PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is treated with a combination of antibiotics to clear the underlying strep infection, anti-inflammatory therapies to calm the immune response attacking the brain, and psychiatric support to manage symptoms like OCD and tics. Treatment is tailored to severity: mild cases may resolve with antibiotics alone, while severe cases can require immunotherapy or plasma exchange. The key principle is that PANDAS is driven by a misdirected immune response to strep, so effective treatment targets the root cause rather than just the behavioral symptoms.
How PANDAS Is Diagnosed
Before treatment begins, a child needs to meet specific diagnostic criteria established by the National Institute of Mental Health. PANDAS requires OCD, a tic disorder, or both, with sudden onset in childhood (ages 3 through puberty). Symptoms follow an episodic pattern, flaring up and then fading, and must be linked to a confirmed strep infection within three months of onset. Children also typically show physical hyperactivity or unusual jerky movements they can’t control. A positive throat culture, strep blood test, or history of scarlet fever helps confirm the strep connection.
Severity is classified by how much of the child’s day symptoms consume. Mild cases cause disruptions at home or school but occupy only a few hours daily. Moderate cases are distressing enough to interfere with daily activities and take up 50% to 70% of waking hours. Severe cases are incapacitating, occupying 71% to 100% of the child’s waking time, and can include life-threatening behaviors.
Antibiotics: The First Line of Treatment
Because PANDAS is triggered by strep, the first step is eliminating the infection. An initial course of antibiotics is recommended for all newly diagnosed cases. In one large study of 345 children meeting PANDAS criteria, patients received a 10- to 21-day course at diagnosis. Research suggests that longer, more aggressive antibiotic courses (beyond 30 days) with broader-spectrum coverage tend to produce better results than shorter ones.
After the acute infection clears, many children need ongoing preventive antibiotics to stop future strep infections from triggering new flares. This is called prophylactic therapy, and it’s particularly recommended for children with severe neuropsychiatric symptoms or a pattern of repeated strep-triggered episodes. In the same large study, children received long-term preventive treatment for at least five years. The logic is straightforward: if strep is the match that lights the fire, keeping strep away prevents the next flare.
Anti-Inflammatory Therapies
Since PANDAS symptoms stem from inflammation in the brain, reducing that inflammation is a core part of treatment. Over-the-counter anti-inflammatory pain relievers (NSAIDs like ibuprofen) are sometimes used as maintenance therapy during flares, typically for at least 10 days. They’re a lower-risk option that can help with milder inflammation.
For more significant flares, doctors may prescribe a short course of corticosteroids, often called a “steroid burst.” This typically lasts five days, sometimes followed by a gradual taper. Steroids are powerful at tamping down the immune response, but they can temporarily worsen psychiatric symptoms like agitation or mood swings. For families who may struggle to manage those side effects at home, doctors often opt for NSAIDs instead.
IVIG for Moderate to Severe Cases
When antibiotics, anti-inflammatories, and standard psychiatric medications aren’t enough, intravenous immunoglobulin (IVIG) is the next step. IVIG delivers a concentrated dose of antibodies from donated blood to help reset the immune system. It’s typically reserved for children with moderate to severe PANDAS whose symptoms haven’t responded to less aggressive treatments.
The evidence for IVIG is encouraging. In a clinical study of children aged 4 to 16 with moderate to severe symptoms, IVIG produced statistically significant reductions across all six measures of symptoms. OCD symptoms improved by more than 50%, and that improvement held for at least 8 weeks after the final infusion. A subset of patients tracked for 29 to 46 weeks after treatment showed that while tics did partially return, they remained below the levels seen before treatment began. Meaningful improvement was typically visible by the third infusion.
Plasma Exchange for Severe Cases
Therapeutic plasma exchange (sometimes called plasmapheresis) is the most intensive immunotherapy option. It filters the child’s blood to remove the harmful antibodies attacking the brain. This treatment is reserved for children who remain severely symptomatic after trying less invasive therapies.
There are two situations where doctors may move to plasma exchange more quickly, bypassing the usual stepped approach. The first is life-threatening behavior: suicidality or dangerous aggression. Published case examples include children attempting to jump from moving vehicles or exhibiting violence toward siblings. The second is severe food or fluid restriction leading to weight loss of 10% to 15% or more of the child’s body weight, or restriction severe enough to require tube feeding.
Managing Psychiatric Symptoms
While the immune-focused treatments address the underlying cause, children with PANDAS often need direct help managing their OCD, anxiety, tics, and other psychiatric symptoms. Cognitive behavioral therapy (CBT) is a cornerstone, teaching children practical strategies to resist compulsions and manage anxiety. For OCD specifically, a form of CBT called exposure and response prevention is the standard approach.
SSRIs (the same class of antidepressant medications commonly used for OCD and anxiety) can also help, but there’s an important caveat: children with PANDAS are unusually sensitive to side effects from these medications. Starting at a lower dose than typical and increasing very gradually helps minimize problems like increased agitation or behavioral changes. This heightened sensitivity is well-documented enough that it’s included in clinical guidance from major treatment centers.
Tonsillectomy as a Treatment Option
For children whose symptoms keep flaring despite antibiotic therapy, removing the tonsils may help by eliminating a common reservoir for strep bacteria. In a 2014 study published in JAMA Otolaryngology, children with PANDAS who had incomplete responses to antibiotics showed significant improvement after tonsillectomy. Starting from a baseline symptom severity score of 10, antibiotics alone brought scores down to 8. After tonsillectomy, scores dropped to 3 at three, six, and twelve months, and to 0.5 at three years post-surgery.
The evidence is still considered inconclusive overall, so tonsillectomy isn’t a first-line recommendation. But for children stuck in a cycle of recurrent strep and repeated neuropsychiatric flares, it’s a reasonable option to discuss with your child’s treatment team.
School Accommodations During Flares
PANDAS flares can make school extremely difficult. A child who was functioning normally may suddenly struggle with concentration, handwriting, emotional regulation, or sensory overload. Under Section 504 of federal law, children with PANDAS can qualify for a formal accommodation plan. Parents, doctors, therapists, or teachers can initiate the request, which involves submitting written determination and evaluation requests to the school.
Common accommodations include:
- Instruction changes: additional check-ins, one-on-one time, and breaking long assignments into smaller parts
- Environmental adjustments: a pass to visit a designated safe space, private testing areas, movement breaks, and flexible attendance policies (excused absences, early dismissals, or late arrivals)
- Sensory accommodations: leaving class five minutes early to avoid loud hallway noise, for example
- Fine motor support: typing responses or using a recording device instead of handwriting, along with tools like calculators, fidget devices, and graphic organizers
- Related services: occupational therapy, tutoring, or transportation services
These accommodations can make the difference between a child falling behind academically during a flare and staying on track while treatment takes effect. Since PANDAS is episodic, the plan can be activated during flares and scaled back during periods of remission.