Restless legs syndrome

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction 

Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common causes of poor sleep in children and can result in insomnia and daytime sleepiness, often leading to cardiovascular and neurocognitive consequences.

RLS is characterized by an unpleasant sensation in the legs that leads to an urge to move when at rest, particularly at night, that can result in sleep onset and maintenance issues ¹. PLMD is characterised by periodic episodes of repetitive and highly stereotypic movements during sleep, often very subtle, that can impact sleep quality, resulting in unrefreshing sleep and impaired daytime functioning ². There is increasing evidence for iron therapy in the management of RLS/PLMD, with studies showing low levels of serum ferritin have been associated with elevated numbers of periodic limb movements on sleep study in children ³. 

Pre-referral investigations

Sleep history

• Sleep Hygiene
• Sleep Hours
• Snoring
• Restlessness
• Day Consequences

Assessment

• Tonsil Size

Consider blood tests

• FBC (Full Blood Count)
• Iron Studies
• Coeliac Serology
• TSH (Thyroid Stimulating Hormone)
• UEC
• LFT (Liver Function Tests)
• Random Glucose
• Vit B12 and Folate

Pre-referral management

• Consider 3 months of oral iron if Ferritin < 50 micrograms/L
• 3-6 mg/kg/day of elemental iron - retest after 3 months⁴. See Iron deficiency - pre-referral guideline
• Discuss sleep hygiene
• Educate on adequate sleep hours for age.
• Consider trial of low dose magnesium orally at bedtime – continue if helpful
• Consider trial of oral melatonin at bedtime if persistent sleep onset difficulties
• Consider trial of Nasonex nasal spray if coexisting snoring
• Where possible avoid medications known to worsen RLS/PLMD such as Selective Serotonin Reuptake Inhibitors, Tricyclic Antidepressants, antihistamines and caffeine²

When to refer

If ongoing difficulties despite trying the above, then refer to Respiratory Medicine – Sleep Disorders, and include results of all investigations.

If symptoms of Obstructive Sleep Apnoea (such as snoring or apparent apnoea in the presence of large tonsils) then refer to the Ear, Nose and Throat Department.

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service.
• Routine non-urgent referrals from private hospitals go to the PCH Referral Office.
• Urgent referrals (less than seven days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with on call Respiratory doctor.

Essential information to include in your referral

• A sleep history
• Detailed description of any investigations and management trialled – including results of any blood tests.

Useful resources

• Sleep tips for children - Health Direct
• Sleep Hygiene - Government of WA Centre for Clinical Interventions
• About sleep - Raising Children
• Sleep Health Foundation Fact Sheets
• Melatonin and Children - Sleep Health Foundation
• Iron Deficiency - Queensland Health
• Iron Deficiency - Royal Children’s Hospital Melbourne

References

1. Allen RP, Picchietti D, Hening WA,et al. 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.
2. Durmer JS, Quraishi GH. Restless legs syndrome, periodic leg movements, and periodic limb movement disorder, in children. Pediatr Clin N Am 2011; 58: 591-620
3. Dye TJ, Jain SV, Simakajornboon N. Outcomes of long-term iron supplementation in pediatric restless legs syndrome/ periodic limb movement disorder (RLS/PLMD). Sleep Medicine. 2017; 32:213-9
4. Simakajornboon N, Kheirandish-Gozal L, Gozal D,et al. A long term follow-up study of periodic limb movement disorder in children after iron therapy. Sleep2006; 29 (Suppl):A226.
    

Reviewer/team:	Department of Respiratory and Sleep	Review date:	Mar 2025
		Date:	Mar 2022

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