Treating Pandas Naturally - A Guide to PANS/PANDAS Treatment

Written by Kate Shore - 12th July, 2024

Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) can be incredibly challenging for families. While many parents start with conventional medical treatments, there's a growing interest in exploring natural PANDAS treatment options. Therapies such as nutritional guidance, microbiome biome support and herbal medicines can work alongside pharmaceutical or medical approaches to help manage and reduce symptoms, offering a holistic approach to your child's health.

Understanding PANS/PANDAS

PANS and PANDAS are two conditions characterised by the sudden onset of symptoms - such as severe anxiety, obsessive-compulsive behaviours, vocal or motor tics, mood swings, aggression or sleep disturbances - following triggers such as infections like strep throat.

To dive deeper into what is PANS/PANDAS and the full range of symptoms children can experience, you can go back and catch up on Part 1 and Part 2 of this series that breaks it all down. But if you’ve read through the first articles already, you’re probably hanging out for information about the options for PANS/PANDAS treatment - so let’s dive in!

Common PANS/PANDAS Treatments

The typical medical approach to treating PANS/PANDAS often involves a range of interventions to address any underlying infection and support the overactive immune system. This can include one or more of the following:

• Antibiotics - used to address any initial bacterial infection, such as streptococcal infection in PANDAS (1). Antibiotics such as Azithromycin are also used prophylactically in severe cases.

• SSRIs - psychiatric medications such as sertraline or fluoxetine are commonly used to reduce anxiety and obsessive-compulsive behaviours (2).

• Intravenous Immunoglobulin (IVIG) - involves the infusion of antibodies to modulate the immune system (3).

• Steroids - steroids, such as prednisone, are used to reduce acute inflammation in PANS/PANDAS by suppressing the immune system and decreasing inflammation in the brain and other tissues (4).

• Low Dose Naltrexone (LDN) - used to alter the immune system, and for its anti-inflammatory effects (5)

• Cannabidiol (CBD): A compound from cannabis, such as NTI164, researched and trialled at Children’s Hospital at Westmead and the Paediatric Neurology Unit at Monash Medical Centre, for reducing neuroinflammation, preventing neurodegeneration and improving overall brain health.

While these treatments can be effective, they often have side effects, don’t always address all aspects of PANS and improvements can be short-lived. In these instances, naturopathic treatments can work alongside medical interventions to enhance overall well-being and tackle the root causes of symptoms to work towards full remission of PANS symptoms.

The Naturopathic Approach to PANS

There is no doubt that PANS is a complex condition, and reducing flares, uncovering the causes and supporting children and families requires a methodical and systematic approach. The naturopathic approach to treating pans centres around four key aspects:

1. Reducing Neuroinflammation

Reducing neuroinflammation is the number one priority in treating PANS naturally, as ongoing inflammation in the brain drives many symptoms, including tics, anxiety, and OCD (7, 8)

At the heart of neuroinflammation is the activation of microglia, the primary immune cells in the brain. Normally, microglia help maintain brain health by clearing debris and supporting healthy brain function. However, in PANS/PANDAS, these cells can become overactivated, and this hyperactivation leads to the release of pro-inflammatory immune cells (9). This creates an inflammatory environment within the brain and the disruption of normal brain function, leading to symptoms such as anxiety, tics and OCD. Through reducing neuroinflammation we can better manage the symptoms of PANS/PANDAS.

2. Reducing Triggers

Reducing triggers is another important part of managing PANS/PANDAS because these triggers often set off flare-ups and exacerbate symptoms. Identifying and addressing the unique triggers for each child can help reduce the frequency and severity of these episodes, leading to more stable and manageable health outcomes.

Common triggers include frequent infections such as colds, urinary tract infections (UTIs), sinus infections, and tonsillitis. Many children with PANS/PANDAS have low immune resilience, making them more susceptible to infections and subsequent symptom flare-ups. Strengthening the immune system through natural therapies, proper nutrition, and lifestyle adjustments is essential in managing these cases effectively.

Other triggers can include environmental factors, such as exposure to mould and allergens, worms or other pathogens, stress, teething or other dental work, and concussion.

3. Regulating the Immune System

Immune dysregulation is at the heart of PANS/PANDAS, and many of the symptoms are driven by an overactive immune response. The goal of supporting kids with PANS is to retrain the immune system, promoting a balanced response that prevents excessive inflammation while maintaining its ability to fight off infections. The process of retraining the immune system includes addressing the factors that contribute to immune dysregulation, such as gut health, key nutrients, and lifestyle habits.

4. Improving Gut-Brain Connection

And lastly - but most importantly - supporting a healthy gut environment. The gut is often referred to as the "second brain" because it contains a vast network of neurons and this complex relationship between the gut and brain means that disturbances in gut health can directly affect neurological and psychological well-being, as we see in PANDAS (11).

An unhealthy gut can cause a "leaky gut," allowing harmful substances like LPS (10) from certain bacteria to trigger inflammation. The imbalanced gut microbiome affects neurotransmitter production, impacting mood regulation, and pro-inflammatory immune cells from gut dysbiosis can worsen neuroinflammation. In children with PANS/PANDAS, this can lead to anxiety, tics, or OCD symptoms. Maintaining a healthy gut reduces inflammatory signals to the brain, easing these common symptoms.

Treating PANDAS Naturally

Within this framework, it is important to remember that each child is unique, with individual risk factors and vulnerabilities that influence triggers, flares and recovery. Therefore, the key to treating PANDAS naturally involves identifying and addressing individual factors and implementing a treatment plan that supports these areas.

For example, one child might develop PANDAS following a streptococcal infection and also have genetic vulnerabilities - such as a family history of autoimmunity (6) - and a history of gut issues. In this instance, the treatment plan would focus on modulating the immune system and improving gut function, alongside strategies to prevent future infections. Another child might have PANS triggered by a viral infection, with ongoing flares that are exacerbated by chronic stress and mould exposure. Here, the treatment plan would focus more on antiviral herbs, nervous system support and mould remediation.

This individualised approach not only provides symptomatic relief but also aims to uncover and address the root causes - rather than just band-aid symptoms - so that each child aim for complete remission of symptoms.

Natural Treatments for PANS/PANDAS

After taking into consideration individual circumstances, a treatment plan or protocol can be created that steps through each of the key four stages, and uses a combination of diet, lifestyle adjustments, herbal medicine, and nutraceuticals. Some commonly used treatments and supplements are listed below, but it's important to understand that these recommendations are not standalone solutions or a magic bullet, and can’t be applied uniformly to all children with PANS.

Anti-Inflammatories

Natural anti-inflammatories such as curcumin, N-acetyl cysteine (NAC) and Omega-3’s are important in calming down neuroinflammation (14).

Curcumin in particular is often used in PANS to reduce flares, due to its extensively researched for its ability to reduce inflammation in the brain (12). It inhibits inflammatory mediators and suppresses microglial activation, which helps reduce neuroinflammation. However, curcumin's bioavailability can be a challenge, so it's important to use formulations that enhance its absorption (13).

Antioxidants

Oxidative stress contributes to neuroinflammation and immune dysfunction. As well as being anti-inflammatory, N-acetyl cysteine (NAC) is also crucial for producing glutathione, a major antioxidant that combats oxidative stress (12). NAC is also neuroprotective, helps break down bacterial biofilms, and modulates glutamate levels in the brain. NAC is also well-researched and used widely in the treatment of OCD symptoms (15, 16). Proper dosing is essential to maximize NAC's benefits.

Probiotics

Probiotics are often a component of PANS treatment plans, but the key to probiotics is choosing the appropriate strain. In general, probiotics help reduce inflammation, reduce LPS, increase butyrate and maintain a healthy microbiome, which are all crucial for immune function. For a more specific prescription, we need to consider what is trying to be achieved - e.g. reducing the frequency of infection or improving the frequency of bowel motions - and then prescribing accordingly. On many occasions, this is best determined after microbiome testing.

Nutritional Supplements

Nutritional supplements can play a helpful role in managing PANS, by replenishing essential nutrients that may be deficient due to restricted eating, dietary preferences, lifestyle habits or genetic predispositions. There is no blanket approach or one-size-fits-all when it comes to nutritional supplements, and these will be recommended after thorough evaluation, including blood tests, to ensure tailored and effective treatment.

For example, Vitamin D plays a significant role in immune regulation and reducing inflammation. Deficiencies in Vitamin D have been linked to an increased risk of infections and autoimmune conditions and, maintaining optimal Vitamin D levels can help modulate the immune system and potentially reduce the severity and frequency of symptom flare-ups (1).

It is important to know that some nutrients, such as Vitamin D and iron have upper limits and should only be given if a child is deficient - more is not always better!

Diet Support

One of the most frequently recommended dietary changes for children with PANS is the elimination of gluten, which can exacerbate inflammation and autoimmune responses in susceptible individuals. Removing these potential triggers from the diet can help reduce systemic inflammation and mitigate neuropsychiatric symptoms associated with PANS/PANDAS.

However, this is not a one-size-fits-all approach and should only be implemented after consideration and discussion with an experienced practitioner. Many children with PANS are already experiencing disordered eating patterns, and removing foods from an already restrictive diet can be problematic (17). Introducing dietary changes gradually and with sensitivity to the child’s preferences and psychological needs is essential.

Antimicrobials

Natural antimicrobial herbs can be useful to help manage infections that trigger PANS/PANDAS symptoms, but these should be used under the guidance of a healthcare professional to ensure safety and efficacy. Antimicrobials such as Clove (Syzygium aromaticum) and Myrrh (Commiphora molmol) are often used to reduce inflammatory gut bacteria or pathogens, such as Clostridium difficile, E. coli or Staphylococcus aureus (18 , 19,) that contribute to ongoing exacerbations of flares, however, these are prescribed only after stool testing, when it can be determined what species need to be targeted.

Herbal Medicine

Beyond antimicrobial herbal medicines, there are also various herbal options for supporting the immune and nervous systems. Herbs such as Echinacea and Elderberry are just a few examples of herbs that can support immune health (20), adaptogenic herbs like Ashwagandha can help manage stress and support adrenal function (21), and Passionflower can reduce anxiety (22).

Important note: Not all children with PANS require all of the above interventions, and those that do, will require so in varying dosages and frequencies. New supplements or herbal medicines should only be prescribed by an experienced practitioner, that takes into consideration any safety issues or contraindications.

Treating PANS Naturally

There is no doubt - navigating PANS/PANDAS is extremely challenging, but a holistic approach offers hope for managing symptoms and healing PANDAS naturally. By reducing neuroinflammation, addressing triggers, regulating the immune system, and supporting the gut-brain connection, natural treatments can play a crucial role in your child’s health journey, working alongside other medical approaches.

Beyond PANS, implementing a holistic approach to your child’s health can provide numerous benefits, addressing not just the symptoms but also the underlying causes of health issues. By focusing on nutrition, lifestyle modifications, and natural remedies, you can support your child’s overall well-being and promote long-term health.

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This article is part of a series on all things PANS and PANDAS. Go back and check out Part 1, ‘What is PANS/PANDAS'?’ and Part 2 ‘PANS/PANDAS Symptoms & Signs: A Checklist For Parents’ if you missed them.

This series is for educational purposes and does not constitute individual health advice. PANS and PANDAS are complex conditions, and it is important to seek the advice of a practitioner to assess what is right for your child. If you have questions, speak with your primary healthcare practitioner or book a free chat here where we can discuss the individual circumstances of your family.

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More about Kate Shore - Paediatric Naturopath:

Kate Shore is a children’s naturopath with a special interest and clinical focus on working with kids with PANS and PANDAS. Kate received her Bachelor of Health Science from Torrens University and has established her practice in North Warrandyte, Melbourne, where she sees clients locally and worldwide. Her approach draws heavily on nutrigenomics, microbiome testing, nutritional foundations, and lifestyle support. She works with a range of children and conditions, from PANS/PANDAS, OCD, tics, anxiety and depression, ADHD and autism.

If you want to get in touch or have any more questions about the above, you are welcome to get in touch here or make time for a free chat here.

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If you want to keep learning, read the research here:

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2. Sigra, S., Hesselmark, E. and Bejerot, S. (2018) ‘Treatment of pandas and pans: A systematic review’, Neuroscience & Biobehavioral Reviews, 86, pp. 51–65. doi:10.1016/j.neubiorev.2018.01.001

3. Hajjari, P. et al. (2022) ‘Paediatric acute-onset neuropsychiatric syndrome (PANS) and intravenous immunoglobulin (IVIG): Comprehensive open-label trial in Ten children’, BMC Psychiatry, 22(1). doi:10.1186/s12888-022-04181-x.

4. Brown, K. et al. (2017) ‘Pediatric acute-onset neuropsychiatric syndrome response to oral corticosteroid bursts: An observational study of patients in an academic community-based Pans Clinic’, Journal of Child and Adolescent Psychopharmacology, 27(7), pp. 629–639. doi:10.1089/cap.2016.0139.

5. Stancil, S. L., Abdel-Rahman, S., & Wagner, J. (2021). Developmental Considerations for the Use of Naltrexone in Children and Adolescents. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 26(7), 675–695. https://doi.org/10.5863/1551-6776-26.7.675

6. Gagliano, A., Carta, A., Tanca, M. G., & Sotgiu, S. (2023). Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatric Disease and Treatment, 19, 1221–1250. https://doi.org/10.2147/NDT.S362202

7. Gerentes, M. et al. (2019) ‘Obsessive-compulsive disorder: Autoimmunity and neuroinflammation’, Current Psychiatry Reports, 21(8). doi:10.1007/s11920-019-1062-8.

8. Gagliano, A., Carta, A., Tanca, M. G., & Sotgiu, S. (2023). Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatric Disease and Treatment, 19, 1221–1250. https://doi.org/10.2147/NDT.S362202

9. Fornari Laurindo, L. et al. (2024) ‘Immunological dimensions of neuroinflammation and microglial activation: Exploring innovative immunomodulatory approaches to mitigate neuroinflammatory progression’, Frontiers in Immunology, 14. doi:10.3389/fimmu.2023.1305933.

10. Loffredo, L. et al. (2020) ‘Oxidative stress and gut-derived lipopolysaccharides in children affected by paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections’, BMC Pediatrics, 20(1). doi:10.1186/s12887-020-02026-8.

11. Baj, J. et al. (2020) ‘Alterations in the nervous system and gut microbiota after β-hemolytic streptococcus group a infection—characteristics and diagnostic criteria of pandas recognition’, International Journal of Molecular Sciences, 21(4), p. 1476. doi:10.3390/ijms21041476.

12. Moore K. N-Acetyl Cysteine and Curcumin in Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol. 2018 May;28(4):293-294. doi: 10.1089/cap.2017.0165.

13. Lopresti, A.L. (2017) ‘Curcumin for Neuropsychiatric Disorders: A review of in vitro, animal and human studies’, Journal of Psychopharmacology, 31(3), pp. 287–302. doi:10.1177/0269881116686883.

14. Poles, J., Karhu, E., McGill, M., McDaniel, H. R., & Lewis, J. E. (2021). The effects of twenty-four nutrients and phytonutrients on immune system function and inflammation: A narrative review. Journal of clinical and translational research, 7(3), 333–376.

15. Oliver, G., Dean, O., Camfield, D., Blair-West, S., Ng, C., Berk, M., & Sarris, J. (2015). N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review. Clinical psychopharmacology and neuroscience : the official scientific journal of the Korean College of Neuropsychopharmacology, 13(1), 12–24. https://doi.org/10.9758/cpn.2015.13.1.12

16. Gadallah, A.-H.A. et al. (2020) ‘Efficacy and safety of N-acetylcysteine as add-on therapy in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis’, Journal of Obsessive-Compulsive and Related Disorders, 25, p. 100529. doi:10.1016/j.jocrd.2020.100529.

17. Khimani, K., Abadia-Barrero, C. and LaRusso, M. (2024) ‘Implementing dietary changes with children affected by pans/pandas’, Children’s Health Care, pp. 1–19. doi:10.1080/02739615.2024.2338763.

18. Maggini, V. et al. (2024) ‘Antimicrobial activity of syzygium aromaticum essential oil in human health treatment’, Molecules, 29(5), p. 999. doi:10.3390/molecules29050999.

19. Aljarallah, K. M. (2016). Inhibition of Clostridium difficile by natural herbal extracts. Journal of Taibah University Medical Sciences, 11(5), 427-431. https://doi.org/10.1016/j.jtumed.2016.05.006

20. Schapowal, A., Klein, P., & Johnston, S. L. (2015). Echinacea reduces the risk of recurrent respiratory tract infections and complications: a meta-analysis of randomized controlled trials. Advances in therapy, 32, 187-200. doi.org/10.1007/s12325-015-0194-4

21. Speers, A. B., Cabey, K. A., Soumyanath, A., & Wright, K. M. (2021). Effects of Withania somnifera (Ashwagandha) on Stress and the Stress- Related Neuropsychiatric Disorders Anxiety, Depression, and Insomnia. Current neuropharmacology, 19(9), 1468–1495. https://doi.org/10.2174/1570159X19666210712151556

22. Janda, K., Wojtkowska, K., Jakubczyk, K., Antoniewicz, J., & Skonieczna-Żydecka, K. (2020). Passiflora incarnata in neuropsychiatric disorders—A systematic review. Nutrients, 12(12), 3894. doi.org/10.3390/nu12123894