1. First-line infection management (strep & other triggers)
Penicillin V (oral)
Amoxicillin
Amoxicillin–clavulanate (Augmentin)
Cephalexin
Cefdinir
Azithromycin
Clarithromycin
Clindamycin
Benzathine penicillin G (IM injection)
Short-term broad-spectrum antibiotics when specific pathogen is unclear (under specialist care)
Longer antibiotic courses (beyond typical strep protocols) in carefully selected cases
Prophylactic/maintenance antibiotics for recurrent strep or severe relapsing cases
Treatment of non‑strep bacterial infections (e.g., sinusitis, otitis, pneumonia) that may trigger flares
Treatment of profoundly common Bartonella, Borreli/Lyme, Babesia, Mycoplasma pneumoniae when implicated. Diagnostic labs should be able to detect 95+% of positives. The Labs that are this good are not national large commercial laboratories. Sadly, only 0.2% might pre-kill all these germs so the antibodies would be positive
Treatment diagnosed
2. Immunomodulatory / anti-inflammatory therapies
Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen for acute flares
High-dose oral steroid bursts (e.g., prednisone)
Steroid tapers after a burst to prevent rebound
IV methylprednisolone (IV pulse steroids) in severe cases
Intravenous immunoglobulin (IVIG) – standard dosing (e.g., 1–2 g/kg)
Repeat or maintenance IVIG in carefully selected, refractory cases
Therapeutic plasma exchange (plasmapheresis) in severe, treatment‑resistant cases
Low‑dose naltrexone (LDN) as an immune-modulating adjunct
Hydroxychloroquine (Plaquenil) in selected immune-mediated presentations (rheumatology oversight)
Immunosuppressive agents in extreme, carefully documented autoimmune cases (e.g., mycophenolate mofetil)
Rituximab in highly selected, severe autoimmune encephalitis–like presentations (very specialist-level)
Vitamin D optimization (for immune modulation)
Omega‑3 fatty acids (EPA/DHA) to support anti-inflammatory effects
Curcumin/turmeric supplements (adjunct anti-inflammatory; watch interactions)
3. Psychiatric / symptom-targeted medications
A. For OCD and anxiety
SSRIs at very low and slowly titrated doses (e.g., sertraline)
Fluoxetine (careful dosing; PANS kids can be very sensitive)
Escitalopram (again, very slow titration)
Clomipramine (specialist oversight; more side effects)
Short‑term benzodiazepines for acute, severe agitation/anxiety (cautious, time‑limited use)
Buspirone for chronic anxiety, sometimes as an adjunct
B. For tics, agitation, mood dysregulation
Alpha‑2 agonists like guanfacine
Clonidine (oral or patch)
Atypical antipsychotics in severe agitation or aggression (e.g., risperidone, aripiprazole; specialist-led)
Mood stabilizers such as valproate (if bipolar‑like mood swings; close monitoring)
Lithium in carefully evaluated mood disorders (with appropriate lab monitoring)
Propranolol for physical anxiety symptoms, rage episodes, or tremors (in appropriate patients)
C. For ADHD‑like symptoms, sleep, etc.
Stimulant medications for ADHD symptoms (used with caution because they can sometimes worsen anxiety/tics)
Atomoxetine as a non‑stimulant ADHD option
Melatonin for sleep onset problems
Trazodone or mirtazapine in select cases for insomnia or severe anxiety with poor sleep
4. Behavioral & psychological therapies
Cognitive Behavioral Therapy (CBT) targeted to OCD and anxiety
Exposure and Response Prevention (ERP) – a specific CBT for OCD
Parent training in ERP and behavioral strategies for home
Family therapy to reduce stress, improve communication, and manage accommodations appropriately
School-based behavioral interventions and accommodations (e.g., IEP/504 plan)
Habit Reversal Training (HRT) or Comprehensive Behavioral Intervention for Tics (CBIT)
Trauma‑informed therapy (for children traumatized by sudden onset or medical experiences)
Psychoeducation for child and family about PANS/PANDAS and OCD/tics
Coping skills training (relaxation, grounding, problem-solving)
Group therapy or support groups (for child/teens, when appropriate)
5. Nutritional & metabolic support
General diet optimization: balanced, minimally processed, adequate protein and healthy fats
Elimination of specific food triggers when clearly identified (e.g., gluten, dairy)
Anti‑inflammatory style diet (Mediterranean‑like)
Vitamin B complex supplementation when deficient or borderline
Methylated B12/folate in patients with relevant deficiencies or MTHFR issues (under supervision)
Magnesium (often for sleep, anxiety, constipation, or muscle tension; watch dose)
Zinc supplementation if deficient
Iron repletion if low ferritin or iron deficiency (can affect cognition, energy, mood)
Probiotics to support gut microbiome during/after antibiotic therapy
Prebiotic fiber to support healthy gut bacteria
N‑acetylcysteine (NAC) for glutamate modulation and as a possible adjunct for OCD and oxidative stress
Coenzyme Q10 (CoQ10) for mitochondrial support/energy (if fatigue prominent)
L‑carnitine in selected cases with fatigue or suspected mitochondrial issues
Antioxidant support (e.g., vitamins C and E) as adjuncts
6. Management of co‑infections and comorbidities
Treatment of chronic sinusitis (ENT evaluation, nasal steroids, saline rinses, appropriate antibiotics)
Treatment of chronic tonsillitis; ENT evaluation for recurrent strep
Evaluation and treatment of sleep apnea (sleep study, CPAP, ENT interventions)
Allergist/immunologist management for allergic triggers (allergy meds, environmental control)
Treatment of chronic gastrointestinal issues (constipation, reflux, IBS, SIBO)
Tonsillectomy in carefully selected children with very frequent strep infections or tonsillar disease
Adenoidectomy where indicated for chronic ENT problems
7. Non‑pharmacologic medical or procedural options
Intranasal steroid sprays for allergic rhinitis/sinusitis
Saline nasal irrigation for nasal congestion/infection prevention
Phototherapy/light therapy for mood or sleep circadian issues
Occupational therapy for sensory processing difficulties
Physical therapy for motor issues, deconditioning, or pain
Speech-language therapy for regression in language or communication issues
Neuropsychological testing to better tailor educational and therapy plans
8. Integrative / complementary approaches (evidence variable, use cautiously)
Acupuncture (for pain, anxiety, or sleep)
Mindfulness and meditation practices
Yoga or gentle movement programs
Biofeedback or neurofeedback (results mixed; provider-dependent)
Massage therapy for muscle tension and relaxation
Craniosacral therapy (low evidence but some families pursue it)
Herbal antimicrobials (e.g., certain botanical protocols) ONLY with knowledgeable clinicians
Quercetin and other plant-based anti-inflammatories (under guidance)
Epsom salt baths (magnesium sulfate) for relaxation, soreness
Aromatherapy as a minor adjunct for relaxation (if not sensory-aversive to the child)
9. Environmental and lifestyle modifications
Sleep hygiene interventions (regular schedule, screen limits, dark/cool bedroom)
Structured daily routine to reduce uncertainty and anxiety
Stress reduction strategies for family: therapy, support groups, respite care
Minimizing exposure to sick contacts when child is highly vulnerable to infection-triggered flares
School collaboration to reduce academic overload and social stress during flares
Gentle, regular physical activity as tolerated (walking, swimming, light sports)
Ongoing, coordinated care with a multidisciplinary team (pediatrics, psychiatry, neurology, immunology, therapy), adjusting the treatment plan over time