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  1. Son (7) had his pandas onset in February 2018, treatment starting in April 2018, and mostly in remission by June. He was on abx until September with no problems. Had a dental cleaning in November 2018 and a few days later we were pretty sure he was having a flare. That said, we think the flare probably started the week prior to the dental cleaning. Being honest, we have no idea if the teeth cleaning had any correlation to the flare. In any event, once the flare was obvious, we started abx again and symptoms went away in a day. In February, his bloodwork showed low neutrophils so his doctor took him off abx again. He's been going strong without abx since then! He is scheduled for a dental cleaning on Wednesday. As noted, i have no idea if his previous flare was correlated to the dental cleaning. Should we be taking any precautions in advance, during or after the appointment? I'd prefer the least intervention as possible, but am open to advice.
  2. Maryangela - thanks for your response! It sounds like you have a kid like mine who has pandas and also adhd - is that right? Or did he only have adhd symptoms because of the pandas? My son has had adhd symptoms since infancy..... The adhd med we are currently on (concerta) keeps him pretty close to his natural personality (which is very happy, go with the flow -- which is why, when he suddenly started being defiant last year, we knew something major was going on). Previous stimulants made him moody. I am trying to follow your timeline: what happened to the bug fear? Was it just that one summer? Did it eventually go away? What do you think made it go away? It's interesting because if you google adhd and bug fears, there are a ton of people talking about the correlation. But if you google bug fears and pandas, or specific phobias and pandas, there aren't so many hits. I'd love to have someone tell me that's it's most like the adhd (or stimulant) and not pandas. Because we can deal with the adhd. Versus if we think the bug fears are pandas, then we're looking at much bigger questions. For instance, his pandas symptoms have all responded very quickly to abx. But the bug fear doesn't seem to correlate to when he's on abx. So i don't even know what treatment we'd do for this. Would we do ivig because we *maybe* think this is a symptom?
  3. Son (7) was diagnosed with Pandas over a year ago, treated and generally went into remission by June 2018. After going off abx in September, he had one flare last fall, and possibly a small flare this last January (both immediately treated with abx, and symptoms immediately resolved), but otherwise he is back to baseline. His primary symptoms were hyperactivity and rage/defiance. He never had classic tics or OCD. I know ocd/anxiety can look different in different kids, but his specialist confirmed he didn't have oct/anxiety. She said that she anecdotally sees a subset of boys with preexisting autism/adhd/add whose pandas doesn't always have tics/ocd/anxiety. Because he has been at baseline for a while, we stopped abx at the end of february. Son has had a minor recurring fear of insects for some time. Hard to pinpoint when it started - sometime last year. It just wasn't a big deal and we didn't pay a ton of attention to it. The fear had gone away for a while (probably since last summer) and then after xmas picked up a bit. A few weeks ago, it escalated significantly and for the first time is now a significant impact on his life. He freaks out when he sees anything that could be a bug. Sticks with the teacher at recess for fear of bugs. No longer wants to stay after school at the playground. Runs from the car to inside after school. Really freaking out when one gets near him. Hard to console. As soon as he gets inside, he's immediately better. We have not had any other signs of pandas since at least January (really not since November). In fact, son has never been better personality wise. Well behaved, happy, non-defiant, etc. My preference is that this has nothing to do with pandas. He is also medicated for adhd, and we've struggled with side effects from that (both the adhd and the medication can cause weird symptoms). But it's very difficult to tease out what is tied to the adhd/medication because he needs it for school - so we can't really take him off the drugs. Has anyone seen a lone anxiety without any other symptoms of pandas?
  4. We have a son who likely didn't have any significant tics or OCD relating to PANDAS. His primary symptoms are rages and increased hyperactivity. He had adhd symptoms from birth, but the rage and extreme hyperactivity came out of the blue when he was 6. He was always a quirky kid, but during the 6 months of his initial onset, many doctors and therapists and teachers suggested autism. After two months of abx and some trials of steroids, most of the problems had completely disappeared subject to periodic flares. Our situation is muddled by his pre-existing adhd diagnosis. He was already on adhd medication for his hyperactivity. It has been very hard to untangle four possible sources of behavior: (1) regular evolving behaviors of a 5-7 year old; (2) adhd; (3) pandas; or (4) adhd medication. Several months before he fell off the pandas cliff, he started having some increased problems in school. We increased his adhd medication. In hindsight he had a bunch of minor symptoms crop up between the time of increasing his adhd medication and his "pandas cliff" moment a few months later. Tics: Throat clearing, swallowing, sniffing, but usually only during concentrating on an activity. A significant increase in a complex stereotypy that he'd had since infancy. He developed a significant fear of spiders, bugs, hurricanes and sinkholes. But not serious enough fears that they interfered in daily life. In hindsight, we have no idea if all of this was pandas. Or caused by the adhd medication. It took almost a full year to tease out what symptoms came from what (and honestly, we are still working on it). The rages and increased hyperactivity went away on abx, so we are sure they are pandas. The fears mostly went away when we changed his adhd medication. The tics and stereotypy lingered. And then we stopped his adhd meds altogether over this xmas break, and both tics and stereotypy 90% disappeared. His pandas specialists never though the tic was from pandas - because he only did it when he worked on certain activities. And she never thought his fears were sufficient to count as pandas OCD, because they were pretty minor. She said that anecdotally she has seen a subset of pandas kids who don't exhibit classic pandas (ocd and anxiety) but instead show as more autism/stereotypy/hyper -- and that these kids are often adhd/autism-light kids to begin with. Which describes my son. Not sure if that helps your question.
  5. Hi - I posted most recently back in November when DS(7) was having his first flare. His initial onset was last winter, and with abx he returned to 100% by summer. In sept we took him off abx, and 7 weeks later he had a minor flare. Re-started abx, and the flare disappeared immediately. His specialist advised continuing abx until at least the next appointment (in two weeks). After the November flare, his augmentin dose was dropped by 30% (convoluted story that the original dose was technically a bit high for his body weight, but they didn't offer pills for his body weight. So now we cut ONE and a HALF clav250 125mg tablets twice a day - which is treatment dose for his weight). It's been 3 months and we just confirmed yesterday that DS started another flare last week. His early onset symptoms are increased hyperactivity and new irritability. Because he already had adhd prior to the pandas, it's not until we see him get irritable that we know it's a flare. His behavior is still mostly pretty great at home. It's only at school that he's likely to have more serious behavioral issues. (during his acute onset last year, he had moderate to severe problems at both home and school that required withdrawal from school) No idea what the trigger is. Our household is pretty healthy, no one's been sick, no loose teeth, etc. But he attends school - so obviously could get exposed to anything there. He has never tested positive for strep on a swab or culture (nor have mom and dad). However, he has consistently high dnase titers (upper range is ~275, and he tested 1350 during his acute event, 850 during his november flare, and 750 during xmas break when in remission). I doubt he would test positive for strep now, but titers would probably still be high. At the advice of our specialist at the last appt in november, yesterday i started dosing him 400mg of advil three times a day. He also takes his regular adhd medication, augmentin, plus probiotics, D3 and fish oil. I am calling his specialist this morning for next steps. Just curious what everyone on here recommends for treating a flare when you are already on treatment dose abx. Should we request going back up to the slightly higher abx dosage? Steroid burst? (during the acute event last year, we did both a steroid burst and then 30 day taper - which caused immediate 100% improvement but benefits went away within days - but not sure if the steroids helped contribute to his longer recovery?) Are we at a place where we need to consider ivig, etc etc - even if his flares have been very minor? Is the fact that he's flaring at all (whether minor or major) mean that we need to bring out the so-called big guns?
  6. DS(7) had been on treatment dose augmentin for 6 months following his diagnosis. Then we tapered off abx, and he was successfully off for 7 weeks. Then he had a minor-moderate flare at the beginning of November. It took us 10 days to determine it really was a flare (symptoms got bad at day 10), then we started on abx again. Major symptoms immediately disappeared, and all symptoms fully remitted within 10 days of abx. Doctor recommended staying on treatment dose abx longterm. Son was on 500 augmentin twice a day, but two days ago we reduced to 375 (which is technically his treatment dose based on age, but his doctor had previously just rounded up). So a 25% reduction in abx dosage starting two days ago. Not sure what caused the November flare: his strep antibodies are quite high, but he also lost a tooth in the peak of the flare (tooth fell out 3 days before worst symptoms/starting abx). So could be either, or something else. Now in the last 24 hours, he seems like he has minor flare symptoms again (hyper and moody). Two possibilities: He lost a tooth two days ago, but we also dropped the abx 2 days ago by 25%. Not sure what the issue is, but when we tapered the abx in september, there was no increase in pandas symptoms. So thinking this maybe tooth related. This minor flare is not as bad as the november flare, but the major difference is he is already on antibiotics this time. So presumably that would have helped take the edge off things. For those who have minor flares while on treatment dose abx, what's your protocol? Especially if tooth related? Should we be increasing abx? Should we just ride out a minor flare? ibuprofen?
  7. We just returned from an appointment with our specialist following son's (7) first flare. In brief: - Son's first symptoms of pandas cropped up either last November (in earnest) but exploded in February. On a scale of 1 to 10 (10 being the worst) relative to other pandas' kids as reported on this and other sites, i'd say he got as bad as a 5 or 6. His symptoms were increased adhd, new anger and emotional liability, and some autistic qualities. - Two months after the explosion (but potentially 4-5 months after very first symptoms), he was diagnosed and treated with augmentin. We saw positive changes at two weeks, and then by six weeks he was at 90%. Only remaining issue was lingering emotional liability (uncharacteristic moodiness, anxiety and irritability), which went away a few months later when we adjusted his adhd meds. Son was on abx for 5.5 months total. - Seven weeks after dropping the abx, son had his first flare (late october). Symptoms were minor at first (1 out of 10 on the pandas scale). On day 10, he got uncharacteristically angry about a few things and was acting a bit autistic, so it was clear he was in a flare (3 out of 10 on the pandas scale for exactly one day - still not bad) and we started abx. 12 hours later he was back to 90%. Within 10 days he was back to 100%. Stayed on abx for the whole 20 day duration with no additional issues. The whole flare lasted approximately 3 weeks (from 100% back to 100%), and it was -- in hindsight -- not difficult at all. - Son tested negative for strep several times this fall and no symptoms of strep. After the flare started, he did bloodwork with high dnase antibodies (850 with normal range 350). We don't have a baseline to compare against. - Just went to the specialist for what i thought was a routine follow up post-flare, and he wants to keep son on abx for 3 more months -- even though he is at 100%. His theory is that the worst cases of pandas are those with increasing severity of flares that are less likely to respond to treatment, and so we should avoid flares at all costs. The fact that son only went seven weeks after stopping abx suggests that his immune system might not be sufficiently repaired to deal with future triggers, and we'd rather not test it out. He couldn't say how long we'd be on abx, but we'll reassess in 3 months, but he could be on much longer than that even if he's symptom free for the next 3 months. He said the abx will help avoid strep infections, but also may serve to bolster the immune system to protect against flares once we stop abx. I'm surprised they are recommending this because this practice has previously told me that they are not big on long term abx -- and they are well known on this forum and elsewhere as being very conservative on pandas treatment (following academic/research recommendations, and less on anecdote/experimental). Son went from having a moderately bad pandas onset that took 6-8 weeks to respond to abx, to having a flare that had almost immediate responsiveness to abx. Everything i've read about prophylactic abx suggests it's reserved for the most severe cases, and that almost all pandas cases (i.e., not just the most severe) have a relapse-remitting course of flares. So the fact that son had a (minor) flare doesn't seem severe to me, but par for the course, right? I know lots of people on this forum have kids who were on long term abx, but my read was that it was for kids who had severe pandas, never reached 100% while on treatment , and/or relapsed as soon as they stopped the abx. Just wondering what other people's understanding is of the proper use of long term abx, if the treatment protocol has changed, etc. Anyone have any thoughts?
  8. Can a pandas kid produce strep antibodies (dnase) without a strep infection? During his recent flare, his dnase were 850 (upper normal is 350). I'm 99% sure he has not had strep in a year -- because he was on abx until 6 weeks before the flare, and then we did a bunch of strep swabs and cultures (including anal) after stopping abx right through to when the flare started. Everything was negative. He had no symptoms of strep during any of this. Unfortunately we don't have a baseline dnase number - we didn't run bloodwork when he was feeling better. So it's possible he always runs high. I know pandas kids can be asymptomatic carriers of strep - but would the swabs and cultures be negative for those kids? We know other kids at school had strep. I know pandas kids can flare based on exposure to strep - but would antibodies go up in those cases? If his flare was caused by something other than strep, would that cause the antibodies to go up?
  9. Not getting any hits on my last question (flare versus reemergence) so let's narrow down the question a little! Let's assume DS is having a flare. He was at 100% remission, no abx prior to the flare. Flare started out with minor symptoms (minor irritability at school), and within 10 days escalated to minor-moderate -- which is when we realized something was happening. Our pandas doctor immediately prescribed 10 days abx. We also restated ibuprofen, fish oil, and D3. We are awaiting new bloodwork to see if there is an infection (but don't have anything recent to compare to, for purposes of seeing the trend). We saw improvement to 80-90% within a day or starting abx. For those of you whose kids (1) don't take prophylactic abx; and (2) got to 100% remission between flares: What is your protocol for dealing with flares that start in earnest? Does it matter if the trigger is strep infection, versus a non-bacterial trigger? Obviously, if the trigger is strep, you need to address the underlying infection with abx, and presumably the issue could escalate if untreated. But do you need abx if it's a non-infectious trigger (loose tooth) or mere exposure to (but no symptoms of) strep? If your kids just have a moderate flare from, say, a loose tooth, can you minimize the flare with ibuprofen, and then it passes after a couple weeks? Or do you need abx? For those non-infectious flares, if you didn't treat, would it pass within a couple weeks, but with more severe symptoms?
  10. DS(6) was diagnosed with pandas in April. Symptoms likely started 5 months before that, but he really fell off a cliff in February. His Pandas is not classic with tics and classic OCD. Rather, he looks more hyper, disengaged and autistic. DS had a previous adhd diagnosis at age 3 and has always had some autistic characteristics. Pulled him out of school when diagnosed in April because he was unable to function there. Started Augmentin in April, and saw gradual improvements over 2 months. After two months on augmentin, he seemed much improved at home but hard to tell because school is his real trigger. But he still seemed very moody all summer. Ultimately decided his adhd meds could be contributing to the problem, and dropped the adhd meds slightly. That immediately had a big improvement in his mood. (We also tried some steroids during this time -- always with freakishly fast, good results -- that ended within 2-3 days of stopping. I ultimately decided the improvement had nothing to do with pandas, and more to do with his adhd, as there is literature that steroids improve adhd and autistic symptoms significantly. The steroids didn't feel like we were getting our kid back, but rather like we were getting a stepford wives version of our son). Started school in August and things went pretty well. By this point, it was clear he was 100% recovered and probably had been for a while (the summer moodiness was probably related to the adhd meds). Decided to taper down the abx, and on Sept 15 we stopped giving him Augmentin altogether. He had a few days of dicey behavior, but then reverted to being well behaved. For the following six weeks, school went great. Teacher reported that the 504 we had previously requested was barely needed. Then we got word that on oct 26, 29 and 30 he had weird, bad behavior in class. We hadn't seen any problems at home and thought the teacher was overreacting. But a few days later, we saw some of the first creeping signs of his pandas: hyperactivity, stereotypies, etc. He was otherwise in good spirits, so we couldn't conclusively say it was pandas. But then this Tuesday night, he was angry, oppositional, defiant, saying gibberish, disengaged.... not as bad as he got last year, but my husband and i could definitively say he was having pandas symptoms again. Started Augmentin and ibuprofen that night, and he was pretty recovered 24 hours later. We are doing a 10 day course at the advice of the Rothman Center, and then will reassess. But if we have 2 more days of his current behavior, i think we can say he is back to 100%. So now i'm wondering: is this a flare? Or is this the reemergence of his original course of pandas? A distinction without a difference? There were 6 weeks between stopping Augmentin and the first potential sign of pandas. Eight weeks between stopping Augmentin and the "it's clearly pandas" moment we had on Tuesday. I know some people need to be on Abx permanently -- doctors aren 't sure but think it's because either the infection never really goes away, or they have suppressed immune systems, or maybe that the Abx provides anti-inflammatory properties. But i see people on this site talk about how the symptoms return in those cases within days -- much like they did for us when DS stopped steroids. But what about if the symptoms come back in six weeks or more? Possible triggers for a flare: exposure to any one of the million kids in his school who are currently sick (we've had several reports home of strep from his school); dad had a cold (not strep) 2 weeks ago; DS had a cold (not strep) 4 weeks ago, DS has had a ton of "dental activity" in the last 2 weeks (wiggly tooth that fell out on Saturday, and some serious dental scraping on Friday - but the dental appointment and tooth were after he first started showing symptoms, but a few days before the symptoms got worse). The reason it matters to me if this is a flare versus the inevitable reemergence following stopping abx: If it's the latter, we presumably need to be on Abx for years. If the former, we can probably deal with flares as they happen and start to predict them. Maybe address them even though ibuprofen. Obviously, like all parents on here, i'd rather my son not be on abx long term if he doesn't have to be. Anyone have any ideas? Or it's all just the unknown netherworld of pandas....?
  11. Our son started a steroid taper 2.5 weeks ago. First 7 days on 2mg/kg, next 7 days on 1mg/kg, next 7 days on .5mg/kg, and last 7 days on .5mg/kg every 2 days. Within hours of the first dose, we saw a huge improvement. First 12 days were consistently fantastic. Mood was greatly improved, anxiety reduced (but not entirely), son was totally amenable to stopping his stereotypies (he has what we initially thought were tics, but were in fact very complex stereotypies involving full body movements along with imagining sessions). On the 13th day (six days after the first decrease, and 1 day before the next decrease) we saw a return of some issues -- some tears, increased anxiety and irritability, and a minor reemergence of the stereotypie. So we went from maybe 90% improvement to 60% -- all while still on the taper. When we tried a 5-day steroid burst a few months ago, his symptoms disappeared on day 5 (right before the last dose) and stayed away for 3 days before total reemergence. What could account for his initial improvement on steroids and then reemergence of issues on day 13? The obvious answer is that his symptoms seem to be tracking the tapering of the steroid. But if we're addressing autoimmune inflammation, wouldn't we expect some continued benefit without tracking, almost day by day, the tapering? My fear is the benefits we were seeing the first 13 days were in fact simple positive side effects of steroids (which, for many people taking it for asthma etc, produce a "high" that gives them a good mood and more energy) and not necessarily anti-inflammatory properties relating to autoimmune. Any thoughts?
  12. We had our follow up at Rothman Center on Thursday. Unfortunately Dr. Murphy was sick, so we saw her RN in her absence. Dr. Murphy had given her the go-ahead for my son to start a steroid taper. We picked the prescription up yesterday for the first 7 days, and it's 15mg/5ml. He's 6 yo and 59lb, so the dosing is 26.4ml twice a day. That is a lot of liquid - a couple centimeters at the bottom of the glass. And it's really hard to swallow. We had it grape flavored but it doesn't really help. We've gotten him to take two doses but it's been tough (and i don't blame him). When our pediatrician prescribed the steroid burst (which gave us 3 days of symptom relief), it was 15mg/5ml. He was only taking 8.6ml so it was much easier to swallow in a quick burst. I asked the pharmacist about it, and she said the 15mg/5ml would have been prednisolone, which is effectively the same thing as prednisone, and she could swap it for me without checking with the doctor. Other alternative is a tablet, but she'd need our doctor's approval monday to do that. I struggle to imagine 2 more days of doing the full 26.4ml.... Any thoughts on whether there's any difference between prednisolone versus prednisone in terms of treating pandas? I quick google search says one is used for people who have kidney issues, which my son does not, but otherwise there's no difference. But wondering if pandas is a different beast. Should we wait until monday to email the nurse practitioner?
  13. We are likely going to start a 4 week steroid taper next week for my son's PANDAS. Following two months of antibiotics with some improvements, the primary symptoms we still have are major anxiety, increased hyperactivity, and very significant stereotypies (specifically: intense imagery movements). We previously did a 5 day steroid burst, and saw good effects on day 5, that lasted for 3 days. I understand this suggests that a full steroid taper is likely to be helpful. I see a lot of people on this site say how steroids were fantastic, but that they rarely have lasting effects. Question for everyone: Did the steroids-benefits go away because your child was ultimately exposed to another trigger? Or was it because the benefits simply faded over time?
  14. I've posted on some other posts about my son's PANDAS - the most dramatic symptoms of which struck overnight in February (it's possible other symptoms were creeping in since November). He does not have debilitating OCD or tics, but had increased anger, adhd, emotional liability, defiance, ASD type behavior and meltdowns that make school untenable, minor sleep disturbances, very complex stereotypies, separation anxiety, etc. Some of these behaviors were drastically increased behaviors of existing conditions (adhd, stereotypies, some minor ASD qualities), while the others were totally new behaviors (anger, defiance, meltdowns, anxiety). After months of thinking these behaviors were adhd medication side effects, our primary care doctor suggested pandas. He tested with very high strep antibodies, so our primary put him on antibiotics and then a 5 day steroid burst. He had great improvement for three days after steroids. We thereafter got in to see Dr. Murphy in florida. She recommended continuing antibiotics for several weeks and reassess. At the 1.5 month mark, we felt like we'd seen great improvements: the anger and defiance were mostly gone, and sleep improved. He was, however, home full time with a nanny. When we recently resumed camps and some other "stressful" activities, he had major behavioral problems again. So the antibiotics probably took the edge off things, but we think we still have anxiety as a core issue, and that anxiety makes school an impossibility right now. Dr. Murphy said that if the antibiotics don't work, we'd probably jump right to steroids (since he already responded positively to the 5 day burst). She mentioned a 1-month taper, or IV steroids ( but said those could be more challenging to administer - because of insurance and finding a provider), and then IVIG as a potential too. Our insurance (cigna) likely does not cover IVIG. We are seeing Dr. murphy next week to discuss. Should we try the 1 month steroid taper first? Or should we push for IV steroids? In either case, what co-medicines (like steroid extenders) do we need to ask about? If we start with the one-month taper, does that take IV steroids off the table for some period of time (Dr. Murphy said she won't do steroids for longer than a month)? Without insurance, is IVIG really worth doing (one treatment we would pay for. But so many people report needing 5+ treatments - which would be like $40,000+, which seems like a lot for something that may or may not work). What other options should we be considering? Our case is no longer severe --in that we can easily work around his issues so long as he is at home. But it's very severe -- in that he can't attend school. I know there are right answers for everyone, and what works for some doesn't work for others. Just wondering what seems like the next logical steps for us.
  15. Thanks for your thorough response! Yes, we are very sure the behaviors are PANDAS driven (or something analogous) -- because there was such a sudden onset, and the rage/violence/dissociation were so incredibly out of character for him. So we continue to actively treat the PANDAS. We had hoped antibiotics were doing the trick, because home life had been pretty flawless for the 6 weeks he was home from school with a nanny. But the travel and camp i guess pushed his boundaries, and he's not as remedied as we had hoped. We are going back to see Dr. Murphy, who, based on our last appointment, will likely recommend steroids for a month. (We had tried a steroid burst at the time of diagnosis, and it worked well for a few days). But i recognize it could take months for successful treatment - potentially years. In the mean time, i have a kid who literally cannot attend school because he has these manic episodes. I agree we can minimize camp and try some other activities instead. (I don't think there's much we can work with the camp on -- as said, he is effectively dissociated in these sensory overload times. He's exceptionally well behaved elsewhere, and tightly follows rules. His various therapists all agree that there are no tools you can give him in these moments where he loses it because his mind goes to a place where he can't access the tools). There are other camps he's doing this summer that we know will be a much better fit, so he will attend those. But he needs to go to school in august! He's an only child, my husband and i both work (and want to continue working), i'm not someone who would enjoy homeschooling (tho i would if i had to), we're not religious, and most importantly, this kid needs some regular socialization! The two months home with a nanny were super calm, but without too many details, it was very clear he needs to be in some kind of daily school setting with other kids. Before we withdrew him from school (and before the PANDAS diagnosis), we tried a lot of things in school - including me spending 2 full weeks in the classroom with him. Even then, i spent a lot of time diffusing him, dragging him out of the class, spending time alone with him, etc. For those two months, one would barely say he was "in school", given how low his engagement was. And that was with me -- his greatest expert -- making every accommodation we could. Point of all this is: If he's going to be in school, we need to cure the pandas OR medicate. If the dissociation in school/camp is presumably anxiety based, what kinds of meds have worked best for PANDAS kids, and at what doses? He is currently on 15mg adderall (which he's been on for 2 years for adhd, before the PANDAS) and we have added 2mg Intuniv (guanfacine) since the PANDAS diagnosis (which he probably needed for the adhd, even before the pandas). I have read stuff about pandas kids in particular needing low doses of SSRIs? I'm sure dr. murphy will go through all this with us, but it may be weeks or longer before we can see her, and our psychiatrist is pretty open to whatever we need to do now.
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