**9. Conclusions**

Pediatric MS is a rare disorder, but the long-term clinical implications in those who are diagnosed lead to significant cognitive and physical disability in adulthood, even with current first-line treatments. The ultimate aim of the treatment of pediatric MS is to reach a state of NEDA. More recently, the goals have been aimed towards NEDA-4, which is a state of no clinical relapse, no disease progression, no new MRI activity, no cognitive decline, and no evidence of brain atrophy present [107,108]. Given the elevated annualized relapse rate, increased rate of cognitive disability, and younger age at reaching disability milestones in pediatric MS, to achieve NEDA-4, the treatment paradigm may need to shift towards that of treatment with higher e fficacy medications.

**Author Contributions:** K.S.F. designed and wrote the manuscript. F.X.C. reviewed the manuscript. V.M.R. reviewed the manuscript. G.J.H. reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
