It's estimated that 1 in 200 children may experience PANS or PANDAS in the United States. These conditions are associated with autoimmune and inflammatory responses that can affect various aspects of a child's well-being. Due to the sudden onset and significant changes in behavior and abilities that are characteristic of PANS and PANDAS, it is important to seek care as soon as symptoms begin. Clinical expertise suggests that the prognosis can be positive if the child is diagnosed early and receives appropriate care. These conditions may become more challenging to manage if identification and care are delayed. Research and integrative approaches for supporting children with PANS/PANDAS are needed to provide broader support in this area.
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What is PANS/PANDAS?
PANS stands for Pediatric Acute-onset Neuropsychiatric Syndrome, while PANDAS is an acronym for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection. It is considered a subset of PANS. Both conditions involve a sudden onset of neuropsychiatric symptoms, including behaviors similar to OCD. Warning signs often include sudden mood and behavior changes and eating restrictions that the child did not previously exhibit. Many parents report that their child "changed overnight" due to the noticeable differences.
What's the Difference Between PANDAS and PANS?
While these two conditions are very similar, there are slight differences based on causation. PANDAS is thought to be associated with Group A Streptococcus infection, while PANS may be linked to other infectious agents such as the flu, chickenpox, Lyme disease, or mold exposure.
What Causes PANS/PANDAS?
Scientific research suggests that an abnormal immune system response may contribute to these conditions. It is theorized that when an infection such as strep or influenza occurs, the immune system may mistakenly target self-cells in the brain and nervous system. In PANDAS, this process is thought to occur through molecular mimicry, where Group A Streptococcal antibodies may cross-react with brain antibodies, potentially leading to psychiatric and neurological challenges. This cross-reaction may impact and cause inflammation in the brain's basal ganglia, which are involved in emotions, behavior, cognitive and sensory processing, learning, and motor function. This theory aligns with the sudden onset of changes observed in children who develop PANS/PANDAS.
What Age Does PANS/PANDAS Affect?
These conditions most frequently affect children ages 3 to 12 years old. Clinical observations suggest it may affect males more than females. There is no set age limit for developing PANS/PANDAS, but evidence suggests that older adolescents may not have the same immune response to pathogens.
Symptoms of PANS/PANDAS
The sudden onset of symptoms is a distinguishing feature of PANS/PANDAS. While a child's clinical presentation can vary, they typically display both neurological and psychological symptoms:
- Mood or personality changes, especially if irritable or suddenly enraged.
- Bedwetting
- Depression or anxiety
- Issues sleeping
- Disinterest in foods
- ADHD symptoms, including fidgeting
- Obsessive-compulsive-like behavior
- Tics and/or jerky movements
- Aggressiveness
- Baby talk or acting clingy
- New onset of bedtime fears
- Memory issues that can impact reading and math skills
- Sensitivity to noise, touch, clothing, or light
How is PANS/PANDAS Diagnosed?
Criteria for diagnosis of both conditions are based on three parameters assessed clinically. This includes observation of abrupt onset or recurrence of restrictive eating or OCD. The second criterion is the sudden onset of at least two neuropsychiatric symptoms: anxiety, behavioral regression, mood disorder, regression in school performance, dramatic response to sensory input, abnormal motor movement, and sleep or urinary disturbances. In conjunction with those two parameters, the child's symptoms cannot be explained by any other known or investigated medical or neurological disorder. A PANDAS diagnosis must also meet the criteria of having a previous group A Beta-hemolytic strep infection, confirmed through either a positive swab strep test or a history of scarlet fever. A current or recent streptococcal infection can also be confirmed by titer tests for antistreptolysin-O (ASO) or anti-DNase B antibodies against strep.
Functional Medicine Labs That Can Help Individualize Treatment of PANS/PANDAS
These conditions are assessed clinically, as there are no specific labs to diagnose them. Basic lab work, microbe-specific panels, and antibody markers can be helpful to see if any infection is present or if organ systems are functioning abnormally. All of these labs require a blood draw, but if done together, it is only one poke and can be managed with care.
Basic Labs
Obtaining a Complete Blood Count (CBC) with Differentials and Comprehensive Metabolic Panel (CMP) can provide insight into the status of the liver, kidney, blood sugar, and any indication for conditions like anemia or an infection.
Inflammatory Markers
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are two inflammatory biomarkers that can indicate if inflammatory processes are occurring in the body. Testing these can provide a good benchmark when considering anti-inflammatory approaches.
Streptococcal Antibodies
Two antibodies can indicate if a recent or current strep infection occurred. Mosaic Diagnostics offers a combo Streptococcus Antibodies Profile that tests for Anti-DNase and Antistreptolysin O (ASO) Antibodies. This test can support a PANDAS diagnosis if all diagnostic criteria are also met.
Comprehensive Stool Analysis
Getting a microbial stool analysis test can provide insight into gut health. The GI-MAP by Diagnostic Solutions offers a comprehensive option for assessing various microbial factors. It includes testing for Streptococcal species, which is a concern with PANDAS. The results can assist with understanding microbial imbalances, some of which may correlate with illness, inflammation, and immune function.
Additional Labs to Check
A rapid strep test is typically performed and sent out for further culturing. This can confirm an active group A Streptococcus, the commonly linked form of PANDAS. Ensuring the swab sample is cultured allows time for the bacteria to grow, providing a more thorough evaluation.
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Conventional Treatment for PANS/PANDAS
Treatment for PANS and PANDAS can vary depending on the severity of symptoms. For present infections and situations that are mild to moderate, the child may receive a combination of antibiotics, corticosteroids, behavioral therapy, anti-inflammatories, and low-dose SSRIs. For moderate to severe PANS/PANDAS, the child may receive all the previously mentioned interventions with the addition of Intravenous Immunoglobulins (IVIG) and Plasmapheresis. IVIG has been reported to improve symptoms associated with PANS and is a sought-after approach when children are diagnosed with this condition. Plasmapheresis is a process that may help manage these conditions. The approach is more intensive for adolescents dealing with severe and extreme versions of PANS/PANDAS. This includes multiple rounds of steroids, antibiotics, IVIG, Plasmapheresis, Rituximab (a monoclonal antibody), and DMARDS (Disease-Modifying Antirheumatic Drugs).
Complementary and Integrative Medicine Treatment for PANS/PANDAS
Complementary and integrative medicine approaches can be valuable additions to a holistic plan for children with PANS/PANDAS. Below are some options to consider:
Cognitive Behavioral Therapy (CBT) for PANS/PANDAS
CBT, especially with exposure and response prevention (ERP), has been widely used to address the OCD features of PANS/PANDAS. CBT aims to help kids develop coping skills and change intrusive thought patterns, behaviors (such as OCD), and any related emotions. Exposure and response prevention involves confronting the thoughts, actions, or situations your child may obsess about and then reframing how to respond to those urges. This therapeutic approach can help retrain the brain to process these obsessions differently.
Nutrition for PANS/PANDAS
Often in these conditions, a child's eating pattern becomes very restrictive. In these situations, it's important to emphasize healthy food choices that the child will eat. Due to the inflammatory nature of PANS/PANDAS, an anti-inflammatory diet may benefit a child experiencing one of these conditions. Another aspect to consider is the gut-brain connection. If their gut microbiome is imbalanced, supporting the child's gastrointestinal tract through eating habits may be helpful. An example of a microbiome diet includes the 4 Rs, which are Removing the interfering foods that are impacting the gut, Repairing the gut wall, Replacing the gut with necessary nutrients, and Reinoculating the gut with beneficial probiotics.
Supplements and Herbs That May Support PANS/PANDAS
Complementary approaches for PANS/PANDAS have not yet been extensively studied. However, natural therapies for symptoms of these conditions have been explored in some evidence-based studies.
Probiotics
Gut dysbiosis has been linked to neurocognitive and mental health challenges. One of the causes of gut dysbiosis can be antibiotic-induced, as it disrupts both harmful and beneficial gut flora. The use of probiotics, especially strains of Streptococcus spp, Bacillus, Lactococcus, Lactobacillus, Saccharomyces, Bifidobacterium, and Leuconostoc cremoris, has been shown to support gut health. While probiotic use for PANS/PANDAS has not been directly studied, the use of antibiotics as a first-line approach to manage the condition may indicate that probiotics are beneficial for maintaining gut health.
Omega-3 Fatty Acids
The use of Omega-3 Fatty Acids for supporting a healthy inflammatory response has been recognized in scientific studies. Providing your cells with these omegas is important as the body doesn't inherently produce them. If the child is exhibiting ADHD-like behaviors, using Omega-3 may also support their neurocognitive function. The suggested intake for kids is 500-2400mg per day, depending on individual needs.
Curcumin
The active ingredient in the Turmeric plant has been studied for its potential role in supporting mood balance. If your child is experiencing symptoms of mood imbalance due to the sudden onset of PANS/PANDAS, curcumin may be helpful. The use of this compound may help support mood balance. This plant extract has been studied and used at doses between 45mg-4000mg daily to support immune and inflammatory responses. It's best to consult with your integrative healthcare provider for specific guidance for your child.
Mind-Body Therapies for PANS/PANDA
There is no evidence-based data on the effectiveness of mind-body or relaxation therapies specific to PANS/PANDAS. However, there are options to support anxiety, mood balance, and focus. Equine Therapy (horse therapy) has been a proven intervention for supporting relaxation in children experiencing focus challenges. Mindfulness meditation has also been shown to be a helpful tool in supporting children with mood and focus challenges.
Acupuncture with Moxibustion for PANS/PANDA
Regarding Tic symptoms in these conditions, acupuncture has been explored as an integrative approach. A meta-analysis assessed 39 studies that used acupuncture and Traditional Chinese Medicine to address TICS. The results suggest that acupuncture may help manage muscle twitching episodes. Chinese Medicine can support the body's natural healing processes. Acupuncture and TCM can be considered as part of a comprehensive approach alongside Western Medicine interventions.
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Summary
Promptly assessing a child who presents with sudden onset of OCD, restrictive eating, and other neuropsychiatric symptoms is important for supporting their health. Exploring areas of susceptibility to pathogenic microbes in children may help identify those at greater risk of developing these conditions. While research and science continue to advance in understanding PANS/PANDAS, taking steps with conventional medicine, functional medicine testing, and complementary and integrative approaches can provide supportive outcomes for a child.
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