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Drooling in Children with Special Health Care Needs

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Boy with classmates wearing a bandana for drooling
Sialorrhea, commonly known as drooling, is defined as the inability to manage one’s secretions. [Rapoport: 2010] [Meningaud: 2006] In children with a developmental disability, persistent drooling beyond infancy and toddlerhood is often caused by lack of strength, coordination, or sensation in the mouth, tongue, and throat; overproduction of saliva (hypersalivaton) can contribute as well.

Reflux, nausea, teething, malocclusion, enlarged tongue or persistent tongue thrust, painful oropharyngeal or esophageal lesions such as herpes, and use or exposure to certain drugs (e.g. antipsychotics especially clozapine, and some antibiotics, tranquilizers, and medications used to treat Alzheimers) or chemicals (such as mercury) can also contribute to drooling. [Meningaud: 2006] Children with neurodevelopmental or neuromuscular disorders, genetic conditions (e.g., Rett syndrome), traumatic brain injury, and dysautonomia are at increased risk of sialorrhea.

Approximately 1/3 of children with cerebral palsy or other neurological conditions have sialorrhea, although not all of these children have problematic drooling. [Rapoport: 2010] The following aims to help clinicians and families discuss treatment options when a child has persistent, problematic drooling.

Other Names

Hypersalivation
Sialorrhea

Assessment

Parents may not be aware of interventions that can reduce drooling, so the clinician should ask the child and family how much the persistent drooling impacts them and if they would like to explore interventions. In addition to social stigma, drooling can contribute to odor, rash, chapped lips, mouth infections, aspiration, dehydration, stained clothes, frequent laundry, and ruined computers or other hardware. [Walshe: 2012] [Rapoport: 2010] Encourage parents to ask the child's teacher about the amount of drooling observed at school and its social impact on the child.

Assessment scales can be used before and after treatment to monitor its effectiveness. Examples include the Drooling Quotient, Drooling Severity and Frequency Scale [Rashnoo: 2015], and The Drooling Impact Scale (PDF Document 100 KB) . [Reid: 2010]

The Teacher's Drooling Scale , below, is a brief assessment tool to help track drooling over time and in response to treatment; the Modified Teacher's Drooling Scale has 4 additional questions to more finely gauge drooling severity.

Teacher Drooling Scale [Robert: 2000]

  1. No drooling
  2. Infrequent drooling, small amount
  3. Occasional drooling, on and off all day
  4. Frequent drooling, but not profusely
  5. Constant drooling, always wet

Treatment

Response to treatment is variable; multiple trials may be valuable in finding the best approach. The clinician can work with the family and pediatric specialists to discuss options and determine when intervention trials are warranted.

Pearls & Alerts

Off-Label Use of Atropine
As an off-label use, atropine drops are sometimes used sublingually to treat drooling:
  1. Premoisten cotton-tipped applicator -- hold tip upright and apply 2-4 drops normal saline
  2. Apply 2-6 drops of atropine 1% ophthalmic solution to the pre-moistened applicator tip
  3. Swab/twist applicator inside one cheek for 10 seconds.
  4. Repeat using new applicator, saline, and atropine drops for the other cheek.
  5. May repeat the process every 6-8 hours as needed.
Anticholinergic Medications for Single Occasions
Anticholinergic medications are occasionally requested by parents 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. Families should try the medication prior to the event to assess response and side effects.
Illness Can Affect Dosing
During respiratory illnesses affecting the child’s airway, the clinician may consider adjusting the child’s antisialorrheic medication dose up or down to either decrease secretions or reduce the thickness of the secretions. Increase fluid intake accordingly if the child has increased losses from excessive secretions.

Therapies

Oral motor or oral sensory therapy is aimed at decreasing tongue thrusting, enhancing tongue mobility, improving postural control, improving sensation to the area, and promoting jaw/lip closure. [Walshe: 2012] There is low-grade evidence to suggest that application of Kinesio tape to jaw muscles, a practice sometimes used by physical therapists, may help children to improve oral motor skills. [Mikami: 2017] A child may be referred to a speech or occupational therapist to evaluate the likely impacts of such strategies.
Behavioral therapy can help train some children to swallow more frequently, wipe the jaw, close the mouth, correct posture, and develop more self-control. [van: 2018] [Walshe: 2012] Behavioral modification techniques are often used in conjunction with oral motor therapy.
Intra-oral appliances, some of which are similar to retainers, may be made by a dentist or orthodontist to attempt to improve oral control and contain saliva in the mouth. [Inga: 2001] Intra-oral prostheses, such as a lip plumper prosthesis, may be used to help approximate lips and create a better oral seal. [Moulding: 1991] Limitations include cost, comfort, and sensory defensiveness. [Walshe: 2012]

Medications

Medications to inhibit secretions are variably successful and may be complicated by side effects. The medications used to treat drooling in children are typically used off-label because most are not FDA-approved for such use in children, and dosing is usually derived from clinical studies, care guidelines, or experts in practice. The Medical Home Portal advises prescribers to check the drug manufacturer's website prior to prescribing any of these medications.
Anticholinergics used to decrease saliva production include atropine, glycopyrrolate, scopolamine (hyoscine), and benzhexol (trihexyphenidyl). Side effects of these medications may include thick secretions, constipation, dry mouth, vomiting, diarrhea, pyrexia, flushing, nasal congestion, sleepiness, urinary retention and infections, blurry vision, rash, headache, seizures, and behavior changes. [Walshe: 2012] [Zeller: 2012] [Zeller: 2012]
  • Atropine
    • 2-6 drops per cheek of the 1% solution every 6-8 hours (see Pearls & Alerts, above)
    • Alternative dosing: 1-2 drops of 0.5% ophthalmic solution every 4-6 hours may be used sublingually, providing local treatment and resulting in fewer systemic side effects or medication interactions. [Rapoport: 2010] Another study noted that several parents found it difficult to administer. [Norderyd: 2017]
    • Atropine gel is also undergoing phase 2 clinical study.
    • There is still a potential risk of systemic anticholinergic side effects; however, sublingual atropine has lower potential for side effects and medication interactions compared to glycopyrrolate.
  • Glycopyrrolate
    • The solution formulation was approved by the FDA in 2010 for children ages 3-16 years with neurologic disorders and severe sialorrhea. [Eiland: 2012]
    • Patients with Down syndrome and children with spastic paralysis or brain damage may be hypersensitive to antimuscarinic effects. See Glycopyrrolate (Drugs.com).
    • Dosing recommendations for oral use vary among studies. One controlled trial in the United Kingdom used gradual upward titration from 0.04-0.1 mg/kg/dose, up to 3-4 times per day orally or via feeding tube; max 2 mg. [Parr: 2018] [Rapoport: 2010]
  • Scopolamine (hyoscine) patch
    • In the United Kingdom, this medication is used more frequently than glycopyrrolate for problematic drooling; however, it has more side effects than glycopyrrolate. [Parr: 2018] It is well known as a treatment to prevent motion sickness.
    • Patients with Down syndrome and children with spastic paralysis or brain damage may be hypersensitive to antimuscarinic effects. See Glycopyrrolate (Drugs.com).
    • A pediatric drug trial evaluated dosing ranges of ¼-1 full transdermal patch every 3 days, but the patches are not designed to be cut. [Parr: 2018]
    • Another trial used 1 patch every 3 days in children >12 years. [Rapoport: 2010]
    • A safe and effective pediatric dose has not been established in the U.S. See Scolopamine Patch (Drugs.com).
  • Benzhexol (trihexyphenidyl)
    • Drug information recommends that patients should undergo a gonioscope evaluation of intraocular pressures prior to use and receive close monitoring of intraocular pressures periodical during use. Do not use the drug in children <3 years of age. See Benzhexol (Drugs.com) and Trihexyphenidyl (Encyclopedia of Mental Disorders).
    • In a study of off-label use of this medication for treatment of dystonia or sialorrhea in children with cerebral palsy, it was generally well tolerated and effective. [Carranza-del: 2011]
    • Dosing in the study increased gradually from a mean of 0.095 mg/kg/day to around 0.55 mg/kg/day divided 2 or 3 times per day with higher doses associated with increased side effects. [Carranza-del: 2011]
Anti-reflux medications may help if reflux is contributing to excessive salivary production, though that is less frequently a cause of drooling in kids with special health care needs. [Walshe: 2012]
Botulinum toxin injections into the salivary glands is also a common method to treat sialorrhea and an effective therapy for many children. The injections usually need to be repeated every 3 to 6 month by, usually by pediatric otolaryngologists or physiatrists. Side effects may include dry mouth, decreased coordination of chewing and swallowing, facial weakness, mandibular dislocation, fever, constipation, parotitis or infection, pain, and hematoma or bleeding[Walshe: 2012]

Surgery

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, hearing loss, taste loss) or minor (thick saliva, dry mouth, crusted lips, difficulty with swallowing) complications. [Walshe: 2012] 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. [Garnock-Jones: 2012]

Complementary and Alternative Medicine

Acupuncture to the tongue has been explored to help decrease drooling. [Walshe: 2012] Practitioners of Traditional Chinese Medicine typically perform acupuncture; however, specially trained allopathic and osteopathic physicians may offer this type of intervention.

Subspecialist Collaboration

Pediatric Physical Medicine & Rehabilitation (Pediatric Physical Medicine & Rehabilitation (see RI providers [6]))
Provide treatments for sialorrhea including medications or botulinum injections. They also help determine appropriate therapies and specialist referrals, and adjust medications that may contribute to drooling.

Pediatric Otolaryngologists (Pediatric Otolaryngology (ENT) (see RI providers [7]))
Provide treatments for sialorrhea including medications, botulinum injections, or surgery.

Pediatric Ophthalmologists (Pediatric Ophthalmology (see RI providers [8]))
Perform gonioscope evaluations prior to and during use of certain medications like Benzhexol.

Speech Pathologists (Speech - Language Pathologists (see RI providers [32]))
Work with patients to improve control of oromotor and feeding skills.

Occupational Therapist (Occupational Therapy (see RI providers [20]))
Work with patients to improve feeding skills.

Resources

Information & Support

For Parents and Patients

Seven Tips to Stop Your Child with Special Needs from Drooling (Friendship Circle)

Tools

Drooling Impact Scale (PDF Document 100 KB)
A 5-minute, 10-question screen to help measure the impact drooling is having on the child and family.

Modified Teacher's Drooling Scale (MTDS)
A free, 9-point scoring system measured by parents/caregivers. Scores range from 1 to 9, with a higher score indicating more severe drooling.

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Walshe M, Smith M, Pennington L.
Interventions for drooling in children with cerebral palsy.
Cochrane Database Syst Rev. 2012;11:CD008624. PubMed abstract
Cochrane review of studies of safety and effectiveness of interventions for problematic sialorrhea in children.

Rapoport A.
Sublingual atropine drops for the treatment of pediatric sialorrhea.
J Pain Symptom Manage. 2010;40(5):783-8. PubMed abstract
Case study of pediatric application of sublingual atropine for drooling. Also contains dosing guidance for several anticholinergics used to treat sialorrhea.

Authors & Reviewers

Initial publication: November 2013; last update/revision: December 2018
Current Authors and Reviewers:
Author: Jennifer Goldman, MD, MRP, FAAP
Authoring history
2016: update: Meghan S Candee, MD, MScA; Nicholas Johnson, MD, MS-CIA
2013: first version: Lynne M. Kerr, MD, PhDA; Lisa Samson-Fang, MDA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Carranza-del Rio J, Clegg NJ, Moore A, Delgado MR.
Use of trihexyphenidyl in children with cerebral palsy.
Pediatr Neurol. 2011;44(3):202-6. PubMed abstract

Eiland LS.
Glycopyrrolate for chronic drooling in children.
Clin Ther. 2012;34(4):735-42. 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

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

Meningaud JP, Pitak-Arnnop P, Chikhani L, Bertrand JC.
Drooling of saliva: a review of the etiology and management options.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(1):48-57. PubMed abstract

Mikami DLY, Furia CLB, Welker AF.
Addition of Kinesio Taping of the orbicularis oris muscles to speech therapy rapidly improves drooling in children with neurological disorders.
Dev Neurorehabil. 2017:1-6. PubMed abstract
Small study to evaluate the effects of Kinesio Taping applied to the orbicularis oris muscles as an adjunct to standard speech therapy for drooling.

Moulding MB, Koroluk LD.
An intraoral prosthesis to control drooling in a patient with amyotrophic lateral sclerosis.
Spec Care Dentist. 1991;11(5):200-2. PubMed abstract

Norderyd J, Graf J, Marcusson A, Nilsson K, Sjöstrand E, Steinwall G, Ärleskog E, Bågesund M.
Sublingual administration of atropine eyedrops in children with excessive drooling - a pilot study.
Int J Paediatr Dent. 2017;27(1):22-29. PubMed abstract / Full Text

Parr JR, Todhunter E, Pennington L, Stocken D, Cadwgan J, O'Hare AE, Tuffrey C, Williams J, Cole M, Colver AF.
Drooling Reduction Intervention randomised trial (DRI): comparing the efficacy and acceptability of hyoscine patches and glycopyrronium liquid on drooling in children with neurodisability.
Arch Dis Child. 2018;103(4):371-376. PubMed abstract / Full Text

Rapoport A.
Sublingual atropine drops for the treatment of pediatric sialorrhea.
J Pain Symptom Manage. 2010;40(5):783-8. PubMed abstract
Case study of pediatric application of sublingual atropine for drooling. Also contains dosing guidance for several anticholinergics used to treat sialorrhea.

Rashnoo P, Daniel SJ.
Drooling quantification: Correlation of different techniques.
Int J Pediatr Otorhinolaryngol. 2015;79(8):1201-5. PubMed abstract
Compares the Drooling Quotient (DQ) score with the questionnaire-based Drooling Severity and Frequency Scale (DSFS) to the number of bibs changed per day; recommends the DSFS as a quick and comparable assessment tool.

Reid SM, Johnson HM, Reddihough DS.
The Drooling Impact Scale: a measure of the impact of drooling in children with developmental disabilities.
Dev Med Child Neurol. 2010;52(2):e23-8. PubMed abstract
Describes the development of the Drooling Impact Scale for use in measuring severity of drooling.

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

van der Burg JJW, Sohier J, Jongerius PH.
Generalization and maintenance of a self-management program for drooling in children with neurodevelopmental disabilities: A second case series.
Dev Neurorehabil. 2018;21(1):13-22. PubMed abstract
Small study of a program in children with oral-motor problems and normal intelligence or mild intellectual disabilities that appeared to be helpful in self-management of drooling.

Walshe M, Smith M, Pennington L.
Interventions for drooling in children with cerebral palsy.
Cochrane Database Syst Rev. 2012;11:CD008624. PubMed abstract
Cochrane review of studies of safety and effectiveness of interventions for problematic sialorrhea in children.

Zeller RS, Davidson J, Lee HM, Cavanaugh PF.
Safety and efficacy of glycopyrrolate oral solution for management of pathologic drooling in pediatric patients with cerebral palsy and other neurologic conditions.
Ther Clin Risk Manag. 2012;8:25-32. PubMed abstract / Full Text
Discusses the adverse effects as well as the benefits from a study comparing use of glycopyrrolate to placebo for treatment of severe childhood drooling.

Zeller RS, Lee HM, Cavanaugh PF, Davidson J.
Randomized Phase III evaluation of the efficacy and safety of a novel glycopyrrolate oral solution for the management of chronic severe drooling in children with cerebral palsy or other neurologic conditions.
Ther Clin Risk Manag. 2012;8:15-23. PubMed abstract / Full Text
Randomized controlled trial showing benefits of oral glycopyrrolate solution to control severe drooling in children compared to placebo.