Amy Licis, MD: Restless Leg Syndrome is an Overlooked Cause of Sleep Disturbance

In an interview with HCPLive, expert Amy Licis, MD, MSCI, Associate Professor, Pediatric Neurology and Sleep Medicine, Washington University Department of Neurology, discussed the various sleep disorders that impact children who have autism or attention deficit hyperactivity disorder (ADHD).

She explained that there are relatively high rates of obstructive sleep apnea, as well as restless leg syndrome in these populations. Because of this, it's especially important for physicians to provide a comprehensive sleep evaluation for pediatric patients that are either having sleep issues or have been diagnosed with ADHD or autism.

"With regard to obstructive sleep apnea, often, children with autism or ADHD may have sensory sensitivities," Licis said. "But there are still many treatment options available including adenotonsillectomy or if CPAP (continuous positive airway pressure) is indicated there are desensitization programs."

Additionally, high flow or supplemental oxygen flow are options. The high flow treatment has an interface similar to an oxygen cannula, that facilitates airflow instead of oxygen flow. The supplemental oxygen flow is comparable to CPAP, with a smaller interface, and can help with tolerance, according to Licis.

"There are other treatments for which there's some evidence that can be considered in children with autism or ADHD for their obstructive sleep apnea, if indicated, such as rapid maxillary expansion in our nasal steroid sprays, and Montelukast, for which there's some evidence about those therapies," she said. "So, we do have a range of treatment options."

Licis said that there's some evidence indicating that restless leg syndrome may be an underlying cause of insomnia in these children.

"For restless leg symptoms we think that there's some evidence that may underlie their insomnia. Many children with autism and ADHD have been found to have relatively low levels of iron stores, perhaps low levels of vitamin D, and potentially other nutrients as well," she explained. "Those relationships need to be further studied, such as vitamin B, 12, or magnesium, but relatively low iron stores have been shown."

This had led Licis and other professionals to believe there could be differences in iron metabolism among children with ADHD or autism, which can contribute to restless leg symptoms.

"To have restless leg syndrome there's supposed to be leg discomfort that is worse at night and worse with rest but better with movement," she said. "Often children who have autism or ADHD have communication impairments that make it hard for them to fulfill full criteria."

"So," she continued, "the index of suspicion should be relatively low, recognizing that children may have underlying restless leg symptoms that might be a little harder to pick up, and treating it can help insomnia improve."

Checking these patients' levels of iron, vitamin D, and ferritin is an approach that Licis recommended. Ultimately, being able to identify and then treat the "broader sleep disorders" is important when addressing insomnia in children.

Licis recently spoke on this treatment topic at the Associated Professional Sleep Societies (SLEEP) 2022 Annual Meeting with a presentation titled "Tired and Wired: Sleep in Children with Autism or Attention Deficit Hyperactivity Disorder (ADHD)".