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Drooling

Drooling in children with CP and other chronic conditions

In children with a developmental disability, drooling is primarily due to inefficient and less frequent swallowing along with poor lip closure. Parents should be encouraged to discuss the amount of drooling observed at school and its social impact on the child with the child's teacher to give them additional data on deciding whether to seek treatment. The scale below may be helpful in tracking drooling over time and in response to treatment.
Teacher Drooling Scale (quantitative scale for periodic assessment of drooling [Robert: 2000])
  • No drooling
  • Infrequent drooling, small amount
  • Occasional drooling, on and off all day
  • Frequent drooling, but not profusely
  • Constant drooling, always wet
Treatment modalities are multiple and no approach is consistently successful. They include:
  • oral motor therapy - aimed at decreasing tongue thrusting, enhancing tongue mobility, and promoting jaw/lip closure. This is combined with behavioral modification to increase swallowing frequency. A child may be referred to a speech or occupational therapist to evaluate the likely impacts of such programming. The improvement may not generalize beyond therapy sessions.
  • botulinum toxin injections - are becoming increasingly common. Botulinum toxin injections into the salivary glands may be an effective therapy in many children. They need to be repeated every 3-6 months. These are usually performed by pediatric otolaryngologists and some physiatrists. See [Reddihough: 2010].
  • surgery - to decrease salivary gland function (e.g., removal of salivary glands, ligation of salivary ducts, repositioning of salivary ducts, and division of parasympathetic nerves to the salivary glands). Surgery is helpful for some but not all patients. Surgery may cause major (e.g., airway obstruction) and minor (dry mouth, crusted lips, difficulty with swallowing) complications. Thus, other options are generally tried first. Ironically, while the patient with the most severe oral functional impairment is most likely to be referred for surgery (because of aspiration of oral secretions), the patient with milder degrees of impairment might be more likely to benefit from such surgery. Children can be referred to an otolaryngologist familiar with these procedures if a family desires evaluation for surgical intervention.
  • dental appliances - which are thought to work by increasing swallow frequency, have shown good success in a limited patient series. There has been limited evaluation of this approach but, if fundable, it is more benign than surgery. Information can be obtained from Scottish Rite Hospital on how to construct the appliance and the child can be referred to a local orthodontist for appliance construction. One caveat, many children have oral hypersensitivity and a strong gag. The orthodontist must first decide if the child will tolerate the appliance. [Inga: 2001]
  • medications to inhibit secretions - Medications are variably successful and may be complicated by side effects. The most common medication utilized is glycopyrrolate since it has a good safety profile with fewer central side effects compared to benztropine and scopolamine. Dosing recommendation for oral use is 0.04-0.1 mg/kg/dose, three to four times per day. The most commonly reported side effects are dry mouth and/or thick secretions, urinary retention, flushing, sleepiness, and constipation. Patients may occasionally report blurry vision. Pseudo-obstruction, agitation, and personality changes have been reported. Occasionally parents want to use glycopyrrolate or other medication in a limited time frame for an important occasion (e.g., a family wedding). Although these medications might decrease drooling in the acute setting, they also might cause drowsiness and families should try the medication prior to the family event.

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Helpful Articles

Blasco PA, Stansbury JC.
Glycopyrrolate treatment of chronic drooling.
Arch Pediatr Adolesc Med. 1996;150(9):932-5. PubMed abstract

Inga CJ, Reddy AK, Richardson SA, Sanders B.
Appliance for chronic drooling in cerebral palsy patients.
Pediatr Dent. 2001;23(3):241-2. PubMed abstract

Burton MJ.
The surgical management of drooling.
Dev Med Child Neurol. 1991;33(12):1110-6. PubMed abstract
A little dated but reviews the various options.

Authors

Author: Lynne M Kerr MD, PhD, 2/2009
Content Last Updated: 5/2011

Page Bibliography

Inga CJ, Reddy AK, Richardson SA, Sanders B.
Appliance for chronic drooling in cerebral palsy patients.
Pediatr Dent. 2001;23(3):241-2. PubMed abstract

Reddihough D, Erasmus CE, Johnson H, McKellar GM, Jongerius PH.
Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement.
Eur J Neurol. 2010;17 Suppl 2:109-21. PubMed abstract

Robert E. Nickel, M.D. & Larry W. Desch, M.D. .
The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions .
Baltimore, MD: Paul H. Brookes Publishing Co.; 2000. 1-55766-446-3 http://www.pbrookes.com/store/books/nickel-4463/index.htm