Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)

Infant and Children | July 10, 2017 | Author: Naturopath

Children, Psychological disorders

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS)

What is PANDAS?

PANDAS is a paediatric autoimmune neuropsychiatric disorder associated with a streptococcal infection. The streptococcal infection appears to be linked to a group A beta-haemolytic (GABHS) strain and triggers the immune system to produce antibodies. Instead of attacking the streptococcal infection, the antibodies start to attack the basal ganglia which is the part of the brain that controls emotions, behaviours, and physical movement.  As a result, the brain becomes inflamed and a child exhibits symptoms of obsessive-compulsive disorder (OCD), anxiety, tics, personality changes, decline in cognitive ability, fine motor skill problems, sensory sensitivity and restrictive eating. 

PANDAS was first identified in 1998 by a paediatrician Susan Swedo at the National Institute of Mental Health (NIMH).

How is PANDAS Diagnosed?

The diagnosis of PANDAS is a clinical diagnosis. This means that there is no lab test that can be performed in order to arrive at a diagnosis. Instead, health care providers use diagnostic criteria for the diagnosis.

The diagnostic criteria are as follows:Neuropsychiatric Associated Disorders in children

  • The presence of Obsessive-compulsive disorder (OCD) and/or a tic disorder or ADHD symptoms.
  • Abrupt onset and/or symptoms varying in intensity
  • Neurological abnormalities such as hyperactivity, abnormal movements such as involuntary jerky movements, anxiety, emotional lability, bedwetting, or other regressive behaviours like tantrums.
  • Personality changes and deterioration in cognitive ability and fine motor skills.
  • Onset of symptoms appear between the ages of 3 years up to puberty
  • An association with group A beta-hemolytic streptococcal infection found either by culture or lab test results.

What is an episodic course of symptoms?

Children with PANDAS have ups and downs in their OCD behaviour and/or tic severity. OCD and tics that are almost always present at a consistent level do not represent an ‘episode’. Patients with PANDAS have a very sudden onset or worsening of their symptoms, followed by a slow and gradual improvement. If they get another streptococcal infection their symptoms will get worse once again. This increased symptom severity usually persists for at least several weeks but can last for several months or longer.

Are there any other symptoms associated with PANDAS episodes?

Neuropsychiatric Associated Disorders in children 1Children can experience one or more of the following symptoms in conjunction with their OCD and/or tics.

  • Separation anxiety
  • Irritability, sadness, laughing or crying at inappropriate times.
  • Trouble sleeping and night time bed wetting
  • Joint pain

Treatment for PANDAS

Antibiotics

Penicillin and other types of antibiotics may help to treat a sore throat that has been caused by a streptococcal infection by simply killing off the bacteria. However, research suggests that it is not actually the streptococcal infection that is the issue, instead, it’s the bodies inappropriate immune response and the production of antibodies attacking the basal ganglia that is causing the PANDAS symptoms rather than the bacteria itself.  Therefore, there is little research to suggest that treating PANDAS with antibiotics is the most appropriate treatment option.   

Currently researchers at the National Institute of Mental Health are investigating the use of antibiotics as a form of prophylaxis for PANDAS patients.  At this stage, its use has not been proven and until so, antibiotics should not be used as long-term treatment for OCD and tics in PANDAS.

Plasma Exchange and Immunoglobulin (IVIG)

Plasma exchange or immunoglobulin (IVIG) may be an option for children that are severely affected with PANDAS. This type of treatment has been shown to help with particular PANDAS symptoms like depression, emotional ups and downs and a multitude of OCD symptoms. However, IVIG isn’t without its side effects which include nausea, vomiting, headaches, and dizziness as well as the chance of infection due to the invasiveness of the procedure.

Tonsillectomy and adenoidectomy

Neuropsychiatric Associated Disorders in children 3There are to date, a very small number of studies that have looked at removing children’s tonsils and/or adenoids as a treatment option for PANDAS if the symptoms are severe enough and resistant to antibiotics.

All studies have shown that there is no difference between treatment with those children who were given antibiotics and those that had their tonsils removed.

Whilst there is insufficient evidence to show that a tonsillectomy and/or adenoidectomy helps in the treatment of PANDAS, it should not be considered a treatment option unless there are other reasons to warrant surgery.

Are there any long-term health problems for children who have had PANDAS?

It is still not known if there are any long-term ill-effects for children who have had PANDAS. Doctors that have been watching PANDAS patients over the last decade have suggested that if a child continues to suffer from some sort of dysfunction like anxiety or mild tics then the long-term outcome is dependent on the severity of the initial episode, the number or recurrences, and family history.

The function of the basal ganglia that is the part of the brain affected in PANDAS is very difficult to monitor which is the reason that Doctors are not yet able to evaluate if persistent symptoms are related to dysfunction which, may be temporary or damage, which is long term.

Any Natural Treatments for PANDAS?

Because there are few treatment options available for PANDAS in mainstream medicine, it would be ideal to look at the root cause of the infection and help a child’s immune system to be better equipped with dealing with the streptococcal infection rather than looking for ineffective ways to treat the symptoms.

One hypothesis that has been presented and published in numerous medical journals is the concept that the root cause of OCD is a dysfunction of the gut microbiome, resulting in a susceptibility to obsessional thinking. If this holds true then it would make sense to start off the treatment of PANDAS by looking at gut health.

Neuropsychiatric Associated Disorders in children foodA change in the child’s diet to exclude all gut irritants like sugar, grains and starches would be of the utmost importance.

Also, the inclusion of nourishing foods like bone broth, organ meats, and fermented foods would be optimal. Getting a child on to a very good quality/strain probiotic in addition to dietary changes would additionally allow for the encouragement of healthy gut microbiome and, in turn, have a positive effect on the immune system.
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Addressing the infection once gut health is under control would be the next step. There are many herbal alternatives to antibiotics that have a very strong anti-bacterial, anti-viral and anti-parasitic properties. One example is oregano leaf which is especially effective in healing strep throat.  Other herbs include olive leaf, astragalus and garlic. These herbs don’t necessarily have to be used in the acute treatment of a streptococcal infection, instead, they could be used long-term or over an extended period like the winter months to additionally boost the immune system and allow it to function correctly.
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References 

https://www.ncbi.nlm.nih.gov/pubmed/27619047

https://www.ncbi.nlm.nih.gov/pubmed/25569020

https://www.ncbi.nlm.nih.gov/pubmed/27504155

https://www.ncbi.nlm.nih.gov/pubmed/24332563      

https://www.ncbi.nlm.nih.gov/pubmed/22972724

https://www.ncbi.nlm.nih.gov/pubmed/23518825

https://www.ncbi.nlm.nih.gov/pubmed/25569020

https://www.ncbi.nlm.nih.gov/pubmed/27619047

https://www.ncbi.nlm.nih.gov/pubmed/28025607

Snider LA, Lougee L, Slattery M, Grant P, Swedo SE. Antibiotic prophylaxis with azithromycin or penicillin for childhood-onset neuropsychiatric disorders. Biological psychiatry. 2005;57(7):788-792.

Toufexis MD, DeOleo C, Elia J, Murphy TK. A Link Between Perianal Strep and Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS). The Journal of Neuropsychiatry and Clinical Neurosciences. 1966;38(6):946-956.

Murphy ML, Pichichero ME. Prospective identification and treatment of children with paediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Archives of paediatrics & adolescent medicine. 2002;156(4):356.

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