Self-management treatment of drooling: a case series

Drooling outcome measures in paediatric disability: a systematic review

Drooling, or sialorrhea, is a common condition in patients with cerebral palsy, rare diseases, and neurodevelopmental disorders. The goal of this review was to identify the different properties of sialorrhea outcome measures in children. Four databases were analysed in search of sialorrhea measurement tools, and the review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used for quality appraisal of the outcome measures. The initial search yielded 891 articles, 430 of which were duplicates. Thus, 461 full-text articles were evaluated. Among these, 21 met the inclusion criteria, reporting 19 different outcome measures that encompassed both quantitative measures and parent/proxy questionnaires.   Conclusions: Among the outcome measures found through this review, the 5-min Drooling Quotient can objectively discriminate sialorrhea frequency in patients with developmental disabilities. The Drooling Impact Scale can be used to evaluate changes after treatment. The modified drooling questionnaire can measure sialorrhea severity and its social acceptability. To date, the tests proposed in this review are the only tools displaying adequate measurement properties. The acquisition of new data about reliability, validity, and responsiveness of these tests will confirm our findings. What is Known: • Although sialorrhea is a recognized problem in children with disabilities, especially those with cerebral palsy (CP), there is a lack of confidence among physicians in measuring sialorrhea. What is New: • Few sialorrhea measures are available for clinicians that may guide decision-making and at the same time have strong evidence to provide confidence in the results. • A combination of both quantitative measures and parent/proxy questionnaires might provide an adequate measurement of sialorrhea in children.

Sialorrhoea Management Practices in Residential Older Adults Care Settings: A Qualitative Study

AIM

The aim of this research was to explore both older adults' and health care professionals' experience and views of sialorrhoea management practices in older adult residential care settings.

BACKGROUND

Sialorrhoea is quite a bothersome symptom among patients with certain neurological conditions. The complexity of sialorrhoea and its complications can be quite challenging for health care professionals. In the management of sialorrhoea, a multidisciplinary approach is proposed as an effective way of sialorrhoea management.

METHODS

Thematic analysis of collected data via semi-structured qualitative interviews with five focus groups involving 28 multidisciplinary health care members and 1 patient.

RESULTS

The older adult and multidisciplinary health care professionals' view of the management of sialorrhoea in residential care settings were established under three main themes: 1) 'Sialorrhoea compromising patient's dignity', 2) 'Ad hoc local management' and 3) 'Further integration of care required'.

CONCLUSION

At present, there have been no comprehensive multidisciplinary sialorrhoea management strategies to meet the various needs of older adults with sialorrhoea.

IMPLICATION FOR NURSING MANAGEMENT

It is important to minimize the negative impact of sialorrhoea on the patients. The recognition of issues associated with sialorrhoea provides constructive scope for the health care professionals to further investigate and develop more effective integrated sialorrhoea care protocols.

Addition of Kinesio Taping of the orbicularis oris muscles to speech therapy rapidly improves drooling in children with neurological disorders

OBJECTIVE

To evaluate the effects of Kinesio Taping (KT) of the orbicularis oris muscles as an adjunct to standard therapy for drooling.

METHODS

Fifteen children with neurological disorders and drooling received speech therapy and twice-weekly KT of the orbicularis muscles over a 30-day period. Drooling was assessed by six parameters: impact on the life of the child and caregiver; severity of drooling; frequency of drooling; drooling volume (estimated by number of bibs used); salivary leak; and interlabial gap. Seven markers of oral motor skills were also assessed.

RESULTS

KT of the orbicularis oris region reduced the interlabial gap. All oral motor skills and almost all markers of drooling improved after 15 days of treatment.

CONCLUSION

In this sample of children with neurological disorders, adding KT of the orbicularis oris muscles to speech therapy caused rapid improvement in oral motor skills and drooling.

Submandibular duct transposition for drooling in children: A Casuistic review and evaluation of grade of satisfaction

INTRODUCTION

Drooling of saliva is the unintentional loss of saliva from the mouth resulting in excess pooling of saliva in the anterior portion of the oral cavity. It is considered normal in infants and usually resolves itself by 15-18 months of age. It is a common problem in pediatric patients with cerebral palsy or other neurological disorders. Drooling interferes with speech, impairs oral hygiene and contributes to oral dermatitis, aspiration pneumonias and fluid electrolyte imbalances. It has a profoundly negative impact on quality of life and contributes to social exclusion, self-esteem problems and significant discomfort, especially amongst school-aged children. In addition, it can present a serious challenge for caregivers. Various approaches to manage this condition have been described in the literature. Submandibular duct relocation allows salivary flow and is the surgical approach undertaken by the authors.

OBJECTIVES

The aim of this study is to share our experience with the surgical approach to drooling children and to evaluate clinical outcomes and long-term caregiver satisfaction outcomes.

METHODS

The authors conducted a retrospective study with a review of the medical records of 43 children and adolescents who had been submitted to submandibular duct relocation in the Centro Hospitalar Tondela-Viseu, between January 2003 and December 2017. The authors analyzed the clinical history, bibs used per day before and after surgery, and caregivers' satisfaction was assessed by interview using a questionnaire. The results of this procedure, technical considerations and outcomes are presented in this work.

RESULTS

Forty-three patients (15 girls and 28 boys), between the ages of 3 and 18 at time of surgery (mean age of 9), underwent bilateral submandibular duct transposition for drooling. All children have neurological disorders, with cerebral palsy being the predominant diagnosis. The majority were hospitalized for 1-2 days and no surgical complications were observed. The number of bib or clothing changes fell from more than ten in 23 patients (53%) pre-operatively to less than five in 33 patients (77%) post-operatively. 30% of caregivers were satisfied and 53% were very satisfied with the results of surgery.

CONCLUSIONS

The results of this study show that submandibular duct relocation is an effective method in the resolution of uncontrolled drooling in children, contributing to the improvement of children's quality of life. The degree of satisfaction with the surgical results is in agreement with the published international studies, proving once again the effectiveness of the surgical technique implemented in our Hospital.

Generalization and maintenance of a self-management program for drooling in children with neurodevelopmental disabilities: A second case series

In this case series (n = 10) with a non-concurrent multiple baseline design, a self-management program was shown to be effective during inpatient training in eight participants with oral-motor problems and normal intelligence or mild intellectual disabilities. They were taught to perform a self-management routine and to remain dry for increasing time intervals. In addition, the program provided differential (self-) reinforcement of swallowing, controlling and wiping behavior, explicit formulation of motivational factors, instruction and feedback for parents and teachers, and continued practice after discharge. Generalization of the initial effect to the school setting was demonstrated in seven participants. Follow-up assessments demonstrated maintenance of positive results in four children up to 24 weeks, and for two other participants until 6 weeks after discharge. These results appeared to be relevant to parents and teachers. Teaching parents and teachers to implement the procedure enables them to support the child without professional supervision in the case of relapse.

Factors in the Efficacy, Safety, and Impact on Quality of Life for Treatment of Drooling with Botulinum Toxin Type A in Patients with Cerebral Palsy

OBJECTIVE

To assess the efficacy and safety of botulinum toxin A (BoNT-A) injected in both submandibular and parotid versus only in parotid glands as a treatment for drooling in patients with spastic and dyskinetic cerebral palsy (CP), including an assessment of impact on quality of life (QoL) based on items from the International Classification of Functioning, Disability, and Health (ICF) core set.

DESIGN

Forty patients with CP 18 years or older (mean, 21.8 years) participated in a prospective, single-center, randomized controlled interventional study. All participants were classified as Gross Motor Function Classification System level III or higher and all had significant drooling as defined in prior studies. One group (group A) was treated with 100 U of BoNT-A, and another group (group B) served as control. In the treatment group, all patients first received combined parotid and submandibular injections, and then parotid injections only. The main outcome variables were a postinjection decrease in the drooling quotient (DQ) of 50% or more, total flow of 30% or more, and QoL as assessed by a set of 10 items related to drooling from the ICF.

RESULTS

The proportion of patients who achieved at least 50% reduction in DQ was 45% in group A versus 0.0% in group B; 0.0% (P = 0.0012); and of those who achieved at least 30% reduction in total flow was 90% in group A versus 10% in group B (P < 0.0001). Within group A, 42.1% of the dyskinetic patients versus 58.0% of the spastic ones showed 50% or better response in DQ, which is not a statistically significant difference (P = 0.8045). With regard to ICF questions, group A showed statistically significant improvements in several related items. There did not seem to be a significant difference in overall response for providing parotid-only injections. Additional correlations and uncommon adverse effect experiences are also reviewed.

CONCLUSION

Botulinum toxin A injection of the salivary glands is frequently effective and generally safe for the treatment of drooling in patients with either spastic or dyskinetic CP, both in objective measurement of saliva production and subjective symptoms related to the condition. There does not seem to be a significant advantage of injecting both submandibular and parotid glands over injecting parotid glands alone.

Outpatient Treatment Based on Self-Management Strategies for Chronic Drooling in Two Children

Drooling is a distressing condition, which is often caused by reduced oral motor control associated with a neurological disorder. It has significant medical, practical and psychosocial impact on children or youth and their families. Therefore, treatment is necessary. Although behavioural therapy for drooling shows promising results, it is generally time- and cost-intensive. For this reason, alternative ways to provide behavioural treatment for chronic drooling need to be explored. In a pair of case studies, the feasibility and potential of an outpatient variant of a behavioural treatment programme for drooling based on self-management strategies was researched with two children with oral motor difficulties. In a three week programme, these children were taught to perform a self-management routine in order to achieve saliva control during regular visits to the child rehabilitation centre. In addition, their parents and teachers were taught to prompt the self-management routine and instructed to provide additional practice at home and at school. In doing so, they were offered support by means of telehealth and personal contact. At the end of the treatment programme, both children showed a significant decrease in drooling severity. Their parents and teachers were satisfied with the treatment effect. Although the present treatment programme showed promising results, further adaptions are necessary to make the treatment programme more widely accessible.

The impact of submandibular duct relocation on drooling and the well-being of children with neurodevelopmental disabilities

OBJECTIVE

The aim of this study was to evaluate the impact of a reduction in drooling after bilateral submandibular duct relocation (SMDR) with sublingual gland excision on daily life and care, as well as social and emotional consequences in children and adolescents with neurodevelopmental disabilities.

METHODS

This prospective cohort study included 72 children and adolescents (46 males, 26 females) with moderate to severe drooling, and their caregivers. Mean age at the time of surgery was 15 years 2 months (SD 4y 3mo). Fifty-two children were diagnosed with cerebral palsy and 20 had other non-progressive developmental disabilities. A caregiver questionnaire to document the impact of drooling on daily care and economic consequences, social interaction and emotional development and self-esteem was administered before, and 8 and 32 weeks after surgery.

RESULTS

Following bilateral SMDR the mean Visual Analogue Scale (VAS, 0-100) scores demonstrated a significant (p < 0.001) reduction in the severity of drooling from 81 at baseline to 28 and 36 after 8 and 32 weeks, respectively. This was accompanied by a decrease in the amount of daily care required and reduced economic consequences. In addition, an increase in social contact with other children and adults was reported by caregivers after surgery.

CONCLUSION

Bilateral SMDR with sublingual gland excision provides a significant positive reduction in daily care of children suffering from drooling. Caregivers also report positive changes in their child's social interaction and sense of self-esteem.

Persons with multiple disabilities increase adaptive responding and control inadequate posture or behavior through programs based on microswitch-cluster technology

Study I used typical microswitch-cluster programs to promote adaptive responding (i.e., object manipulation) and reduce inappropriate head or head-trunk forward leaning with a boy and a woman with multiple disabilities. Optic, tilt, and vibration microswitches were used to record their adaptive responses while optic and tilt microswitches monitored their posture. The study included an ABB(1)AB(1) sequence, in which A represented baseline phases, B represented an intervention phase in which adaptive responses were always followed by preferred stimulation, and B(1) represented intervention phases in which the adaptive responses led to preferred stimulation only if the inappropriate posture was absent. Study II assessed a non-typical, new microswitch-cluster program to promote two adaptive responses (i.e., mouth cleaning to reduce drooling effects and object assembling) with a man with multiple disabilities. Initially, the man received preferred stimulation for each cleaning response. Then, he received stimulation only if mouth cleaning was preceded by object assembling. The results of Study I showed that both participants had large increases in adaptive responding and a drastic reduction in inappropriate posture during the B(1) phases and a 2-week post-intervention check. The results of Study II showed that the man learned to control drooling effects through mouth cleaning and used object assembling to extend constructive engagement and interspace cleaning responses functionally. The practical implications of the findings are discussed.

Interventions for drooling in children with cerebral palsy

BACKGROUND

Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP.

OBJECTIVES

(1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning.

SEARCH METHODS

We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by MW, MS and LP and differences resolved through discussion.

MAIN RESULTS

Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies.

AUTHORS' CONCLUSIONS

It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.

Interventions for drooling in children with cerebral palsy

BACKGROUND

Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP.

OBJECTIVES

(1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning.

SEARCH METHODS

We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by MW, MS and LP and differences resolved through discussion.

MAIN RESULTS

Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies.

AUTHORS' CONCLUSIONS

It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.

Clinical practice: swallowing problems in cerebral palsy

Cerebral palsy (CP) is the most common physical disability in early childhood. The worldwide prevalence of CP is approximately 2-2.5 per 1,000 live births. It has been clinically defined as a group of motor, cognitive, and perceptive impairments secondary to a non-progressive defect or lesion of the developing brain. Children with CP can have swallowing problems with severe drooling as one of the consequences. Malnutrition and recurrent aspiration pneumonia can increase the risk of morbidity and mortality. Early attention should be given to dysphagia and excessive drooling and their substantial contribution to the burden of a child with CP and his/her family. This review displays the important functional and anatomical issues related to swallowing problems in children with CP based on relevant literature and expert opinion. Furthermore, based on our experience, we describe a plan for approach of investigation and treatment of swallowing problems in cerebral palsy.

Promoting mouth drying to reduce the effects of drooling in a woman with multiple disabilities: a new evaluation of microswitch-programme conditions

OBJECTIVE

Extending the use of microswitch-based programmes to (a) establish mouth-drying responses and reduce the effects of drooling, (b) assess the possibility of widening inter-response intervals and (c) determine whether different microswitch solutions would impact the accuracy/effectiveness of mouth drying.

METHOD

During the intervention phases of the study, the participant (woman) performed mouth-drying responses via a special napkin. Such napkin contained two pressure sensors/microswitches, a microprocessor and an MP3 serving to monitor responses and ensure stimulation contingent on them.

RESULTS

The participant (a) learned to dry her mouth and reduce her chin wetness, (b) stabilized her responding at lower frequencies (i.e. when the stimulation period was extended) and (c) produced more accurate/effective responses when she was required to trigger both sensors of the napkin.

CONCLUSION

Microswitch-based programmes may promote practically sustainable and effective mouth drying to reduce drooling effects in persons with multiple disabilities.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement

Many individuals with neurological problems or anatomical abnormalities of the jaw, lips or oral cavity may drool, which can impact on health and quality of life. A thorough evaluation of the patient's history, examination of the oral region by a speech pathologist and, in individuals over 3 years, a dental examination is warranted. Questionnaires with established validity such as the Drooling Impact Scale are useful assessment tools. A hierarchical approach to treatment is taken from least invasive therapies, such as speech pathology, to more invasive, such as injection of botulinum neurotoxin type-A (BoNT-A) into the salivary glands (parotid and submandibular). The wishes of the individual and their carer are crucial considerations in determining the suitability of the intervention for the patient. In the presence of dysphagia and cerebral palsy (CP), careful assessment is required prior to the injection of BoNT-A. Favourable responses to intervention include a reduction in the secretion of saliva and in drooling, as well as psychosocial improvements. BoNT-A is usually well tolerated, although potential side effects should be discussed with the patient and carer.

Promoting mouth-drying responses to reduce drooling effects by persons with intellectual and multiple disabilities: a study of two cases

This study assessed the use of microswitch technology to promote mouth-drying responses and thereby reduce the effects of drooling by two adults with severe intellectual and multiple disabilities. Mouth-drying responses were performed via a special napkin that contained pressure sensors, a microprocessor and an MP3 to monitor the responses and ensure positive stimulation contingent on them. Initially, the responses produced 10 or 15 s of preferred stimulation. Subsequently, preferred stimulation was supplemented with matching periods of lower-grade stimulation to extend the inter-response intervals. Results showed that both participants (a) learned to dry their mouth consistently and reduce their chin wetness during the intervention, (b) stabilized their responding at lower frequencies as the lower-grade stimulation was added to the preferred stimulation, and (c) maintained the latter levels at a 3-month follow-up. Procedure and response conditions and outcome implications are discussed.