A Pediatrician's Protocol for Treating Suspected Mild- Moderate PANDAS 

 

Diagnosis

   Suspicion of Mild to moderate PANDAS comes from the history and clinical picture- not laboratory confirmation. Although these patients do not all meet strict criteria for PANDAS they still warrant consideration and clinical trial of treatment.  Symptoms include unexplained and abrupt onset of any persistent deterioration in the child's behavioral health. Common symptoms include: High irritability,  anger,explosive behavior, emotional lability, sleep disturbance, anxiety symptoms,  fears, phobias,  panic disorder Obsessive Cumpulsive Disorder, frequent urination,  depression, deterioration in cognitive function, poor focusing skills, and deterioration in handwriting .  Motor tics and vocal tics can be noted alone or with behavioral symptoms. Not all children with suspected mild to moderate PANDAS have tics.

Strep

   Most children with PANDAS have a  history of strep infection or a current positive culture,  or exposure to other children with strep. Often the anti DNASE B antibody titers are markedly elevated.  The ASLO titers are elevated if the strep exposure is recent but they are less reliable.  Some children, even those with history of repeated Strep infections  have unusually low titers.  Following titers after initial evaluation is not necessary since clinical signs and symptoms are the only criteria for judging effectiveness of therapy.

 

Anecdotal experience

 

   The following protocol is based on my clinical experience with many( 50) PANDAS children over the last 7 years.   I have found that it results in dramatic improvement in most patients, often obviating the need for psychiatric medication.

 

Starting dose-  clinical trial

  After checking for other stressors like bullying  family strife, child abuse and sexual abuse if PANDAS is suspected I prescribe Zythromax 10 Mg/kg (azythromycin) up to a maximum dose of 500 mg per day.  If the onset of symptoms is within the last three moths I use 14 days.  If longer. I use 21 days as a clinical trial.

 Observe child for lessening of tics, and/or anxiety symptoms.  The first sign of improvement is a decrease in irritability .

 If absolutely no improvement  discontinue Zythromax

 

Maintenance

 .If any improvement is noted (eg: decreased frequency or intensity of tics or lessening of irritability, or phobic or anxious behavior) continue 10/kg Zythromax for two more weeks

Reassess at two week intervals and continue 10/kg as long as there is improvement.

 

Taper

  Once the child has reached baseline or has plateaued in improvement for four weeks consider tapering dose by reducing the dose by 1/4 per dose  weekly. During the taper the parents should watch carefully for return of irritability or other symptoms

 

.  If any deterioration is noted restart 10/kg and continue until the child is back to normal for four weeks.  Then again try to taper by decreasing dose by 1/4 at weekly increments.

 

If repeated tapers fail,(usually the children with longer histories) the zythromax is continued and tapered again in three -six months.

 

Prophylaxis

If there are recurrences or if the symptoms are very distressing I recommend prophylaxis

 

 Prophylactic antibiotics as delineated by the American Heart Association for prevention of Rheumatic Fever  can be given for 6-12 months after stopping the zythromax.

 

Probiotics and Omega 3

 

During the entire course of therapy, probiotics like Lactobacillus GG  (Culturelle) should be given daily  at a different time of day from the administration of Zythromax.   Supplementation with Omega 3    500-1000 mg / day is recommended by many psychiatrists for patients with anxiety and/or depression.

 

Cognitive Behavioral Therapy

 

CBT has been shown to be a powerful tool in treating anxiety patients. If the child has an anxious baseline nature this therapy is also recommended.