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:
  • Oral motor therapy is 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 strategies. The improvement may not generalize beyond therapy sessions.
  • Medications to inhibit secretions 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. [Garnock-Jones: 2012] Dosing recommendation for oral use is 0.04-0.1 mg/kg/dose, 3 to 4 times per day. The most commonly reported side effects are dry mouth, thick secretions, urinary retention, flushing, sleepiness, and constipation. Patients may occasionally report blurry vision. Pseudo-obstruction, agitation, and personality changes have also been reported. Occasionally parents want to use glycopyrrolate or other medication for short-term benefit during an important occasion (e.g., a family wedding). Although these medications might decrease drooling in the acute setting, they may also cause drowsiness. As such, families should try the medication prior to the family event.
  • Botulinum toxin injections are becoming increasingly common. Injection of Botulinum toxin into the salivary glands is an effective therapy for many children. Their benefit is temporary and they usually need to be repeated every 3 to 6 months. These are usually performed by pediatric otolaryngologists or physiatrists. See [Reddihough: 2010], [Chan: 2013], and [Vashishta: 2013].
  • Surgery can decrease salivary gland function (e.g., removal/repositioning of salivary glands, ligation of salivary ducts, and division of parasympathetic nerves away from the salivary glands). Surgery is helpful for some but not all patients. It may cause major (e.g., airway obstruction) or 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), a patient with milder impairment might be more likely to benefit from such surgery. Referral to an otolaryngologist familiar with these procedures is recommended when a family desires evaluation for surgical intervention. [Hornibrook: 2012]



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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
Although dated, the information about various management options is still relevant.


Authors: Lynne M Kerr, MD, PhD - 12/2013
Lisa Samson-Fang, MD - 12/2013
Reviewing Authors: Meghan Candee, MD - 2/2016
Nicholas Johnson, MD - 2/2016
Content Last Updated: 2/2016

Page Bibliography

Chan KH, Liang C, Wilson P, Higgins D, Allen GC.
Long-term safety and efficacy data on botulinum toxin type A: an injection for sialorrhea.
JAMA Otolaryngol Head Neck Surg. 2013;139(2):134-8. PubMed abstract

Garnock-Jones KP.
Glycopyrrolate oral solution: for chronic, severe drooling in pediatric patients with neurologic conditions.
Paediatr Drugs. 2012;14(4):263-9. PubMed abstract

Hornibrook J, Cochrane N.
Contemporary surgical management of severe sialorrhea in children.
ISRN Pediatr. 2012;2012:364875. PubMed abstract / Full Text

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

Vashishta R, Nguyen SA, White DR, Gillespie MB.
Botulinum toxin for the treatment of sialorrhea: a meta-analysis.
Otolaryngol Head Neck Surg. 2013;148(2):191-6. PubMed abstract