. Jick H, Kaye JA, Black C. Incidence and prevalence of drug-
treated attention deficit disorder among boys in the UK. Br J
Gen Pract. 2004;54:345347
66. Essau CA. Frequency and patterns of mental health services
utilization among adolescents with anxiety and depressive dis-
orders. Depress Anxiety. 2005;22:130137
67. Lewin DS, Di Pinto M. Sleep disorders and ADHD: shared and
common phenotypes. Sleep. 2004;27:188 189
68. Goll JC, Shapiro CM. Sleep disorders presenting as common
pediatric problems. CMAJ. 2006;174:61761969. Sevim S, Dogu O, Kaleagasi H, Aral M, Metin O, Camdeviren
H. Correlation of anxiety and depression symptoms in patients
with restless legs syndrome: a population based survey. J Neu-
rol Neurosurg Psychiatry. 2004;75:226 230
70. Winkelmann J, Prager M, Lieb R, et al. Anxietas tibiarum
depression and anxiety disorders in patients with restless legs
syndrome. J Neurol. 2005;252:6771
71. Wagner ML, Walters AS, Fisher BC. Symptoms of attention-
deficit/hyperactivity disorder in adults with restless legs syn-
drome. Sleep. 2004;27:14991504
72. Office for National Statistics. National Statistics Omnibus Sur-
vey. GB Households with home access to the Internet, 2005.
Available at: www.statistics.gov.uk/cci/nugget.asp?id8. Ac-
cessed November 15, 200573. Cheeseman Day J, Janus A, Davis J. Computer and internet
use in the United States: 2003. US Census Bureau, 2005.
Available at: www.census.gov/prod/2005pubs/p23-208.pdf.
Accessed November 12, 2005
74. Pew Internet and American Life Project. 2005. Available at:
www.pewinternet.org/pdfs/InternetStatus2005.pdf. Ac-
cessed March 31, 2006
266 PICCHIETTI et alby guest on November 28, 2011pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/7/30/2019 The PEDS Rest Study: Restless Legs Syndrome
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DOI: 10.1542/peds.2006-27672007;120;253Pediatrics
Myers and Luigi Ferini-StrambiDaniel Picchietti, Richard P. Allen, Arthur S. Walters, Julie E. Davidson, Andrew
The Peds REST StudyRestless Legs Syndrome: Prevalence and Impact in Children and Adolescents
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