adnoids

Saliva is probably one of the least offensive bodily fluids. But it can still be confronting. You only have to look at how many student speech pathologists struggle to overcome their natural aversion when responding to their first case of excessive drooling to know that people are hard-wired to shy away from it. And that’s a big social problem for older children who drool.

1. What’s in a name?

“To drool” means to drop saliva uncontrollably from the mouth (Oxford English Dictionary). It’s a shortening of the Old English word “drivel”.

Both words have strongly negative connotations in general use. “That’s drivel!” means “That’s nonsense!”. And if someone calls you a “drooling idiot”, they are not your friend.

Drooling has a Greek-based medical-sounding name, too: sialorrhoea (“sialo” means saliva, “rhoia” means flow). It might be less offensive, but it’s hard to say and remember and breaks my pointless long word rule.

2. When should you be concerned about it?

• Drooling is perfectly normal in young children until around the age of 2 years.
• Drooling normally fully resolves by the age of 5 years. If it doesn’t, you should consider seeking advice from your child’s General Practitioner (GP).

3. Why does it matter?

• As noted above, drooling can be very embarrassing, especially in social situations. In school-aged children, it can lead to teasing, bullying or even social exclusion.
• For children, drooling may:
  • cause dehydration and cracked and painful lips (e.g. Harris & Purdy, 1987); and
  • require frequent bib or clothing changes by the family.
• Some children who drool have underlying (sometimes undiagnosed) problems swallowing their saliva properly. They may drool to stop themselves accidentally breathing in (“aspirating”) saliva into their lungs. This is a rational fear: dysphagia involving the aspiration of saliva can cause recurrent lung problems including pneumonia and requires urgent assessment by a speech pathologist and GP.
• Control of drooling has lots of potential benefits for older children, including:
  • increased self-esteem and confidence;
  • less washing of clothes; and
  • less damage to school and personal equipment.

4. Common causes and contributors

• Drooling is common for children with cerebral palsy.
• Drooling is commonly observed when assessing and treating children with:
  • developmental delays or disorders (e.g. autism spectrum disorder, general developmental delay);
  • epilepsy;
  • poor oral motor control;
  • dysphagia (swallowing problems);
  • facial paralysis (Tahmassebi & Curzoni, 2003);
  • “oral structural” issues, e.g. caused by conditions like:
    • Beckwith-Wiedermann syndrome (an overgrowth disorder);
    • Pierre Robin sequence;
    • micrognathia;
    • hypoplastic maxilla; and
    • foetal alcohol-syndrome;
  • lip injuries with impaired sensation; and
  • isolated speech delays, although this is thought to be relatively rare (e.g. 5% of children treated in the Montgomery et al., 2016 study).
• Other things that can contribute to drooling including:
  • dental problems (e.g. gingivitis, cavities or malocclusion);
  • nasal obstruction, e.g. in children with enlarged adenoids;
  • habitual finger chewing; and/or
  • acid reflux (Shannon & Feller, 1979; and Boyce & Bakheet, 2005).

5. How should persistent drooling be assessed?

If your older child is drooling, he/she should be assessed by a multidisciplinary team, including:

• a medical team (including a GP, Ear Nose & Throat Specialist (ENT) and/or sleep specialist) for conditions like reflux, nasal obstruction and/or obstructive sleep apnoea;
• a dentist for conditions like gingivitis, cavities and malocclusion; and
• a speech pathologist, for an oro-motor exam and a motor speech assessment.

6. How should drooling be treated?

It depends on the cause(s) and contributing factors.

In some countries, specialised multidisciplinary saliva control clinics exist to help families navigate their options. Management strategies used by some of these clinics include:

• simple reassurance: especially for 2-5 year olds who are typically developing in all other respects;
• speech and language therapy: specifically, so-called non-speech oro-motor exercises – I don’t think these work – see my comments below;
• drugs: a popular option is a group of drugs called anticholinergics, e.g. Hyoscine patches and pills, Trihexyphenidyl, and Glycopyrronium. These drugs can have side-effects, though, with one recent study showing almost 45% of children treated with anticholinergics discontinued because of them (Montgomery et al., 2016);
• botox A injections: an increasingly popular treatment, albeit with a fairly high (~30-40%) no-response rate and some possible side-effects (e.g. Montgomery et al., 2014); and
• surgery: this can include:
  • surgery to relieve nasal obstruction, e.g. adenoidectomy or adenotonsillectomy; or
  • in serious cases (e.g. for children at risk of aspirating their saliva), salivary gland surgery and sub-mandibular duct transfer surgery.

7. Can speech therapy alone reduce drooling?

Short answer: There is no evidence it can.

Long answer: Some speech pathologists think they can reduce drooling with lip-strengthening exercises and graded blowing and sucking tasks, e.g. with straws. These are examples of “non-speech oro-motor exercises”. They sound great in theory. But, having looked at the evidence, I’m not convinced that they work.

Montgomery and colleagues noted in their 2016 study that these exercises seemed to improve drooling symptoms in some children. But there were no controls in their retrospective chart review study and their results may be the result of bias (e.g. through the Hawthorne or placebo effects or confounding variables like natural recovery). Importantly, Montgomery and colleagues noted in their study that:

“There is a generalised paucity of evidence for intervention by [speech language therapists] for drooling. Some studies show limited improvements, but the evidence available is very limited.”

Montgomery cites a 2010 Swedish article by Sjogreen and colleagues that she says is evidence that non-speech oro-motor exercises can lead to “limited improvements” in drooling. That study looked at the effect of lip strengthening exercises using a special device called an oral screen on 8 children and teenagers with myotonic dystrophy type 1 (a slow progressive neuromuscular disease). The researchers found that after 16 weeks of therapy, 7/8 children improved their lip strength, but:

• only 4 showed statistically significant improvements; and
• improved lip strength alone did not have an effect on lip articulation, saliva control, or eating and drinking ability.

In other words, the 2010 study cited by Montgomery provides no support whatsoever for using oro-motor exercises to reduce drooling – quite the contrary – which is consistent with principles of motor learning and previous research on non-speech oro-motor exercises.

Anecdotally, some children with oro-motor speech issues and drooling seem to drool less after treatment with speech-based oro-motor exercises and behavioural cues, e.g. to swallow more often. But this is just an informal clinical observation. In the absence of quality evidence – e.g. peer reviewed research published in a quality journal – I would not advise a parent to expect their child’s drooling to reduce following speech therapy alone.

Clinical bottom line

For older children (and their parents), drooling can be very embarrassing and stressful. If your child is 5 years old or older and drools, you should consider seeking help, starting with your GP. Effective management of drooling may be as simple as getting some much-needed reassurance, or as complicated as a multidisciplinary assessment and multi-step treatment plan including any combination of dental care, speech therapy, medications, botox or even surgery. More information and resources for parents and carers concerned about their child’s drooling can be found below.

Principal sources and resources:

1. Montgomery, J., McCusker, S., Lang, K., Grosse, S., Mace, A., Lumley, R., Kubba, H. (2016). Managing children with sialorrhoea (drooling): Experience from the first 301 children in our saliva control clinic. International Journal of Pediatric Otorhinolaryngology, 85, 33-39.
2. Sjogreen, L., Tulinius, M., Kiliardidis, S., Lohmander, A. (2010). The effect of lip strengthening exercises in children and adolescents with myotonic dystrophy type 1. International Journal of Pediatric Otorhinolaryngology, 74, 1126-1134.
3. For examples of saliva control clinics, see:

• The Royal Children’s Hospital, Melbourne
• Evelina London Children’s Hospital
• The Saliva Management Clinic (a joint project of the MAB-Mackay Rehabilitation Centre and the Montreal Children’s Hospital of the MUHC).

4. Further reading and parent resource: Saliva Control in Children (published by The Royal Children’s Hospital, Melbourne).

Image: http://tinyurl.com/h4wvdbh