Most of us think of multiple sclerosis as a problem affecting adults. But surprisingly children get it too and that’s being increasingly recognised around the world because many of these children go undiagnosed for a long time. Children may also be able to give more accurate clues as to what might trigger this toxic attack by the immune system on the brain.

Lauren Krupp is Professor of Neurology at the State University of New York at Stony Brook and is also Director of the United States’ National Paediatric Multiple Sclerosis Centre.

Lauren Krupp: It’s not particularly common but the number of kids out there are hard to estimate because no one seems to know how to recognise it. The guess is of the two and a half million people with multiple sclerosis worldwide that maybe about 5% have had the onset of their disease earlier than age 18. Previously there was no treatment so when faced with a child that might have MS or might not, there was a great reluctance to burden the family with some

Norman Swan: Incurable disease.

Lauren Krupp: Because not everything that initially looks like MS, particularly in childhood, turns out to be MS.

Norman Swan: So what does a child with MS typically present with, because in adults it’s things like funny neurological symptoms, double vision, pins and needles, weakness in one place or other, so a sort of scattered kind of presentation in adults.

Lauren Krupp: We think that this presentation in children is probably more similar than it is different although there might be some differences. And you can imagine if a child has some problems with vision in one eye, often they don’t tell anybody and then maybe six months later either it happens again or it affects the other eye and now they may mention it to their parents who think oh, you know, they just got some dust in their eye. From there maybe it will go to the point where they’ll see a paediatrician who then might send the kid to an ophthalmologist and slowly the possibility of MS comes up but through a very long circuitous route and when it finally is raised there’s this quandary because the people who manage MS are adult neurologists and the people who manage kids are paediatric neurologists and so what happens is the paediatric neurologist says well I know how to handle kids but I don’t know how to handle this disease. And the adult neurologist says I know how to handle MS but I don’t take care of kids and the family falls in between.

Norman Swan: And is it mainly visual symptoms they can present with? Can you give me a typical story that’s not visual?

Lauren Krupp: Right so one child was doing OK until he developed some double vision and his mum noticed that he was dropping things and he seemed like he was a little unsteady. And he saw his paediatrician, they thought that he had maybe a cold, he slowly got better and then about four months later he developed a weakness on the opposite of his body and he was having trouble walking up stairs and in sports and that led to a neurological evaluation and had a MRI and there were white matter lesions all over his brain. And we’ve seen things like that happen in kids as young as 4. Usually it’s in younger adolescence but it can happen much earlier than that. Other times kids develop sleepiness, or confusion, or even seizures.

Norman Swan: Often when children get what are traditionally adult problems like this they get it in a more toxic fashion it goes a more severe course – is that true of multiple sclerosis?

Lauren Krupp: It’s a good question, we don’t really know because there is not enough systematic studies. There certainly however been in my experience a sub group of kids who have very, very traumatic disease and there was also clearly a group who previously would have gone unrecognised so kids who might have had some mild sensory problems, so there’s definitely a range of populations of kids out there with different degrees of impairment.

Norman Swan: Is it a different disease?

Lauren Krupp: Well we actually think that studying MS in children is an opportunity to pinpoint more clearly what the pathogenesis might be for two reasons. The genetic component is certainly there for kids and adults, the question would be why in a childhood population is the disease getting expressed so soon? It’s also the case that viral exposures are most likely an important trigger to the development of MS. So if that’s the case you would think that you might have a better chance of identifying those viral exposures in someone who’s only been around for say 7 years as opposed to someone who’s been around 27 years when there’s all that much additional irrelevant exposures that that older person has had. So as a result we’ve actually collaborated with investigators from all over the world and have found that there may be a higher frequency of antibodies to EBV virus in children.

Norman Swan: And this is the glandular fever virus (Epstein Barr Virus).

Lauren Krupp: Yes, it’s not thinking that that virus is the cause but it might be easier in this population to see what might be a trigger.

Norman Swan: And how do you treat children with multiple sclerosis – with the same drugs, these relatively new drugs that you are treating adults?

Lauren Krupp: Right now there’s only been sort of scattered reports of the various medications that are used in adult MS as applied to children. However those reports suggest that the medications are very safe in kids.

Norman Swan: These are drugs that essentially affect the immune system?

Lauren Krupp: Yes. In general with MS there is the feeling that the earlier you treat the more likely you’ll be able to intervene favourably.

Norman Swan: How do these kids go at school? Because another area of research that you have in adults is that thinking ability sometimes declines in people with multiple sclerosis, which isn’t something, I was particularly aware of.

Lauren Krupp: One of our major interests in general with MS has been how people with MS process information in a very fast moving internet based kind of world. This interest was there as well in looking at the kids and not surprisingly we found that a lot of kids were actually having trouble at school. And I think the reasons are multiple but certainly there’s a group of children who are experiencing cognitive complications from the MS. Their thinking is slower, their memory is impaired and that in conjunction with missing days of school because of MS relapses, or the emotional distress of having a chronic illness, leads to poor academic performance in many of them.

Norman Swan: And Dr Krupp has trialled an Alzheimer’s drug in adults with MS and found some benefits. Lauren Krupp is Director of the United States: National Paediatric Multiple Sclerosis Centre based at the State University of New York at Stony Brook.


References:

MacAllister WS et al. Cognitive functioning in children and adolescents with multiple sclerosis. Neurology, April 26, 2005;64(8):1422-5

Krupp LB, MacAllister WS Treatment of Pediatric Multiple Sclerosis. Current Treatment Options Neurology, May 2005;7(3):191-199

Krupp LB et al. Donepezil improved memory in multiple sclerosis in a randomised clinical trial. Neurology, November 9, 2004;63(9):1579-85

Krupp LB Fatigue in multiple sclerosis: definition, pathophysiology and treatment. CNS Drugs 2003;17(4):225-34

Guests on this program:
Dr Lauren Krupp
Professor of Neurology
State University of New York
Stony Brook, New York
U.S.A.

Presenter: Norman Swan
Producer: Brigitte Seega