Clinical Reference Systems: Pediatric Advisor 10.0

Definition

It is normal for babies to drool. As babies grow and mature, they are better able to take care of their secretions. Most children don't drool when awake or asleep after the age of 4 years. However, children with neurological problems have difficulty making their muscles and nerves work properly. They have trouble swallowing saliva. Drooling is frequently seen in these children at older ages.

Why should drooling be controlled?

Drooling can irritate the skin of the face, neck, and chest. It can be embarrassing to the child and can make the child socially less acceptable.

What are the benefits of saliva?

Saliva is almost all water. There are small amounts of other substances, such as bicarbonate, sodium, chloride, potassium, and mucous which help the mouth and body. The mucous helps protect the throat and esophagus from injury during eating. Saliva also helps recoat the teeth with calcium. It helps keep gums healthy. It helps remove bacteria from inside the mouth and decreases breath odor. Saliva contains amylase, an enzyme that begins the digestion of starches.

What is the cause of drooling?

Saliva comes from three pairs of salivary glands, plus many smaller glands. All of these are found in the mouth. Two parotid glands are inside the cheek area. The pair of sublingual glands are under the tongue. The two submandibular glands are close to the lower jaw.

Adults and children over the age of 8 years make from one half to one and a half quarts of saliva a day. Younger children can produce as much as eight times more saliva than adults. Drooling occurs because the saliva is not swallowed and flows out of the mouth. This usually occurs from improper, inefficient, or infrequent swallowing. It is unusual for drooling to be caused from making too much saliva.

How is it treated?

The problem of excessive drooling can be treated in several ways:

1. Speech therapy

   A speech therapist can help your child learn to close the lips, move the saliva to the back of the mouth, and swallow. Learning to use a straw for fluids can improve drooling. Speech therapy is the preferred way to correct drooling. Helping your child learn the correct way to swallow solves the problem better than increasing the frequency of swallowing, although the latter does help a little. Improving posture and body position can also be helpful. While your child is taking speech therapy, medications are usually used for immediate improvement.

2. Medication

   The salivary glands are under the control of a part of the nervous system called the autonomic system. The medicines listed below cause the body to make less saliva by inhibiting the part of the autonomic system known as the parasympathetic system. This part of the nervous system also helps regulate urine output and stomach emptying.

   • Robinul (glycopyrrolate) is available as a pill. It can be given by mouth or crushed and put through a gastrostomy site. This medicine does not cause sleepiness or mood changes.
   • Scopolamine patches can be used. The entire patch is placed on the skin for a few hours each day and then removed. A patch has enough medicine for several days. However, once the patch is put on the skin and then taken off, it cannot be used again. Since the medicine is not equally distributed in the patch, the patch should not be cut into smaller pieces. For these reasons, the use of scopolamine for drooling is somewhat wasteful and expensive. There is a small chance you child could develop crossed eyes while wearing the patch. This is reversible when it is removed.
   • Artane (trihexyphenidyl hydrochloride) comes in either liquid or tablet form.
   • Cogentin (benztropine mesylate) comes in tablet form. It can be crushed and either fed orally or put down a gastrostomy tube.

3. Surgery/Botulinum injection/Radiotherapy
   • Surgery involves either changing the direction of the ducts which lead from the salivary glands to the mouth, or removing the salivary gland tissue. Using x-rays to destroy part of the salivary glands is reserved for severe cases.

     Laser surgery has recently been used. This treatment allows a quicker recovery than regular surgery.

   • Botulinum Toxin A injections are done under anesthesia. The toxin is injected into the parotid gland. This treatment lasts up to 8 months. To date this treatment has only been done on adults.
   • Radiotherapy, or use of x-rays, to destroy part of the salivary glands is only used in severe cases and not usually used in children.

4. Alternative Therapies

   Biofeedback and hypnotherapy have been used in some patients with varying amounts of success.

5. Bibs

   Don't forget that bibs are helpful to protect skin and clothing. The use of bandannas, or a bib that matches the shirt or dress, especially in older children, can make the bib less noticeable or add a fashion accent.

How can I take care of my child?

You need the medicine prescribed by your physician.

Call Your Child's Physician Immediately If:

• Your child seems to be holding back urine.
• Your child develops a rash, increased fussiness, or has stomach cramps.