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Pediatric Restless Legs Syndrome: More Common (and Impactful) Than You Might Think

Pediatric Restless Legs Syndrome: More Common (and Impactful) Than You Might Think 1024 683 Katie Brind'Amour, PhD, MS, CHES

This underdiagnosed condition is more than just a bedtime annoyance — it may reflect nutrient deficiencies and have major impacts on daytime behavior.

Restless legs syndrome (RLS) affects 2-4% of school-aged children, with symptoms that can significantly impact sleep quality, family relationships and daytime behavior. The condition causes discomfort in the arms or legs during periods of rest — particularly in the evening and at night — that is alleviated through voluntary movement. Unfortunately, many children go undiagnosed, in part due to an inability to describe their symptoms.

“RLS in children is often underrecognized because symptoms can be subtle and easily misattributed to growing pains, hyperactivity or bedtime resistance,” says Sehyr Imran, MD, a pediatric pulmonologist in the Section of Pediatric Pulmonary and Sleep Medicine at Nationwide Children’s Hospital, and lead author on a childhood RLS review published in Sleep Medicine Clinics. “RLS is not a behavioral choice — it is a neurologic sensorimotor condition with a strong familial predisposition.”

The majority of children with RLS have a parent with the condition, which in children is often caused or exacerbated by an iron deficiency. Without diagnosis and proper treatment, RLS causes sleep loss that may result in irritability, daytime sleepiness, reduced quality of life, poor attention span, learning challenges and other difficulties. The high prevalence merits a high index of suspicion for RLS in children with difficulty falling or staying asleep, as well as in children with low iron levels, among primary care providers, experts suggest.

“The earlier we identify and address it, the better the impact on sleep quality, daytime functioning and overall development,” says Dr. Imran.

Children at particularly high risk for iron deficiency include those born prematurely and those with problems absorbing nutrients, such as those with inflammatory bowel disease.

The team at Nationwide Children’s has now become the first to also confirm an elevated prevalence of RLS of 6.4% among children aged 10-18 years with cystic fibrosis — about twice the prevalence in the general pediatric population. The increase is likely due to nutrition challenges and inflammation in this population, suggests Maninder Kalra, MD, PhD, director of the Pediatric Sleep Disorder Center at Nationwide Children’s and senior author on the pediatric RLS review article.

“The increased prevalence has been recognized among adults with CF, but ours is the first study to show higher prevalence of RLS in children and adolescents with CF,” says Dr. Kalra. “This data highlights the need for increased RLS screening in children with CF.”

The study used a surrogate for iron status using lab values, dividing patients into quartiles according to red cell distribution width (RDW). Nearly 10% of CF patients in the highest RDW quartile had confirmed RLS, supporting the connection to iron dysregulation among these patients, as well. Swati Jayaram, MD, sleep medicine fellow at Nationwide Children’s, presented the research at the SLEEP 2025 conference earlier this year.

“RLS is historically underdiagnosed and unrecognized,” says Dr. Kalra. “However, we have found that by disseminating the latest updates on symptoms and diagnostic criteria to both PCPs and non-sleep specialists, it is being increasingly identified.”

Patients with difficulty falling asleep or restless sleep symptoms now make up about one in every four patients evaluated in the Nationwide Children’s sleep center, but in many cases, RLS can be diagnosed and managed by primary care providers using medical history and ferritin checks. Prior to diagnosis, the clinician must rule out other conditions, such as obstructive sleep apnea or neurologic disorders that may cause similar symptoms. Some medications, including certain antihistamines and SSRIs, may also cause the sensation of restlessness.

Children may describe the discomfort of RLS as tingling, buzzing, tickling, a “creepy crawly” feeling or a sensation that their limbs have too much energy or hurt unless they move. Young children may require leading questions to help characterize the feeling, and others may be able to draw what they experience.

While basic sleep hygiene and pre-bedtime routines such as warm baths and stretching can alleviate some symptoms, children with low iron levels (ferritin <50 ng/mL) should boost dietary iron and/or take oral iron supplements with vitamin C to aid in absorption. Children with severe deficiencies or intolerance to oral formulas may require iron infusions.

In uncertain cases, such as young children with consistent symptoms but an inability to describe the sensation, objective sleep studies to examine limb movement may pinpoint the diagnosis and offer additional insight into abnormal limb movements, breathing issues and sleep quality. Referral to a pediatric sleep specialist is also merited when a child has an atypical presentation, severe symptoms, major comorbidities, significant sleep disruption or substantial impact on daily function or emotional health. Furthermore, children should undergo specialist assessment if symptoms persist despite normal ferritin levels.

“Primary care physicians can help identify children with RLS by asking follow-up questions when parents mention difficulties with sleep or behavior,” says Dr. Imran. “In many children, diagnosis and management are straightforward and can significantly improve quality of life.”

 

References:

  1. Imran S, Jayaram S, Kalra M. Clinical Features of Childhood Restless Legs Syndrome. Sleep Med Clin, 2025 Jun;20(2):165-173.
  2. Jayaram S, Gillespie M, Krivchenia K, Eisner M, Jacobson-Kelly A, McCoy K, Kalra M. 1038: Prevalence of Restless Leg Syndrome in Children with Cystic Fibrosis. Sleep, 2025 May;48(1): A449.

Image credit: Adobe Stock

About the author

Katherine (Katie) Brind’Amour is a freelance medical and health science writer based in Pennsylvania. She has written about nearly every therapeutic area for patients, doctors and the general public. Dr. Brind’Amour specializes in health literacy and patient education. She completed her BS and MS degrees in Biology at Arizona State University and her PhD in Health Services Management and Policy at The Ohio State University. She is a Certified Health Education Specialist and is interested in health promotion via health programs and the communication of medical information.

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