Optimizing treatment for pediatric multiple sclerosis.

Introduction: Pediatric-onset multiple sclerosis (POMS) differs from adult MS in its clinical characteristics and disease course. POMS exhibits a heightened inflammatory activity with higher relapse rates and lesion load, alongside less early physical disability but more pronounced cognitive impairment and impaired brain growth.

Areas covered: This review examines treatment strategy in POMS based on safety and efficacy data from observational studies and randomized controlled trials. This article is based on a literature search conducted using MEDLINE and Google Scholar for the period of 2000 to 2024.

Expert opinion: High-efficacy therapies, including fingolimod, natalizumab, and anti-CD20 therapies, have demonstrated superior disease control and disability prevention. Early initiation of HET is increasingly recommended to optimize outcomes and preserve quality of life.Low/moderate-efficacy therapies, such as interferons, glatiramer acetate, teriflunomide, dimethyl fumarate should be reserved for patients with mild disease. While long-term safety data, personalized prognostic markers and de-escalation strategies are still needed, high-efficacy therapies provide a promising standard of care, especially given enhanced neuroinflammatory activity in POMS. Future research should prioritize strategies to balance disease control with adverse effects (AEs), accounting for aging and individual disease trajectories, to improve long-term quality of life in POMS patients.