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Pediatric MS Information for Health Professionals

Pediatricians as well as adult and child neurologists have often overlooked multiple sclerosis (MS) as a possible diagnosis in children; however it is increasingly being recognized around the world. There are an estimated 8,000-10,000 children with MS in the United States, and another 10,000-15,000 children and adolescents experiencing acquired inflammatory demyelination of the central nervous system (CNS) from disorders such as acute disseminated encephalomyelitis (ADEM), variants of ADEM, neuromyelitis optica, and clinically isolated syndromes (such as optic neuritis and transverse myelitis).

It is unclear how these childhood disorders relate to the probability of a child or teen developing MS. While the exact frequency of pediatric MS is unknown, review of published literature (mostly retrospective studies), suggests that 2-5 % of all cases of MS have symptom onset before age 16.

Differential diagnosis

A child or adolescent with acute neurological problems and white matter abnormalities on MRI presents a diagnostic challenge, even to experienced clinicians. There is a wide range of disorders that need to be considered, many of which differ from the differential diagnosis of MS in adults. To complicate matters, young children sometimes present with symptoms of MS not typically seen in adults such as mental status changes and seizures.

Disorders included in the differential diagnosis of MS include:

  • Infections
  • Genetic/metabolic disorders 
  • Other demyelinating disorders
    (e.g. ADEM)
  • Endocrine disorders
  • Vasculopathies
  • Inflammatory disorders
  • Leukodystrophies
  • Mitochondrial disorders
  • Nutritional deficiencies
  • Neoplasms
    (Neurology 2007;68 (Suppl2):S13-S22)

Clinical presentation

Studies of pediatric MS have reported:

  • A similar frequency of girls to boys under the age of 10 years, but more girls than boys in the above 10 year old group.
  • Significant overlap between the most common symptoms in adults and children with MS, although children are more likely to experience seizures and mental status changes.
  • Poly-symptomatic presentation with motor findings has been reported more frequently than sensory deficits due in part to easier identification of motor dysfunction in children and adolescents.
  • Many children with MS have difficulties in at least one major cognitive domain. Therefore, cognitive testing and evaluation of school progress is essential.

Disease course

Clinical studies have shown:

  • Almost all children diagnosed with MS have a relapsing-remitting (RRMS) course.
  • Primary progressive (PPMS) with or without relapses is rarely seen in children.
  • Some studies have reported a higher relapse rate in children than adults, but symptoms appear to remit more quickly than in adults.
  • Relapsing MS in children appears to transition more gradually to a secondary progressive course than in adults. However, studies suggest pediatric MS patients can reach irreversible disability at a younger age than individuals with adult onset MS.

Implications

Cognitive impairment can affect academic performance and social interaction by:

  • Interfering with a child's ability to participate in school and recreational activities
  • Carrying consequences for the development of self-confidence and self-esteem
  • Impacting the adolescent's ability to adapt to age-related psychological changes
  • Affecting the entire family structure as families try to cope with a life-long illness, with uncertain course and outcome.

It is important that parents and other family members, teachers, physicians and other health care providers understand the psychosocial impact of MS on a child's physical and emotional well-being, and recognize that early assessment can lead to needed intervention and support.

Treatment

Studies in adults with MS have shown significant benefit of early treatment with disease modifying drugs (DMD). The treatments are not currently approved for use in children or adolescents with MS, but small safety trials have shown that the treatments are generally well tolerated and safe for use in children and adolescents, with a caution to watch liver function in younger children. The side effects of interferon beta (IFNB) and glatiramer acetate (GA) appear to be similar in children as in adults. The International Pediatric MS Study Group consensus is that DMD use should be considered in children and adolescents after a definite diagnosis of relapsing-remitting MS. The Study Group also acknowledged that long term tolerability and safety studies are needed, as well as prospective efficacy studies.

The treatments currently being used in children and adolescents for acute exacerbations and symptoms are largely dependent on the experiences of clinicians working with the adult population.

Research

Because of the critical need to better understand childhood MS, the National MS Society launched two ground-breaking initiatives:

  • The International Pediatric MS Study Group — to foster opportunities for collaboration to enhance our understanding of care of children and adolescent (prior to the 18th birthday) with pediatric MS and other related disorders; and
  • The Pediatric MS Centers of Excellence — to set the standard for pediatric MS care and offer optimal medical and psychosocial support to children and their families regardless of their ability to pay.

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