Overview

Paediatric multiple sclerosis (MS) is a rare but serious central nervous system disease that affects children and teenagers. Paediatric MS is difficult to diagnose as a lot of the symptoms are also common for other disorders and diseases of the central nervous system. Most of the information on paediatric MS, such as symptoms, causes and treatments, is based on the information known about adult MS. However, paediatric MS represents its own unique challenges, such as difficulty in diagnosis and attending school. Hence, it is important to understand the symptoms, signs, and potential causes that may affect children.

What is paediatric multiple sclerosis?

Paediatric multiple sclerosis, also known as paediatric-onset MS, early-onset MS, and juvenile MS, is a central nervous system disorder affecting the brain and spinal cord. It is a chronic inflammatory autoimmune disease, where your immune system attacks and destroys a protective coating around the nerves, called the myelin sheath (demyelination).¹

According to the World Health Organization (WHO), the global estimate of people with MS is over 1.8 million. However, some studies estimate that the number of people with MS worldwide could be as high as 2.8 million.² Usually, MS is diagnosed in people between the ages of 20 and 40 years old, however, it can also affect children and teenagers (<18 years old). It is estimated that around 3 to 10% of all people with MS start experiencing symptoms before the age of 16 years, while less than 1% start experiencing symptoms before the age of 10 years.³ MS affects both people assigned male at birth (AMAB) and people assigned female at birth (AFAB) equally before puberty. However, after puberty, it is more common in people AFAB, with the ratio estimated to be 2-3 to 1.

Causes of paediatric multiple sclerosis

The exact cause of MS in children and adults is still unknown. However, there are certain environmental, genetic and familial factors that may increase your or your child’s risk of developing MS:

Maternal illness during pregnancy

In a questionnaire, it was revealed that illness in expecting mothers increased the risk of their child developing MS. However, diabetes, including gestational diabetes, did not increase the risk. Additionally, caesarean delivery seemed to reduce the risk of MS in their children by 60%.⁴

Exposure to toxins

Being exposed to plant-related pesticides from 3 months before pregnancy through to the first year after birth is associated with an increased risk of developing paediatric MS.⁴ Smoking also increases the risk of MS, therefore, secondhand exposure to tobacco smoke to the child might increase their risk of developing MS.⁵ However, secondhand exposure to tobacco smoke in expecting mothers did not seem to increase the risk of their children developing MS later on in life.⁴

Gender

Individuals AFAB have higher chances of developing MS after puberty. This suggests that sex hormones could play a role in the development of MS.⁶

Genetic factors

The lifetime risk of developing MS is increased by 2.5% in people with a first-degree relative (parent or sibling) who has MS.⁷

Epstein-barr virus (mononucleosis) infection

Becoming infected with Epstein-Barr virus (EBV) can increase the risk of developing MS. For example, a study of 10 million young adults revealed that the risk of developing MS increased by 32 times after infection with EBV, but not other viruses.⁸ Another study showed that 100% of 901 patients with early MS had a previous infection of EBV as they had antibodies related to EBV.⁹

However, most people (around 90-95%) have been infected with EBV before the age of 20-24 years. Nevertheless, infectious mononucleosis, which is a symptomatic consequence of EBV occurring in around 70% of people with EBV infection, showed a three-time increase in the development of MS compared to the general public (most of whom have been infected with EBV previously but did not develop symptomatic infectious mononucleosis).¹⁰

Low vitamin D levels

Lack of sunlight exposure and subsequent low vitamin D levels have been associated with MS. Studies have revealed that low levels of vitamin D in the serum (fluid component of blood) are observed before and after the onset of MS and are associated with increased risk of developing MS.¹¹ Additionally, vitamin D supplementation has been shown to have a beneficial effect on people with MS as it reduces relapses up to 50%.¹²

Obesity

Obesity early in life has a strong association with increased risk of MS.¹³

Symptoms of paediatric multiple sclerosis

Symptoms of paediatric MS can vary from child to child as well as from time to time depending on which parts of the brain and spinal cord are being affected. MS can be divided into 4 different types based on the pattern of symptoms:

Clinically isolated syndrome

This is in regard to a first-time experience of neurologic symptoms as a result of inflammation and demyelination in the central nervous system. However, not everyone who experiences clinically isolated syndrome will develop MS.

Relapsing-remitting MS

The most common type of MS. People with this type experience attacks (relapses) of new or progressing symptoms. These attacks are followed by periods of partial or complete recovery (remission), where all symptoms might disappear or some might continue and become permanent.

Secondary progressive MS

This type follows relapsing-remitting MS. Some people with relapsing-remitting MS develop secondary progressive MS, which is characterised by a progressive worsening of symptoms and disability accumulation.

Primary progressive MS

Progressive worsening of symptoms and disability accumulation is observed as soon as symptoms first show, without having a relapse-remission phase first. Around 98% of children with paediatric MS have a relapsing-remitting MS, as compared to 84% of adults with MS.³ Usually, children have a more inflammatory-active disease course, which leads to more frequent relapses, however, it also leads to slower long-term disability accumulation. This is thought to be because of a strong post-relapse recovery because children generally have a higher ability for myelin repair as well as greater plasticity of the developing brain.¹⁴

Paediatric MS can present with multiple symptoms that can be physical (such as sensory or motor), cognitive (such as affecting emotions and thinking) or other:

Fatigue

A common symptom of MS. People with MS describe this type of fatigue as an ‘’overwhelming sense of tiredness with no obvious cause’’.

Balance and coordination issues

Balance issues and dizziness are common symptoms of MS, which can affect your ability to walk.

Pain

People with MS often experience some sort of pain during the course of their disease. Pain can be associated with other symptoms, such as muscle stiffness and spasms, or numbness and tingling.

Tremor

A trembling or shaking movement that you cannot control. Tremors can come and go in people with MS and they can vary in severity, from mild (hardly noticeable) to severe (affecting your ability to carry out everyday tasks).

Speech problems

They can appear only during relapse or they can come and go during the day. Some people with MS experience worsening of speech when they are tired.

Stiffness or spasms

Muscle stiffness and spasms are common MS symptoms, however, these are usually occasional.

Visual problems

The most common problems with vision in people with MS are optic neuritis, double vision, and involuntary eye movements.

Numbness or tingling

Another symptom that many people with MS will experience at some point.

Memory problems and difficulty concentrating

Some people with MS sometimes find it hard to remember something or have difficulty concentrating.

Bladder and bowel issues

Most people with MS will develop some sort of bladder (frequency, urgency, and problems with emptying) and bowel (constipation or incontinence) issues during the course of their MS.

Seizures

Seizures may be more common in people with MS because of how MS affects the brain.

Importantly, some of these symptoms, such as fatigue and balance issues, can affect children’s ability to carry out everyday activities (e.g., going to school or attending extracurricular activities), so proper management of these symptoms and awareness from the schools and teachers is needed.¹⁵ Cognitive issues, such as memory problems and lack of concentration, can also affect performance at school.

Summary

Paediatric multiple sclerosis is a rare but serious chronic inflammatory autoimmune disease of the central nervous system that affects children and teenagers. The actual causes of MS are still not known. However, certain risk factors that may increase the risk of your child developing MS have been identified. These include:

• Epstein-Barr virus (and subsequent infectious mononucleosis) infection
• Low vitamin D levels
• Environmental factors (e.g., secondhand exposure to tobacco smoke or pesticides)
• Genetic factors
• Obesity

There is a large variety of symptoms that people with MS might experience. These will differ from child to child, and from time to time. Some common symptoms include:

• Fatigue
• Balance issues
• Vision problems
• Cognitive problems

Importantly, these symptoms can have a negative impact on your child’s performance at school and their mental health, so it is important to have a proper plan on how to manage this.