A Pediatrician's Protocol for Treating
Suspected Mild- Moderate PANDAS
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.
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.
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.
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
for lessening of tics, and/or anxiety symptoms. The first sign
of improvement is a decrease in irritability .
no improvement discontinue Zythromax
.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
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.
there are recurrences or if the symptoms are very distressing I
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
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
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.