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Could my child have PANS/PANDAS? Did you notice a sudden start  to OCD or Restrictive Eating Disorder? Does your child also experience 2+ of the following: anxiety, sensory amplification or motor abnormalities, behavioral regression, deterioration in school performance, mood disorder, urinary symptoms and/or sleep disturbances Symptoms are not better explained by a known neurologic or medical disorder How do you evaluate a child for PANS? The history (i.e. the description of the illness and its development) is primary. We also check for other things to be thorough. Rule out acute rheumatic fever. Examine for a murmur. If the child has a history of joint complaints, involuntary muscle movements/swallow/headaches, rashes, also refer to a pediatric cardiologist to exclude valve damage rheumatic carditis. Evaluate for Group A streptococcal infection. Throat, skin, anal swaps and exam. Send to lab. Check for other infections. Optional: Blood test - mycoplasma IgM for active infection. If urinary symptoms are present, obtain a urinalysis. In PANS, this is likely to be negative and suggest that the urinary urgency, frequency or secondary enuresis are manifestations of PANS, rather than a urinary tract infection. Consider necessary referrals: Psychologist, Cardiology, Rheumatology, Immunology, Neurology, Sleep, Otolaryngology, and/or Infectious Disease What are the treatment options? We can decide together whether to do the workup first then treat, or to try treatment empirically (as a trial) to see if there is a dramatic change. Treatments may include: Prescribe 14 days of antibiotics (Penicillin/amoxicillin,¹ azithromycin, cefdinir, Augmentin, or others). Consider an initial 3-4 week course or long-term coverage depending on the case. Consider a 5-7 day course (up to 6 weeks depending on severity) of NSAIDs (ibuprofen) and/or prescribe a 5-7 (up to 30) day steroid burst³ or 6 weeks of a NSAID at immunomodulatory dose. Ensure the family has access to CBT/ERP (Cognitive Behavior Therapy/Exposure and Response Prevention) and parent support. Consider initial psychiatric treatment with medication and a referral with a psychiatrist to help with symptom management. IVIG is sometimes used for more advanced cases, but this is something I am not able to administer yet. What to expect with treatment: Unlike traditional OCD, some studies have shown improvement in neuropsychiatric symptoms in patients with PANDAS after 2–6 weeks of antibiotic treatment. It is unclear if these improvements are from treatment of a latent infection or from some other non-microbial effects. PANS OCD has a relapsing remitting course. Most children will experience at least one recurrence of symptom onset due to a PANS trigger. Parents need to understand there is no “quick fix”. Traditional OCD is characterized by a waxing and waning course with modest changes in severity. However, with PANS OCD, the course is relapsing-remitting, with dramatic, abrupt exacerbations of OCD and other PANS symptoms. Residual OCD may persist despite any treatment of infection, inflammation, CBT, or medications. Cognitive-behavior therapy (specifically exposure with response prevention - ERP) can be helpful as well as anti-obsessional medications, but we “start low and go slow.”

Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) are increasingly recognized conditions impacting children's mental health. These disorders can creep in suddenly or be recognized gradually, leaving parents and caregivers scrambling for answers. In this blog post, we will break down the characteristics of PANS and PANDAS, highlight their primary symptoms, and explore effective treatment options. Defining PANS and PANDAS PANS is characterized by a sudden and severe surge of psychiatric symptoms in children, such as anxiety, obsessive-compulsive behaviors, and disruptions in cognitive function. PANDAS, a specific subset of PANS, arises from streptococcal infections. Collectively, these disorders can drastically change a child's life and challenge family dynamics. Recent studies have found that the onset of PANS or PANDAS often results from an autoimmune response. Here, the immune system mistakenly attacks the brain, causing both psychiatric and neurological symptoms. For instance, a study found that about 50% of children with PANDAS showed a notable improvement in symptoms after antibiotic treatment. Spotting the Symptoms Recognizing the symptoms of PANS and PANDAS can be difficult, especially since they may resemble other psychiatric or medical conditions. Here are the key signs to look for: Rapid Onset of Psychiatric Symptoms A defining trait of PANS and PANDAS is the abrupt emergence of psychiatric symptoms. Children may go from being happy and engaged to suddenly anxious, irritable, or withdrawn. For example, a child who previously enjoyed school might suddenly refuse to attend or participate in activities. Neurological Symptoms Many affected children experience neurological issues, including lip smacking or other tics, loss of coordination, or changes in handwriting. These symptoms can seem to arise almost overnight. For instance, a child's ability to ride a bicycle or complete homework may decline dramatically. Sleep Disturbances Sleep problems are frequent in children with these conditions. Research indicates that nearly 80% of children experience sleep disruptions. This might include insomnia, nightmares, or daytime sleepiness. Parents should monitor these changes closely, as they can exacerbate emotional challenges. Changes in Appetite and Behavior Watch for sudden shifts in appetite or routine. A child may refuse meals or begin overeating. They might struggle with schoolwork or social interactions. One survey found that around 65% of parents reported significant changes in their child’s eating habits during the onset of PANS or PANDAS. Regressive Behaviors Affected children may revert to earlier developmental milestones. For instance, a child who was potty-trained may start having accidents, or a previously independent child may become overly clingy. This regression can create additional stress for families. Investigating Treatment Options Timely intervention is crucial for managing PANS or PANDAS. While treatments can vary widely, a combination of approaches often yields the best results. Medication Management Healthcare providers may prescribe medications tailored to specific symptoms. There are three pillars of treatment that usually need to be done together in order to succeed in treatment. These are: treating the infection, calming the immune response, and psychiatric care. Treating Underlying Infections If streptococcal infections trigger PANDAS, antibiotics can lead to a notable improvement in symptoms, sometimes within days. Amoxicillin and azithromycin are examples of commonly used medications. Treatment can last 14 days, 30 days, or even months. Calming the Immune Response Treatment-level doses of Ibuprofen (dosed by weight) can be used to calm inflammatory responses. Prednisone has more side effects but can be stronger in cases that Ibuprofen does not work. Again, crafting an individual plan is key here. Psychiatric Medications and Psychotherapy Options include anti-obsessional medications (eg clomipramine) for obsessive-compulsive behaviors and sometimes very small doses of anti-psychotics. I have not had too much success with SSRIs or guanfacine, though these are considered options as well. The key is to develop a personalized medication protocol. ERP (exposure and response prevention) and Cognitive-behavioral therapy (CBT) have been shown to be effective for children facing anxiety and obsessive-compulsive symptoms due to PANS or PANDAS. A trained therapist can teach children coping strategies to manage emotions. Equally important if not more is for the parents to enter therapy individually or as a couple to help strengthen the bond between the parents in dealing with the stress that an ill child puts on the relationship. This allow parents to set a calm, confident tone in the house and can be the most important part in managing anxiety and OCD in a child. Dietary and Lifestyle Changes Many families find symptom relief through balanced nutrition and healthy lifestyle habits. Incorporating more fruits, vegetables, and whole grains while ensuring regular exercise can boost overall well-being. Some research suggests that a diet low in processed sugars, flours, and dairy may help lessen anxiety symptoms in some children. Pro tip: Aim for a consistent sleep schedule to enhance sleep quality. Building Support Networks Engaging with support groups can offer invaluable resources for families navigating PANS or PANDAS. Sharing experiences and treatment strategies can ease feelings of isolation. Online communities and local support networks can connect families with others who understand the journey. Navigating PANS and PANDAS PANS and PANDAS can dramatically alter a child’s daily life and the lives of their families. Early identification of symptoms and proactive treatment approaches are essential in managing these disorders. Positive outcomes are certainly possible! As you become familiar with the signs and symptoms, and connect with a trusted doctor familiar with PANDs, you can take steps to ensure your child receives necessary support. With the right support, children can overcome these obstacles, leading fulfilling and healthy lives.