Use of benzhexol hydrochloride to control drooling of children with cerebral palsy

Comparative Efficacy and Side Effect Profiles of Interventions for Pediatric Saliva Control: A Cohort Study

OBJECTIVE

To compare efficacy and side effect profile data on conservative, behavioral, pharmacological, and surgical treatments used for pediatric saliva control.

STUDY DESIGN

A cohort study of children (n = 483) referred to a specialty Saliva Control service between May 2014 and November 2019 was performed, using quantitative data from pretreatment and post-treatment questionnaires (the Drooling Impact Scale [DIS], Drooling Rating Scale [DRS]) and recording of side effects. Overall, 483 children were included; treatment choices were based on published international guidelines.

RESULTS

The greatest improvement was seen after intraglandular botulinum toxin A (BTX-A) injections (n = 207; 551 courses; mean DIS change, 34.7; 95% CI = 29.2-35.7) or duct transpositional surgery (n = 31; mean change in DIS, 29.0; 95% CI, 22.3-35.7). Oral anticholinergics were associated with good outcomes, with no significant statistical difference between glycopyrronium bromide (n = 150; mean DIS change, 21.5; 95% CI, 19.1-24.0) or trihexyphenidyl (n = 87; mean DIS change, 22.4; 95% CI, 18.9-25.8). Inhaled ipratropium bromide was not as efficacious (n = 80; mean DIS change, 11.1; 95% CI, 8.9-13.3). Oromotor programs were used in a selected group with reliable outcomes (n = 9; mean DIS change, 13.0). Side effects were consistent with previous studies. Overall, in cases of milder severity, enterally administered therapies provided a good first-line option. With more severe problems, BTX-A injections or saliva duct transpositional surgery were more effective and well tolerated.

CONCLUSIONS

We describe a large, single-center pediatric saliva control cohort, providing direct comparison of the efficacy and side effect profiles for all available interventions and inform clinical practice for specialists when considering different options. BTX-A injections or saliva duct transpositional surgery seem to be more effective for saliva control that is more severe.

Anticholinergic treatment for sialorrhea in children: A systematic review

Background

Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious.

Objective

To examine the effectiveness of anticholinergic medications for sialorrhea in children.

Methods

A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized.

Results

The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis.

Conclusions

Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.

Anticholinergic medications for reducing drooling in children with developmental disability

AIM

To determine: the effectiveness of three anticholinergic medications in reducing drooling in children with developmental disabilities (such as cerebral palsy, intellectual disability, and autism spectrum disorder), the frequency and nature of side effects, and their impact on treatment discontinuation.

METHOD

After prescription of benzhexol hydrochloride, glycopyrrolate, or scopolamine patches at a tertiary saliva control clinic, all carers of 110 consecutive, eligible patients were recruited over a 5-year period. They provided data for 52 weeks, or until drug discontinuation, on compliance, drooling, adverse effects, and reasons for cessation. We evaluated and compared best drooling response, side effects, and drug cessation rates using survival analysis, and the effect of baseline variables on the discontinuation rate using proportional hazards regression.

RESULTS

Among 110 participants (71 males, 39 females; mean age 8y 5mo [SD 4y 3mo], range 1y 11mo-18y 11mo), benzhexol, glycopyrrolate, and scopolamine were prescribed 81, 62, and 17 times respectively, with respective response rates of 85%, 75%, and 65%. Poor head control and poor oromotor function were predictive of poor response. Side effects frequently prompted drug cessation in males more than females (hazard ratio 1.8 [95% confidence interval 1.0-3.2], p=0.048). Glycopyrrolate had the fewest side effects.

INTERPRETATION

Benzhexol, glycopyrrolate, and scopolamine reduce drooling, but improvement is offset by adverse side effects. Overall, glycopyrrolate performs best.

WHAT THIS PAPER ADDS

In drooling, glycopyrrolate produced the greatest improvement with fewer side effects compared with benzhexol and scopolamine. Poor head control and poor oromotor function were associated with poor response. Medication side effects were common and often led to treatment discontinuation. Behavioural issues instigated cessation of benzhexol more often in males than females.

Trihexyphenidyl for dystonia in cerebral palsy

BACKGROUND

Cerebral palsy occurs in up to 2.1 of every 1000 live births and encompasses a range of motor problems and movement disorders. One commonly occurring movement disorder amongst those with cerebral palsy is dystonia: sustained or intermittent involuntary muscle spasms and contractions that cause twisting, repetitive movements and abnormal postures. The involuntary contractions are often very painful and distressing and cause significant limitations to activity and participation.Oral medications are often the first line of medical treatment for dystonia. Trihexyphenidyl is one such medication that clinicians often use to treat dystonia in people with cerebral palsy.

OBJECTIVES

To assess the effects of trihexyphenidyl in people with dystonic cerebral palsy, according to the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) domains of impairment, activity and participation. We also assessed the type and incidence of adverse effects in people taking the drug.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, eight other databases and two trials registers in May 2017, and we checked reference lists and citations to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing oral trihexyphenidyl versus placebo for dystonia in cerebral palsy. We included studies in children and adults of any age with dystonic cerebral palsy, either in isolation or with the associated movement disorders of spasticity, ataxia, chorea, athetosis and/or hypotonia. We included studies regardless of whether or not the study authors specified the method used to diagnose dystonia in their study population. Primary outcomes were change in dystonia and adverse effects. Secondary outcomes were: activity, including mobility and upper limb function; participation in activities of daily living; pain; and quality of life.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified one study, which was set in Australia, that met the inclusion criteria. This was a randomised, double-blind, placebo-controlled, cross-over trial in 16 children (10 boys and 6 girls) with predominant dystonic cerebral palsy and a mean age of 9 years (standard deviation 4.3 years, range 2 to 17 years). We considered the trial to be at low risk of selection, performance, detection, attrition, reporting and other sources of bias. We rated the GRADE quality of the evidence as low.We found no difference in mean follow-up scores for change in dystonia as measured by the Barry Albright Dystonia Scale (BADS), which assesses eight body regions for dystonia on a 5-point scale (0 = none to 4 = severe), resulting in a total score of 0 to 32. The BADS score was 2.67 points higher (95% confidence interval (CI) -2.55 to 7.90; low-quality evidence), that is, worse dystonia, in the treated group. Trihexyphenidyl may be associated with an increased risk of adverse effects (risk ratio 2.54, 95% CI 1.38 to 4.67; low-quality evidence).There was no difference in mean follow-up scores for upper limb function as measured by the Quality of Upper Extremity Skills Test, which has four domains that collectively assess 36 items (each scored 1 or 2) and produces a total score of 0 to 100. The score in the treated group was 4.62 points lower (95% CI -10.98 to 20.22; low-quality evidence), corresponding to worse function, than in the control group. We found low-quality evidence for improved participation (as represented by higher scores) in the treated group in activities of daily living, as measured by three tools: 18.86 points higher (95% CI 5.68 to 32.03) for the Goal Attainment Scale (up to five functional goals scored on 5-point scale (-2 = much less than expected to +2 = much more than expected)), 2.91 points higher (95% CI 1.01 to 4.82) for the satisfaction subscale of the Canadian Occupational Performance Measure (COPM; satisfaction with performance in up to five problem areas scored on a 10-point scale (1 = not satisfied at all to 10 = extremely satisfied)), and 2.24 points higher (95% CI 0.64 to 3.84) for performance subscale of the COPM (performance in up to five problem areas scored on a 10-point scale (1 = not able to do to; 10 = able to do extremely well)).The study did not report on pain or quality of life.

AUTHORS' CONCLUSIONS

At present, there is insufficient evidence regarding the effectiveness of trihexyphenidyl for people with cerebral palsy for the outcomes of: change in dystonia, adverse effects, increased upper limb function and improved participation in activities of daily living. The study did not measure pain or quality of life. There is a need for larger randomised, controlled, multicentre trials that also examine the effect on pain and quality of life in order to determine the effectiveness of trihexyphenidyl for people with cerebral palsy.

Role of Anesthesiologist in the Management of a Child with Cerebral Palsy

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.

Acute colonic pseudo-obstruction in a child taking trihexyphenidyl for drooling: Prescribers beware

Colonic pseudo-obstruction (Ogilvie's Syndrome) in children is relatively uncommon. We report an unusual case of colonic pseudo-obstruction in an 8-year-old child with cerebral palsy and long-term hypomotility issues being treated for drooling with the anticholinergic medication trihexyphenidyl. He presented as an emergency with severe abdominal distension, abdominal tenderness and vomiting. An emergency laparotomy revealed colonic dilatation and a defunctioning ileostomy was created. To our knowledge, this is the first case reporting colonic pseudo-obstruction as a possible complication of treatment with trihexyphenidyl. We suggest prescribers should exercise caution when prescribing trihexyphenidyl in patients with long-term intestinal hypomotility issues.

Accurate assessment of drooling severity with the 5-minute drooling quotient in children with developmental disabilities

AIM

The aims of this study were to examine whether objective measurements of the 10-minute drooling quotient (DQ10) and the 5-minute drooling quotient (DQ5) are interchangeable; to assess agreement between the measurements and their accuracy in classifying drooling severity; and to develop a time-efficient clinical assessment.

METHOD

The study cohort included 162 children (61 females, 101 males; mean age 11 y 6 mo, SD 4 y 5 mo, range 3 y 9 mo-22 y 1 mo) suffering from moderate to profuse drooling. One hundred and twenty-four had cerebral palsy and 38 had other developmental disabilities. Seventy-four of the participants were ambulant and 88 non-ambulant. The original DQ10 was recalculated into a 5-minute score (DQ5). Assessments were undertaken while the participants were in a rest situation (DQ(R)) and while they were active (DQ(A)). Agreement in scores was quantified using intraclass correlations and Bland-Altman plots. To classify drooling, area under the receiver operating characteristic curve analysis was used to compare accuracy of the DQ10 and DQ5 at rest and during activity.

RESULTS

Agreement between DQ10A, and DQ5(A), and between DQ10(R) and DQ5(R) was high (intraclass correlation coefficient >0.90). Moderate agreement existed between DQ(A) and DQ(R). DQ(A) scores were more accurate in classifying children's drooling behaviour. For DQ5(A), a cut-off point of 18 or more (drooling episodes/observation time) might indicate 'constant drooling'.

INTERPRETATION

The DQ10 and DQ5 can be used interchangeably. DQ(A) is most discriminative for drooling severity. For evaluating treatment efficiency the cut-off point can be used. For clinical and research purposes, the DQ5 is time efficient and cost saving while validity, and intrarater and interrater reliability are preserved.

Botulinum toxin type B for sialorrhoea in children with cerebral palsy: a randomized trial comparing three doses

AIM

The aim of the present study was to evaluate the efficacy and safety of three doses of botulinum toxin type B (BoNT-B) in reducing persistent sialorrhoea in children with cerebral palsy (CP).

METHOD

Children with CP and refractory sialorrhoea were randomized to one of four groups: a control group and three experimental groups receiving a low (1500 mouse units [MU]), medium (3000 MU), or high (5000 MU) dose of BoNT-B respectively, into bilateral salivary glands. Drooling was measured using the Thomas-Stonell rating scale, and the weight and the number of bibs used per day were counted in all children at baseline, 4, and 12 weeks after BoNT-B injection.

RESULTS

Twenty-seven children (15 males, 12 females; mean age 7 y 10 mo, SD 1 y 6 mo; range 5-15 y) were randomized into a control (seven children: four males, three females) and experimental groups receiving low (six children: four males, two females), medium (seven children: four males, three females), and high (seven children: three males, four females) doses of BoNT-B respectively. All children had mixed neurological disorders consisting of spastic paraparesis, tetraparesis, dystonic movements, and ataxia. Gross Motor Function Classification System levels ranged from III to V, and all children had moderate or severe intellectual disability. Estimated means with their standard errors (SEM) of drooling were at baseline, 4, and 12 weeks respectively, as follows: control group, 12.1 (2.1), 11.9 (2.1), 11.8 (2.2), p for trend 0.992; low dose group, 13.8 (2.3), 11.4 (2.3), 13.9 (2.3), p for trend 0.952; medium dose group, 13.9 (2.1), 6.7 (2.1), 7.1 (2.1) p for trend 0.008; and for the high dose group 14.4 (2.1), 5.0 (2.1), 5.6 (2.1), p for trend 0.002. Side effects included dense saliva, xerostomia, and difficulty in swallowing, and were more frequent in the high-dose group.

INTERPRETATION

A 3000 MU injection of BoNT-B into the salivary glands significantly improved the frequency and severity of sialorrhoea in children with CP. The lower dose was ineffective, and the higher dose produced no greater benefit and more side effects.

Glycopyrrolate for treatment of clozapine-induced sialorrhea in three adolescents

OBJECTIVE

The aim of this case study was to report preliminary data on the effectiveness and tolerability of glycopyrrolate for the treatment of clozapine-induced sialorrhea, or excessive flow of saliva, in an adolescent population.

METHOD

Three adolescent females (age 13-16), who developed sialorrhea secondary to clozapine treatment, received an open-label trial of glycopyrrolate (4-8 mg) during inpatient hospitalization for treatment-resistant psychotic illness.

RESULTS

The target symptom of sialorrhea was improved in all three cases, with patient self-reports of decreased production of saliva confirmed by staff observation. Glycopyrrolate was generally well tolerated by the patients. One patient reported constipation, which improved with symptomatic treatment. A second patient reported dry mouth, which improved with a reduction in dose of glycopyrrolate.

CONCLUSIONS

These three cases provide support for the potential effectiveness and tolerability of glycopyrrolate for clozapine-induced sialorrhea in adolescents. Further controlled studies are required to determine the safety, efficacy and tolerability of glycopyrrolate in this age group and in adults for clozapine-induced sialorrhea.

Efficacy of Relocation of Submandibular Duct in Cerebral Palsy Patients with Drooling

OBJECTIVE

The efficacy of relocating the submandibular duct to treat drooling in children with cerebral palsy was studied.

METHODS

This was a prospective study to assess, using a visual analogue score by the parents of the patients, the efficacy of relocating the submandibular duct to treat drooling, comparing pre- and postoperative drooling. Complications were also recorded.

RESULTS

Eight children were included in this study. Their mean age was 9.75 years (range, 6-14 years). Seven patients (87.5%) had significant reduction of drooling (from a score of > or = 7 before surgery to < or = 2 after surgery). All the parents of the eight children (100%) were happy with the outcome and would recommend the procedure to the parents of other children. Mean length of hospital stay was 4 days (range, 2-7 days). Three patients developed complications; one patient developed ranula 1 month postoperatively. This was successfully treated by marsupialization. Two patients developed bilateral submandibular sialoadenitis 3 days postoperatively, which resolved with antibiotic therapy.

CONCLUSION

We conclude that this procedure is effective and safe in reducing drooling in patients with cerebral palsy.

Personality analysis of patients complaining of sialorrhoea

BACKGROUND

Sialorrhoea, the symptom of apparent excessive secretion of saliva is a relatively uncommon complaint. Some authors consider that in the absence of clinical findings, then these patients have a psychiatric disorder masquerading as a physical illness. However, there is little evidence in the literature to support this conclusion and a detailed psychological assessment of this population has not previously been reported.

METHODS

In total, 18 patients and 18 age- and sex-matched controls were studied. All had a history of a complaint of excess salivation in the absence of any oral mucosal or systemic abnormality. All patients completed an Eysenck Personality Questionnaire.

RESULTS

There were no differences in the extroversion of psychoticism scores between the study and control group. However, the result showed significant increases in the neuroticism and Lie Scale score in the patient group.

CONCLUSIONS

The overall results of this study indicate that the complaint of sialorrhoea in otherwise healthy individuals does not have an organic basis and suggest that sialorrhoea is associated with high levels of neuroticism and a tendency to dissimulate.

[Treatment of sialorrhea with botulinum toxin: an overview]

Hypersalivation (sialorrhea) is a common complaint of patients with neurodegenerative disorders such as Parkinson's disease or amyotrophic lateral sclerosis and a frequently disabling side effect of atypical antipsychotic drugs. Conventional treatment including oral anticholinergic or antihistamine medication is often limited by adverse effects and lack of efficacy. Over the past few years, several studies reported decreased drooling after injections of botulinum toxin into the salivary glands. This review describes the current state of treatment of sialorrhea with botulinum toxin.

Effect of botulinum toxin in the treatment of drooling: a controlled clinical trial

OBJECTIVE

To investigate the clinical effectiveness of botulinum neurotoxin type A (BoNT) to reduce drooling in children with cerebral palsy (CP).

METHODS

A controlled clinical trial was performed in which the results of single-dose BoNT injections in the submandibular glands were compared with treatment with scopolamine. Forty-five children who had CP and experienced severe drooling were enrolled. Drooling severity was measured at baseline, during application of scopolamine, and at different intervals after BoNT injections up to 24 weeks, using the Drooling Quotient (DQ), the Teacher Drooling Scale (TDS), and Visual Analog Scales (VAS).

RESULTS

Drooling was reduced during scopolamine application as well as after BoNT injections. Compared with baseline, the mean DQ showed a significant decrease throughout the study. Greatest reductions were achieved 2 to 8 weeks after BoNT injection. No significant differences were found between scopolamine measurements and those up to 24 months after BoNT injection. Using VAS, parents recorded the effect on drooling in which significant differences were found between baseline VAS score and all follow-up assessments. According to our definition of "success to therapy," demanding a 2-point decrease on the TDS, 61.5% of patients responded to BoNT injections. Analysis of the DQ demonstrated a response rate of 53% of the patients to scopolamine and 48.7% to BoNT until 24 weeks after BoNT injections, the actual duration of this study. As a reaction to scopolamine, 71.1% of the patients had moderate to severe side effects. Only nonsevere, incidental side effects were reported after BoNT injections.

CONCLUSIONS

During scopolamine application as well as after intraglandular BoNT injections, a clinically relevant reduction in drooling was achieved in children with CP, demonstrating maximum effect 2 to 8 weeks after injections. This is the first controlled clinical trial that confirmed a significant effect of BoNT injections in the treatment of drooling. General anesthesia was needed for all children. BoNT injections show fewer and less serious side effects than transdermal scopolamine treatment.

Management of drooling

Drooling is a frequent complaint for individuals with developmental disabilities and their families. A variety of treatment options exist including behavioral or oral motor therapies, medications and surgical interventions. Several novel alternative therapies are also being explored. However, most treatments lack evidence-based demonstration of efficacy. Management of problem drooling benefits from a team approach.

A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling

Drooling frequently occurs in children with multiple handicaps; application of anticholinergic drugs is a potential strategy to treat drooling. A computer aided search of original studies concerning the treatment of drooling was carried out. The methodological and statistical integrity of the identified studies were assessed with previously defined criteria. The articles were weighed for their separate contribution to the evidence. The search resulted in 64 reports, of which seven studies passed the screening and were subjected to further assessment and discussion by three referees. Because of the small number of reports and the methodological restriction within the studies, no meta-analysis could be performed. No general conclusion could be made about the efficacy of anticholinergic drugs in treatment of drooling in children with multiple handicaps. There was some evidence that three anticholinergic drugs (benztropine, glycopyrrolate, and benzhexol hydrochloride) are effective in the treatment of drooling, but it could not be concluded that one drug is preferable.

Botulinum toxin A as a treatment for excessive drooling in children

Drooling is problematic for some neurologically impaired children. Botulinum toxin A injection to salivary glands has effectively reduced drooling in adults but has only recently been used to treat children. This was a preliminary study to determine the efficacy and safety of botulinum toxin in children. Children identified as having severe daily drooling were enrolled. The preinjection assessment included measurement of the amount and frequency of drool. Each parotid gland was injected with 5 U of botulinum toxin A. Follow-up was for a minimum of 16 weeks. Nine children were enrolled, 4-17 years of age. All children had moderate or severe mental retardation. At week 4, all patients had a reduced drooling frequency and eight of nine patients had a reduction in the weight of saliva. Overall, five of nine parents (55%) deemed the treatment successful. This preliminary study demonstrates that botulinum toxin A is a relatively effective treatment for some children with significant drooling without serious side effects.

Palliative care in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is the most common degenerative motor neuron disease in adults. The clinical picture consists of generalized fasciculations, progressive atrophy and weakness of the skeletal muscles, spasticity and pyramidal tract signs, dysarthria, dysphagia, and dyspnea. Pseudobulbar affect is common. Disease-specific treatment options are still unsatisfactory. Therapeutic nihilism is not justified as a large array of palliative measures available to enhance the quality of life of patients and their families. Because of its clinical characteristics, ALS represents a paradigm for palliative care in neurological diseases. Numerous projects are being undertaken worldwide in an effort to enlarge the evidence base for palliative interventions in ALS. Palliative care in ALS is a multidisciplinary effort requiring careful coordination. An open and empathic disclosure of the diagnosis is essential. Nutritional deficiency caused by dysphagia can be relieved by a percutaneous endoscopic gastrostomy. Respiratory insufficiency can be effectively treated by non-invasive home mechanical ventilation. The terminal phase of the disease should be discussed at the latest when symptoms of dyspnea appear, in order to prevent unwarranted fears of "choking to death." Psychological and spiritual care of patients and families are important. Collaboration with hospice institutions and completion of advance directives can be of invaluable help in the terminal phase.

Traditional Chinese medicine (tongue acupuncture) in children with drooling problems

Tongue acupuncture is an innovative technique in traditional Chinese medicine. We have demonstrated that specific tongue acupoints are related to various functional domains. This study aimed to assess the efficacy of tongue acupuncture in children with neurologic disability who had severe drooling problems. We conducted an intent-to-treat study in a cohort of 10 children. A continuous course of tongue acupuncture was performed daily to five acupoints in the tongue for a total of 30 sessions. Standardized outcome measures of drooling were evaluated by a blinded assessor to study the efficacy at baseline and after a course of treatment. Statistically significant improvement was noted in the following outcome measures: (1) mean visual analog scale (VAS) decreased from 6.6 (pre-TAC) to 4.67 (post-TAC) (P = 0.002); (2) mean drooling quotient (DQ) decreased from 14.016% (pre-TAC) to 8.335% (post-TAC) (P = 0.0078); and (3) mean drooling score (DS) decreased from 7.4 (pre-TAC) to 4.4 (post-TAC) (P = 0.002). This study demonstrated the efficacy of tongue acupuncture as an adjunctive or alternative treatment for patients with drooling problems and can be integrated as part of the oromotor stimulation program, drooling program, and behavioral modification program before subjecting the patient to invasive surgical procedures on the salivary glands.

Glycopyrrolate treatment of drooling in an adult male patient with cerebral palsy

1. The aim of the study was to assess the effect of glycopyrrolate on drooling in an adult male patient with cerebral palsy. 2. After a thorough medical examination and consent in writing by the responsible guardian, a baseline sum score for frequency and seriousness of drooling was established over a 2 week period in addition to data on shifts of handkerchiefs, urination, defecation and observation of behaviour. Glycopyrrolate (1 mg) tablets were then administered, starting with one tablet daily the third week and increasing the daily dose by one tablet per week until a maximum of four tablets during week six and 4 days of week seven when the daily dose was reduced to two tablets for 3 days. For the four weeks 8-11 three tablets were given daily. In week 12 the dose was reduced to two tablets and for the weeks 13-15 no tablets of glycopyrrolate were given. 3. For as long as the patient received three to four tablets of glycopyrrolate daily, drooling was markedly reduced and handkerchiefs were not necessary on some days. After the tablets were withdrawn drooling increased to approximately the same level as it was before treatment. No adverse medical, psychological, or social effects were observed. 4. For shorter periods, glycopyrrolate can be given in controlled doses provided that an adequate medical assessment has been undertaken.

Anaesthesia and pain management in cerebral palsy

Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri-operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri-operative seizure control, respiratory function and gastro-oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.

Use of glycopyrrolate and other anticholinergic medications for sialorrhea in children with cerebral palsy

Fifty-four parents/caretakers of children with cerebral palsy were surveyed regarding their use of antisialorrheic medication for excessive drooling. Glycopyrrolate was used by 37 of 41 respondents, with significant improvement in drooling noted in the vast majority (95%) of cases as indicated by a five-point rating scale. Side effects (dry mouth, thick secretions, urinary retention, or flushing) surfaced in almost half (44%) of the patients but necessitated discontinuation of pharmacologic treatment in less than a third. While larger clinical studies are needed, our preliminary data indicate a trial of glycopyrrolate should be considered in children with cerebral palsy where drooling is a significant problem.

Preliminary study of glycopyrrolate in the management of drooling

OBJECTIVE

A study was undertaken to assess the efficacy of an oral anticholinergic drug, glycopyrrolate, in the management of drooling in children and young adults with disabilities.

METHODOLOGY

Glycopyrrolate was used by 24 children and young adults for up to 28 months. Parents/carers were asked to complete a questionnaire on the effects of the drug on severity and frequency of drooling and to report any side-effects.

RESULTS

Twenty-two questionnaires were returned. There was a statistically significant decrease in both severity and frequency of drooling with minimal side-effects reported.

CONCLUSION

In this preliminary study, glycopyrrolate was found to be an effective and well-tolerated addition to the management of drooling in children with disabilities.

Effect of antireflux medication on salivary drooling in children with cerebral palsy

Salivary drooling is a common and debilitating problem in cerebral palsy (CP). We hypothesised that gastro-oesophageal reflux (GOR) may exacerbate drooling by stimulation of the oesophago-salivary reflex. The aim of our study was to assess the role of GOR in children with CP and severe drooling. Twenty-four children with CP and severe drooling underwent oesophageal pH monitoring (N = 23) or oesophagoscopy (N = 1). Nine had pathological GOR and were enrolled in a double blinded, placebo controlled cross-over trial of medical antireflux therapy (ranitidine plus cisapride) versus placebo. Drooling was measured by semi-quantitative observation (drooling quotient) and a questionnaire-based scoring system (rated by the child's caregivers). Mean drooling quotients and scores for drooling severity and frequency were not significantly different between active medication and placebo. In our study, treatment of pathological GOR did not improve salivary drooling in children with CP.

Dental health of children with cerebral palsy following sialodochoplasty

Drooling occurs commonly in children with cerebral palsy (CP). Surgical procedures, known as slalodochoplasties, are often performed for the control of drooling. These include major salivary gland excision, parasympathetic nerve section, duct ligation, and duct re-routing. Alterations in saliva amount, flow, and consistency occur following sialodochoplasty, and the resultant effect on dental homeostasis requires further investigation. This controlled study investigated 19 children with CP following sialodochoplasty (surgery group) and 75 children with CP treated nonsurgically (control group) who attended our hospital. Dental caries experience-including dmft, DMFT, and partial DMFS scores of mandibular incisors and canines only-plaque index, and enamel developmental defects index were recorded. Saliva buffering capacity and bacterial counts were assessed. The surgical group (median DMFT = 5.00) had significantly more dental caries when compared with the control group (median DMFT = 0.00), Wilcoxon Signed-rank Test, P < 0.0001. This study has shown that children with CP following sialodochoplasty have increased risk of dental caries when compared with those treated nonsurgically for drooling. Although no caries predictors were identified, alterations to the caries-protective role of saliva are considered the likely cause. Children who undergo this procedure should receive intensive pre- and postsurgical preventive dental therapy.

The role of a saliva control clinic in the management of drooling

This paper describes a saliva control clinic which has been established at the Royal Children's Hospital, Melbourne. A team involving two speech pathologists, a paediatrician, a plastic surgeon and a dentist has assessed and managed 68 young people over a period of 2 years. Treatment options have included behavioural programmes, trial of oral appliances, medication and surgery. This multidisciplinary approach has been useful in developing assessment techniques and formulating recommendations.