<p>When the demyelinating disease multiple sclerosis (MS) develops in childhood, it is known as paediatric-onset MS (POMS), which has greater disease activity and burden than its adult-onset counterpart. As there is no cure for MS, disease-modifying treatments (DMTs) are administered to reduce relapse frequency and slow disability progression. However, in paediatric patients, DMT choice is limited: only fingolimod (USA and EU), teriflunomide and dimethyl fumarate (both EU only) are approved for the treatment of POMS, all of which are considered moderate-efficacy therapies. Many DMTs used to treat MS in adults are used off-label to treat MS in children and adolescents, such as moderate-efficacy interferon-β and glatiramer acetate, and high-efficacy natalizumab. Despite their wide use, all clinical data regarding the use of these DMTs in paediatric patients are from observational studies. Treatment of POMS should be initiated early to improve outcomes, and treatment choice should be informed by drug characteristics, in addition to patient and family dynamics.</p>