Drooling in cerebral palsy: hypersalivation or dysfunctional oral motor control?

Drooling may be Associated with Dysphagia Symptoms in Multiple Sclerosis

During the process of the multiple sclerosis (MS), persons with multiple sclerosis (PwMS) may experience drooling (sialorrhea) issues that are frequently disregarded. The exact cause of drooling in PwMS is poorly understood. This study aims to assess potential risk factors for drooling seen in PwMS. The study included 20 PwMS with drooling and 19 PwMS without drooling. The participants' sociodemographic data and clinical parameters were noted. To evaluate dysphagia, fatigue, and hypersalivation, the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS), the Fatigue Severity Scale (FSS), and objective saliva flow rate measurement with cottons placed in Stensen ducts and under the tongue (swab test) were used, respectively. The study employed univariate and multivariate logistic regression models to identify the risk factors linked to drooling. Gender, age, disease duration, MS type, and Expanded Disability Status Scale scores did not differ between the two groups. There was a significant increase in the DYMUS and submandibular/sublingual (SM/SL) saliva flow rate values in PwMS with drooling (p = 0.009 and p = 0.019, respectively). However, in our study, hypersalivation was not observed in PwMS with or without drooling. In the univariate model, DYMUS, SM/SL saliva flow rate, and FSS were found to be risk factors for drooling in PwMS. But only DYMUS was shown to be a significant risk factor in the multivariate model obtained by the backward (Wald) elimination method (p = 0.023). Finally, our research is the first to demonstrate the relationship between drooling and the presence of dysphagia symptoms in PwMS. This is a very important study to determine the nature of drooling in PwMS. This finding shows that our study will serve as a reference for choosing the best method for drooling treatment.

Interdisciplinary assessment and treatment of paediatric drooling: two decades of experience by the Nijmegen saliva control team reflected in a stepwise algorithm

Anterior and posterior drooling are prevalent comorbidities in children with neurodevelopmental disabilities. Considering the heterogeneity of the patient population and the multifactorial aetiology of drooling, an interdisciplinary and individualised treatment approach is indispensable. However, no tool for stepwise decision-making in the treatment of paediatric drooling has been developed previously. Within the Radboudumc Amalia Children's Hospital, care for children with anterior and/or posterior drooling secondary to neurodevelopmental disabilities is coordinated by a saliva control team with healthcare professionals from six disciplines. In alignment with international literature, published guidelines, and evidence gained from two decades of experience and research by our team, this paper proposes an algorithm reflecting the assessment and treatment approach applied in our clinic. First, directions are provided to decide on the necessity of saliva control treatment, taking type of drooling, the child's age, and the severity and impact of drooling into account. Second, the algorithm offers guidance on the choice between available treatment options, highlighting the importance of accounting for child characteristics and child and caregiver preferences in clinical (shared) decision-making.

CONCLUSIONS

With this algorithm, we aim to emphasise the importance of repeated stepwise decision-making in the assessment and treatment of drooling in children during their childhood, encouraging healthcare professionals to apply a holistic approach.

WHAT IS KNOWN

• Children with anterior or posterior drooling secondary to neurodevelopmental disabilities comprise a heterogeneous group, necessitating an individualised treatment approach. • No stepwise decision-making tool is available for the treatment of paediatric drooling.

WHAT IS NEW

• Deciding on the necessity of saliva control treatment should be a conscious process, based on type of drooling, age, and drooling severity and impact. • Type of drooling, age, cognition, oral motor skills, self-awareness, posture, diagnosis, and child/caregiver preferences need to be considered to decide on the optimal treatment.

Oral Health Care for Children and Youth With Developmental Disabilities: Clinical Report

Oral health is an essential component of overall health for all individuals. The oral health of children and youth with developmental disabilities (CYDD) involves unique characteristics and needs of which pediatricians and pediatric clinicians can be aware. Risk for oral disease in CYDD is multifactorial and includes underlying medical conditions, medications, and ability to participate in preventive oral health care and treatment, and lack of access to providers is common for this population despite being eligible for Medicaid. Pediatric clinicians are uniquely positioned to support the oral health needs of CYDD and their families through the medical home. This clinical report aims to inform pediatric clinicians about the unique oral health needs of CYDD. It provides guidance on assessing caries risk and periodontal status using structured screening instruments; understanding dental trauma, the role of diet and caries risk, trauma prevention, and malocclusion; and providing anticipatory guidance on oral hygiene that includes tooth brushing, use of fluoridated toothpaste, assessing community water fluoridation, advocating for a dental home by 1 year of age, and transition to adult dental care as part of adolescent health care. It also highlights special considerations for dental treatment rendered under sedation or general anesthesia that CYDD may need. Pediatric clinicians can help reduce risk of CYDD developing dental disease by understanding the unique needs of their patients and their barriers to accessing oral health care in their community, communicating with the child's dental home, and advocating for safe and accessible dental procedures.

An Observation Study of Caries Experience and Potential Risk Assessments among Disabled Individuals Living in an Institutional Rehabilitation Centre

The aim of this study was to conduct salivary, microbiological, and caries risk assessments in relation to caries experience among individuals with intellectual disability in an institutional center in the Al-Baha region, Saudi Arabia. A cross-sectional study was conducted among 89 patients residing in special care homes in the Al-Baha region, Saudi Arabia, from October 2023 to February 2024. The demographic details of all participants were recorded. Clinical oral examinations were performed for the decayed, missing, or filled teeth (DMFT) and plaque indices. Salivary and microbiological assessments were also carried out. The mean age of the study sample was 30.11 ± 4.39 years, and the mean duration of years spent residing in the facility was 26.49 ± 4.66. There was no significant difference observed across plaque scores, S. mutans colony count, salivary rate, pH, DFMT, and caries experience when they were compared across the levels of severity of intellectual disability. Statistically significant differences were observed across diet score, circumstance score, and chances to avoid caries and were found to be correlated with the severity of intellectual disability (p = 0.001, p = 0.001, and p = 0.002), respectively. The cariogram revealed that participants in this study had poor oral health status, with participants with severe intellectual disability having higher diet scores, frequency scores, and susceptibility scores; hence lesser chances to avoid dental caries. Regular dental check-ups, including cleanings and other treatments if necessary, seem to be fundamental to prevent dental issues and maintain healthy teeth and gums for this group of people. Developing interventions that focus on improving oral health status among intellectually disabled individuals may be recommended to ensure the optimum level of support and reduce the burden of dental decay among those individuals.

Comparing the evidence for botulinum neurotoxin injections in paediatric anterior drooling: a scoping review

Paediatric anterior drooling has a major impact on the daily lives of children and caregivers. Intraglandular botulinum neurotoxin type-A (BoNT-A) injections are considered an effective treatment to diminish drooling. However, there is no international consensus on which major salivary glands should be injected to obtain optimal treatment effect while minimizing the risk of side effects. This scoping review aimed to explore the evidence for submandibular BoNT-A injections and concurrent submandibular and parotid (i.e. four-gland) injections, respectively, and assess whether outcomes could be compared across studies to improve decision making regarding the optimal initial BoNT-A treatment approach for paediatric anterior drooling. PubMed, Embase, and Web of Science were searched to identify relevant studies (until October 1, 2023) on submandibular or four-gland BoNT-A injections for the treatment of anterior drooling in children with neurodevelopmental disabilities. Similarities and differences in treatment, patient, outcome, and follow-up characteristics were assessed. Twenty-eight papers were identified; 7 reporting on submandibular injections and 21 on four-gland injections. No major differences in treatment procedures or timing of follow-up were found. However, patient characteristics were poorly reported, there was great variety in outcome measurement, and the assessment of side effects was not clearly described.   Conclusion: This review highlights heterogeneity in outcome measures and patient population descriptors among studies on paediatric BoNT-A injections, limiting the ability to compare treatment effectiveness between submandibular and four-gland injections. These findings emphasize the need for more extensive and uniform reporting of patient characteristics and the implementation of a core outcome measurement set to allow for comparison of results between studies and facilitate the optimization of clinical practice guidelines. What is Known: • There is no international consensus on which salivary glands to initially inject with BoNT-A to treat paediatric drooling. What is New: • Concluding on the optimal initial BoNT-A treatment based on literature is currently infeasible. There is considerable heterogeneity in outcome measures used to quantify anterior drooling.and clinical characteristics of children treated with intraglandular BoNT-A are generally insufficiently reported. • Consensus-based sets of outcome measures and patient characteristics should be developed and implemented.

Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits

OBJECTIVES

To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP).

METHODS

A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions.

RESULTS

Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p < 0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p = 0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p = 0.002) and EDACS<3 (p = 0.031).

CONCLUSION

Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.

Comparison of factors associated with drooling between intractable neuromuscular disease and cerebral palsy

Drooling represents a common and noteworthy symptom in patients with intractable neuromuscular disease (IND) and cerebral palsy (CP) and can lead to poor quality of life (QOL) and higher incidence of death due to aspiration of saliva. Identifying the factors affecting drooling is crucial to improving QOL and improving the poor prognosis of patients with IND and CP. This study sought to assess the prevalence of drooling and to elucidate the associated factors, drugs, and differences between patients with IND and CP. We included hospitalized patients with IND and CP. Among the 269 patients, 69 of 162 patients with IND (42.6%) and 75 of 107 patients with CP (70.1%) exhibited drooling. Drooling in IND was significantly higher in patients with tube feeding and those who had a previous stroke than in patients with potential oral intake and those having no history of stroke. In individuals with CP, drooling was significantly negatively associated with age. Taltirelin in patients with IND had a significant positive association with drooling, and antipsychotics and centrally acting muscle relaxants in those with CP had a significant negative association with drooling. Our results suggest that the factors associated with frequent drooling differ between IND and CP cases, and patients who should be screened for drooling are those with decreased swallowing function, those with IND who have had a previous stroke, and young patients with CP. Moreover, clinicians should consider the impact of drugs on drooling in IND and CP cases.

Biochemical and Microbiological Aspects of the Oral Cavity of Children and Young People with Neurological Impairment and Oropharyngeal Dysphagia

The components and the salivary flow have a direct influence on the composition of the oral microbiota of children and young people with oropharyngeal dysphagia, and studies have already demonstrated the excessive accumulation of supragingival dental calculus in individuals with enteral nutrition. This study aimed to compare the oral hygiene, biochemical, and microbiological aspects of the oral cavity of children and young people with neurological impairment and oropharyngeal dysphagia. Forty children and young people with neurological impairment and oropharyngeal dysphagia were enrolled and divided into two groups: group I, encompassing 20 participants fed via gastrostomy; and group II, encompassing 20 participants fed via the oral route. Oral hygiene and salivary pH and flow were assessed, and a polymerase chain reaction was performed to evaluate the messenger RNA expressions of Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola. In groups I and II, the mean Oral Hygiene Index-Simplified scores were 4 and 2, respectively, showing a significant difference; the mean Calculus Index scores were 2 and 0, respectively, showing a significant difference; and the mean pH was 7.5 and 6.0, respectively, showing a significant difference. Bacterial analysis indicated no association between the two groups. It can be concluded that children and young people who use gastrostomy had a poorer oral hygiene, greater dental calculus deposition, and higher salivary pH. The saliva of patients in both groups contained Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola.

Randomised, double-blind, placebo-controlled trial of glycopyrronium in children and adolescents with severe sialorrhoea and neurodisabilities: protocol of the SALIVA trial

INTRODUCTION

Severe sialorrhoea is a common, distressing problem in children/adolescents with neurodisabilities, which has adverse health and social consequences. The SALIVA trial is designed to evaluate the efficacy and safety of a paediatric-specific oral solution of glycopyrronium along with its impact on quality-of-life (QoL), which has been lacking from previous trials of sialorrhoea treatments.

METHODS AND ANALYSIS

A double-blind, placebo-controlled, randomised phase IV trial is ongoing in several centres across France. Eighty children aged 3-17 years with severe sialorrhoea (≥6 on the modified Teachers Drooling Scale) related to chronic neurological disorders in whom non-pharmacological standard of care has already been implemented or has failed, will be recruited. Patients will be randomised 1:1 to receive a 2 mg/5 mL solution of glycopyrronium bromide (Sialanar 320 µg/mL glycopyrronium) or placebo three times daily during a 3-month blinded period. After Day 84, participants will be invited into a 6-month, open-label study extension period, where they will all receive glycopyrronium. The primary endpoint of the double-blind period will be the change from baseline to Day 84 in the Drooling Impact Scale (DIS), a validated measure to assess sialorrhoea. A series of secondary efficacy endpoints involving change in total DIS, specific DIS items and response (DIS improvement ≥13.6 points) will be analysed in a prespecified hierarchy. QoL data will be collected from parents, caregivers and patients where possible using specific DIS questions and DISABKIDS questionnaires. Safety endpoints, including adverse events, will be assessed throughout the trial periods.

ETHICS AND DISSEMINATION

In total, 87 children have been recruited and recruitment is now complete. Final results are expected by the end of 2023. Findings will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

EudraCT 2020-005534-15.

The Masticatory Structure and Function in Children with Cerebral Palsy—A Pilot Study

(1) Background: Muscle tension around the head and neck influences orofacial functions. The data exist concerning head posture during increased salivation; however, little is known about muscle tightness during this process. This study aims to investigate whether or not any muscles are related to problems with eating, such as drooling in individuals with cerebral palsy; (2) Methods: Nineteen patients between the ages of 1 and 14 were examined prior to the physiotherapy intervention. This intervention lasted three months and consisted of: relaxing muscles via the strain-counterstrain technique, functional exercises based on the NeuroDevelopmental Treatment-Bobath method, and functional exercises for eating; (3) Results: the tone of rectus capitis posterior minor muscle on the left side (p = 0.027) and temporalis muscle on the right side (p = 0.048) before the therapy, and scalene muscle on the right side after the therapy (p = 0.024) were correlated with drooling behavior and were considered statistically significant. Gross motor function was not considered statistically significant with the occurrence of drooling behavior (p ≤ 0.05). Following the therapeutic intervention, the frequency of drooling during feeding decreased from 63.16% to 38.89% of the total sample of examined patients; (4) Conclusions: The tightness of the muscles in the head area can cause drooling during feeding.

Development of the Korean Version of the Drooling Infants and Preschoolers Scale

Objective. This study is aimed at translating and cross-culturally adapting the Drooling Infants and Preschoolers Scale (DRIPS) into Korean cultural context and examine the content validity and reliability of the Korean version, which is referred as K-DRIPS. Methods. An iterative forward-backward translation sequence of the DRIPS was performed by 20 Korean health professional experts (i.e., occupational therapists (OTs) and professors) with more than 10 years of experience. The study subjects were 77 children with cerebral palsy (CP) exhibiting drooling symptoms aged 2-7 years. They were recruited from two children’s rehabilitation hospitals in Korea and completed the K-DRIPS. The content validity and internal consistency of the K-DRIPS items were examined. Results. An assessment with 20 K-DRIPS items was adequately and cross-culturally adapted into Korea. All the items exhibited good content validity (content validity ratio range 4.00-4.95) and good internal consistency (Cronbach’s $\alpha =0.98$ ). Conclusion. The study findings indicated that the K-DRIPS was successfully adapted to the Korean cultural context and demonstrated good psychometric properties. This instrument could be used for drooling assessment tool in Korean children with disabilities.

Multisystem compensations and consequences in spastic quadriplegic cerebral palsy children

Spastic quadriplegic cerebral palsy (CP) is a permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain. Most children with spastic quadriplegic CP are identified to be Gross Motor Function Classification System (GMFCS) level V, thus they have more comorbidities compared to other types at lower levels. Spastic quadriplegic CP is characterized by weak and inactive postural muscles of the neck and trunk, hence, they will undergo a total body extension as a compensatory mechanism leading to an atypical movement pattern, that give rise to multisystem consequences that reduce their quality of life. The relationship between atypical movement patterns, compensatory strategies, and multisystem consequences have not yet been explored. In fact, these multisystem consequences aggravate their condition and make movement much more atypical, forming a vicious cycle. This review aimed to provide a summary and highlight the mechanism of atypical movement pattern, multisystem compensations, and consequences in spastic quadriplegic CP children. It is true that central nervous system (CNS) lesion in CP is non-progressive, however the multisystem consequences may impair overall function over time. An understanding of how compensatory strategy and multisystem consequences in spastic quadriplegic CP offers the opportunity to intervene as early as possible to improve their quality of life.

Dysphagia limit in children with cerebral palsy aged 4 to 12 years

AIM

To assess the dysphagia limit in children with cerebral palsy (CP) according to Eating and Drinking Ability Classification System (EDACS) level, sex, and age compared to typically developing children.

METHOD

Seventy-seven children with CP (54 males, 23 females; mean age 7y 6mo, SD 2y 2mo, age range 4-12y) were assessed with the Maximum Volume Water Swallow Test. Median dysphagia limit in the CP group was compared with data of typically developing children.

RESULTS

The dysphagia limit of children with CP differed significantly (p<0.001) from typically developing children. The latter showed a threefold higher median dysphagia limit (22mL) compared to children with CP in EDACS level I (7mL). The higher the EDACS level, the lower the dysphagia limit in children with CP. EDACS level explained 55% of the variance in the dysphagia limit of the CP group.

INTERPRETATION

Where children with CP in EDACS levels IV and V showed that their capacity met the level of their performance, children in EDACS level I had the ability to perform a maximum capacity task, but still had a threefold lower median dysphagia limit than typically developing children. Establishment of the dysphagia limit should be part of general swallowing assessment in children with CP.

Evaluation of an intensive voice treatment to reduce anterior drooling in children with cerebral palsy: Protocol for a concurrent multiple-baseline, single case experimental design study

Anterior drooling is common in children with cerebral palsy (CP) and poses significant risks to the child's health. Causes of drooling include oro-motor dysfunction, inefficient swallowing and reduced sensation in the orofacial musculature. Behavioural interventions are frequently recommended to reduce drooling; however, this is in the absence of high-quality research evidence. This paper describes a protocol for evaluating the effectiveness of the Lee Silverman Voice Treatment LOUD (LSVT LOUD®) in reducing drooling; and optimising speech and swallowing in a group of children with CP. A structured and systematic visual analysis supplemented with statistical analyses will be used to analyse the data. The risk of bias in n-of-1 trials (RoBiNT) Scale [1] guided the design and implementation of the study.

Submandibular Gland Excision in Pediatric Patients

INTRODUCTION

Children who require submandibular gland excision for ptyalism often have multiple associated comorbidities, including neurodevelopmental disorders and respiratory risk factors. The purpose of this study is to utilize a large multicenter database to elucidate the perioperative profile of submandibular gland excision in children, with particular focus on children who require submandibular gland excision for ptyalism.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric dataset was queried for submandibular gland excision performed from 2012 through 2018. Indications were subclassified based on International Classification of Disease (ICD)-9 and ICD-10 codes. Complications, readmissions, and reoperations were analyzed with appropriate statistics.

RESULTS

During the study interval, 304 pediatric patients underwent submandibular gland excision, which was mostly performed for ptyalism (56.9%), followed by inflammatory conditions (20.7%). Patients requiring submandibular gland excision for ptyalism were significantly younger (P < 0.001) and underwent significantly longer procedures (P < 0.001). Ptyalism was associated with significantly higher related adverse events (P = 0.010), related readmission (P = 0.013), and medical complications (P = 0.013), which included a significantly higher risk of pneumonia (P = 0.050). Children with ptyalism had significantly higher rates of overall respiratory comorbidities (P < 0.001), including chronic lung disease (P < 0.001), supplemental oxygen support (P < 0.001), tracheostomy (P < 0.001), and ventilator dependence (P < 0.001). Patients undergoing submandibular gland excision for benign (P all ≥ 0.082) and malignant (P all ≥ 0.565) neoplasms did not have significantly higher rates of any indexed postoperative adverse event.

CONCLUSIONS

Children requiring submandibular gland excision for ptyalism represent a unique cohort than those requiring excision for other indications, with significantly higher burden of preoperative risk factors, intraoperative durations, and postoperative adverse events.

Spontaneous Swallowing Frequency, Dysphagia, and Drooling in Children With Cerebral Palsy

OBJECTIVE

To evaluate relationships between spontaneous swallowing frequency, dysphagia, and drooling in children with cerebral palsy. Spontaneous swallowing frequency was predicted to be inversely related to both dysphagia and drooling among children with cerebral palsy. A secondary objective compared patterns among spontaneous swallowing frequency, drooling, and age in healthy children vs children presenting with cerebral palsy.

DESIGN

Cross sectional study.

SETTING

Children with cerebral palsy were tested at a Cerebral Palsy Reference Center in a university hospital. Healthy children were tested in their home setting.

PARTICIPANTS

Twenty children with cerebral palsy were recruited from the local registry for cerebral palsy children and purposive sampling among parents. A group of 30 healthy children was recruited by purposive sampling among family, friends, and the local community. Children below 1 year of age up to 5 years of age were included in the healthy group. This age range was targeted to maximize the potential for drooling in this group.

MAIN OUTCOME MEASURES

Both groups provided data on spontaneous swallowing frequency (swallows per minute, or SPM), dysphagia, and drooling. Motor impairment was documented in the children with cerebral palsy.

RESULTS

SPM was significantly lower in children with cerebral palsy. Among children with cerebral palsy, SPM correlated significantly with dysphagia severity and trended toward a significant correlation with drooling at rest. In this subgroup, SPM was not correlated with age or degree of motor impairment. Dysphagia was significantly correlated with drooling at rest and both dysphagia and drooling at rest were correlated with degree of motor impairment. The 2 groups did not differ in the degree of drooling at rest. Among healthy children, age but not SPM demonstrated a significant inverse correlation with drooling quotient at rest.

CONCLUSIONS

Spontaneous swallowing frequency is related to dysphagia and drooling in children with cerebral palsy. The pattern of relationships among spontaneous swallowing frequency and drooling is different between children with cerebral palsy and younger healthy children.

A cross-sectional cariogram-based comparison of caries risk profile in children with various levels of intellectual disability

AIM

To compare the caries risk profile in children with mild, moderate, and severe intellectual disability (ID) using cariogram.

MATERIALS AND METHODS

A cross-sectional study was conducted to compare caries risk profile using cariogram among 150 children aged 6-18 years, with various levels of ID (50 each in Mild ID, Moderate ID, and Severe ID groups), attending special schools in Bengaluru city. The risk assessment consisted of: a questionnaire, an interview, estimation of oral hygiene, saliva sampling, microbial evaluation and clinical examination. Statistical analysis of the results obtained was performed using Chi-square/Fischer's exact test, Kruskal-Wallis test and Mann-Whitney test.

RESULTS

The overall comparison showed significant differences between the groups across all parameters except diet (P = 0.131), fluoride exposure (P = 1), salivary flow rate (P = 0.3), and buffer capacity (P = 1). Caries risk was high among children with severe intellectually disability while the actual chance to avoid caries was found to be high in the Mild ID group. Bacteria was one of the dominant caries risk sectors followed by susceptibility, circumstances, and diet.

CONCLUSION

Cariogram can be used as an effective tool in assessing caries prediction, thus aiding in identifying different risk groups in a community so that appropriate preventive measures can be implemented to overcome the caries risk.

Submandibular excision with and without parotid duct ligation for sialorrhoea

In this case series with retrospective review we compared the outcomes of patients with sialorrhoea who had a submandibular excision (SE) alone and those who had submandibular excision with parotid duct ligation (SE + PL) between 2012 and 2018. Primary endpoints of complication rates and caregivers' perceptions of success were collected. A total of 41 submandibular excisions were performed for sialorrhoea (26 patients underwent SE, while 15 underwent SE + PL). Significant differences in the groups existed at baseline with patients in the SE plus PL group being more likely to have a tracheostomy (p = 0.015), to use sublingual atropine (p = 0.038) and respiratory medications (albuterol p = 0.0075, gentamicin p = 0.018), to have more pneumonias six months prior to the procedure (p < 0.001), and more hospitalisations six months prior to the procedure (p = 0.046). More postoperative surgical site complications were associated with ligation (p = 0.012). There was no difference in systemic infection (p = 0.25), and no difference in caregivers' perceptions of success in reducing sialorrhoea (18/24 SE compared with 10/14 SE + PL, p = 1.00). There were more surgical site complications in those undergoing SE plus PL than in those who had SE alone. Given this data, parotid duct ligation may not yield additional benefit when combined with submandibular excision.

Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review

OBJECTIVES/HYPOTHESIS

Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP).

STUDY DESIGN

Systematic review.

METHODS

We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included.

RESULTS

Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA.

CONCLUSIONS

Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 2021.

Effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic cerebral palsy: a randomized controlled trial

BACKGROUND

Children with cerebral palsy show various degrees of dysphagia causing late development of oral motor skills.

AIM

To investigate effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic quadriplegia.

DESIGN

This was a double-masked, randomized controlled clinical trial.

SETTING

Out-patient Clinics of Faculty of Physical Therapy, Cairo University and Modern University of Technology and information.

POPULATION

A convenient sample of 71 children age ranged from 12 to 48 months diagnosed with spastic quadriplegia, were randomly assigned into two groups.

METHODS

Children in the control group received 90 minutes conventional physical therapy training five times/week for 4 successive months while those in the experimental group received 20 minutes of oral sensorimotor stimulation before the same program as in control group for 60 minutes. Oral motor function, body weight, segmental trunk control and gross motor function were assessed at base-line and after completing treatment.

RESULTS

In total, 64 (experimental n=32, control n=32) children completed treatment and data collection. The baseline assessment showed non-significant difference regarding all measured variables while with-in group comparison showed significant improvement in the two groups. The post-treatment comparisons revealed significant difference the oral motor function and physical growth in favor of the experimental group (p < 0.05). Finally, there was non-significant difference regarding segmental trunk control and gross motor function (p > 0.05).

CONCLUSIONS

Oral sensorimotor stimulation has the capability to improve feeding in children with spastic cerebral palsy diagnosed with oropharyngeal dysphagia.

CLINICAL REHABILITAYION IMPACT

OSMS has effect on some of the essential oral motor skills that contribute toward the improvement of feeding performance in children with spastic CP. The results of our study offer remarkable clinical importance for the children and their families.

Salivary Biomarker Levels and Oral Health Status of Children with Cerebral Palsy and Their Healthy Siblings: A Comparative Study

BACKGROUND

The dental needs of cerebral palsy children are an area of study much in need of attention. The neglect of this aspect should be rectified, and simpler diagnostic methodologies should be established and used to serve this purpose.

AIM

This study aimed to determine oral health status and salivary biomarkers (salivary flow rate, pH, buffering capacity) among children with cerebral palsy (CP), to compare their data with that of their healthy siblings, and to evaluate the relationship between salivary biomarkers and dental caries.

METHODS

A total of 30 CP children (study group) and 30 normal healthy siblings (controls) were selected between the ages of 5 and 12 years. Salivary biomarkers were assessed, and oral health status was examined.

STATISTICAL ANALYSIS

Chi-square test was used for comparison of oral health status. Unpaired t test was used to compare caries indexes (decay/filled teeth-primary dentition [dft] and decay/missing/filled teeth-permanent dentition [DMFT]) and salivary biomarkers between the groups. Pearson correlation was used to find the correlation between salivary biomarkers and caries.

RESULTS

The dft scores were significantly higher in the study group (P<0.05). The pH values and salivary flow rates were significantly lower in the study group (P<0.05 and P<0.001, respectively). There was a significant correlation between DMFT scores and salivary flow rate in the study group (P<0.05).

CONCLUSION

Low pH and low salivary flow rate might be risk factors for dental caries in CP populations; moreover, the significant correlation between DMFT score and salivary flow rate suggests that salivary flow rate could be used as a screening tool for assessing at-risk subjects in such populations.

Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement

Respiratory illness is the leading cause of mortality in children with cerebral palsy (CP). Although risk factors for developing chronic respiratory illness have been identified, comprehensive clinical care recommendations for the prevention and management of respiratory illness do not currently exist. We invited over 200 clinicians and researchers from multiple disciplines with expertise in the management of respiratory illness in children with CP to develop care recommendations using a modified Delphi method on the basis of the RAND Corporation-University of California Los Angeles Appropriateness Method. These recommendations are intended for use by the wide range of practitioners who care for individuals living with CP. They provide a framework for recognizing multifactorial primary and secondary potentially modifiable risk factors and for providing coordinated multidisciplinary care. We describe the methods used to generate the consensus recommendations, and the overall perspective on assessment, prevention, and treatment of respiratory illness in children with CP. WHAT THIS PAPER ADDS: The first consensus statement for preventing and managing respiratory disease in cerebral palsy (CP). Risk factors for respiratory disease in CP should be identified early. Individuals with CP at risk of respiratory disease require regular assessment of risk factors. Effective partnerships between multidisciplinary teams, individuals with CP, and families are essential. Treatment of respiratory disease in individuals with CP must be proactive.

Exploring treatments for drooling in children with neurological disorders

Introduction: Drooling represents a major problem in the every-day life of pediatric patients with neurological disorders. The significant burden, both physical and socio-psychological, of the disorder requires adequate clinical evaluation and proper management. However, treating drooling remains a challenge for clinicians. This is a review of the most up-to-date therapeutic options for the treatment of drooling in the pediatric population, hence both conservative, pharmacological, and surgical approaches are discussed. Areas covered: Randomized clinical trials (RCTs), structured reviews, and case reports are included. Special focus is paid on the methods used to evaluate the efficacy and safety outcomes in the selected RCTs, trying to promote the use of more validated scales to assess drooling in the future. Expert opinion: The lack of reliable metrics to assess efficacy and safety outcomes in drooling limits researchers from identifying the best patient-suitable treatment. The relatively small number of clinical trials carried out over the last two decades is also due to the difficulty in assessing drooling using subjective scales. A key enabler for new efficient therapies stands in the introduction of accurate and robust metrics to measure treatment effectiveness on drooling.

Team Approach: The Perioperative Management of Reconstructive Hip Surgery for the Non-Ambulatory Child with Cerebral Palsy and Spastic Hip Disease

Cerebral palsy (CP) is the leading cause of physical disability in children. Although physical disability is the hallmark of CP, children with CP also often have complex medical comorbidities. Spastic hip subluxation is the second most common orthopaedic deformity in children with CP, and the incidence increases with the severity of CP. Hip surveillance should be implemented in children with CP to monitor hip stability over time. A reconstructive surgical procedure is recommended when the migration percentage is >40%. Perioperative care of children undergoing a hip reconstructive surgical procedure is a multidisciplinary endeavor requiring the expertise of professionals with different backgrounds. The core team should comprise orthopaedic surgeons, nurses, nurse practitioners, pediatricians, nurse case managers, anesthesiologists, and physical therapists. Additional team members include nutritionists, clinical pharmacists, social workers, child life therapists, and consulting specialty services. This review describes the team approach to the perioperative care of non-ambulatory children with spastic hip subluxation undergoing a reconstructive hip surgical procedure, utilizing a case scenario of a 7-year old girl with CP and complex associated medical comorbidities.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

Oral and maxillofacial conditions, dietary aspects, and nutritional status of children with congenital Zika syndrome

OBJECTIVE

The aim of this study was to investigate oral and maxillofacial outcomes in children with congenital Zika syndrome (CZS) and the presence of nonnutritive sucking habits, functional habits, and features related to breastfeeding and nutrition of these children.

STUDY DESIGN

We conducted a cross-sectional study with 45 children with CZS and 50 healthy controls in Sergipe state, Brazil, from February 2018 to June 2018. Demographic and clinical data, including breastfeeding and feeding data, were obtained for each child. Additionally, oral and maxillofacial evaluation was performed.

RESULTS

Low weight (prevalence rate [PR] 8.33; 95% confidence interval [CI] 2.02-34.45), nonexclusive breastfeeding up to 6 months (PR 1.56; 95% CI 1.18-2.08); mouth breathing (PR 3.46; 95% CI 1.83-6.52); difficulty in swallowing (PR 6.00; 95% CI 2.53-14.25); and excessive salivation (PR 4.81; 95% CI 2.18-10.62) were more frequent in children with CZS. Children with CZS were more likely to have abnormal insertion of the upper labial frenulum (PR 7.04; 95% CI 2.23-22.20); ogival palate (PR 3.70; 95% CI 1.63-8.40), dental enamel defects (PR 2.22; 95% CI 1.05-4.69); and delayed dental eruption (PR 8.89; 95% CI 1.16-68.32) compared with healthy children.

CONCLUSIONS

Children with CZS had a higher frequency of problems related to breastfeeding, low weight, and oral and maxillofacial abnormalities compared with healthy children.

Salivary gland ablation: introducing an interventional radiology treatment alternative in the management of sialorrhea

BACKGROUND

Sialorrhea is common in children with neurological disorders and leads to social isolation, aspiration pneumonia and increased caregiver burden. Sialorrhea management includes anticholinergic medications and a variety of surgeries, but these are limited by side effects, recurrence and risks.

OBJECTIVE

We present our method of salivary gland ablation, an interventional radiology treatment for sialorrhea, and report safety and efficacy data from pediatric patients who underwent salivary gland ablation.

MATERIALS AND METHODS

Salivary gland ablation uses image-guided sotradecol and ethanol dual-drug injection into the salivary glands. Submandibular and sublingual glands are injected percutaneously using ultrasound. Parotid glands are injected retrograde through Stensen ducts using fluoroscopy. We conducted a retrospective review of the medical records of patients who underwent salivary gland ablation at our institution between 2005 and 2019. Pre- and post-procedure Drooling Frequency and Drooling Severity (DFDS) scale scores were compared and caregiver satisfaction was assessed. We devised two cohorts, one to study patient safety and a subcohort to study clinical efficacy using DFDS scores.

RESULTS

One hundred and seventy salivary gland ablation procedures were performed in the 99 patients comprising the safety cohort. Of the procedures, 88.8% resulted in no or minimal complications. Respiratory difficulty, temporary nerve palsy and infection represent the majority of the 11.2% of patients who experienced periprocedural complications. There were no complications resulting in permanent sequelae. Twenty-seven patients met our inclusion criteria for the efficacy subcohort with a mean follow-up time of 5.4 years. DFDS at follow-up decreased from a median score of nine to a seven post-procedure (P=0.000018). The proportion of caregivers who were satisfied with the procedure increased as more glands were ablated, which suggests a causal link between the number of glands ablated and the outcome.

CONCLUSION

Salivary gland ablation is a safe and effective procedure with the potential for permanent decrease in symptoms related to sialorrhea.

Submandibular gland botulinum neurotoxin A injection for predicting the outcome of submandibular duct relocation in drooling: a retrospective cohort study

AIM

This study evaluated whether the effect of submandibular gland botulinum neurotoxin A (BoNT-A) injection can predict the outcome of submandibular duct relocation with sublingual gland excision (SMDR) in children with drooling. Furthermore, we compared the effectiveness of both procedures.

METHOD

A retrospective cohort study was performed in 42 children and adolescents (25 males, 17 females; mean [SD] age at BoNT-A injection 11y [4], range 4-20y; mean [SD] age at SMDR 15y [4], range 7-23y) with cerebral palsy or another non-progressive developmental disability who had undergone both BoNT-A injection and SMDR for drooling. Main outcomes were the drooling quotient and the visual analogue scale (VAS) on drooling severity at 8 weeks and 32 weeks follow-up.

RESULTS

Failure or success of previous BoNT-A injections had no influence on success of consecutive SMDR. Relative change in main outcomes showed no significant relation between BoNT-A injection and SMDR for any follow-up measurement. After 8 weeks, SMDR was more successful than BoNT-A injection in diminishing VAS (VAS 80.0% vs 54.3%; drooling quotient 56.2% vs 51.0%). After 32 weeks, both drooling quotient (64.3% vs 29.5%) and VAS (75.7% vs 37.1%) showed significantly higher proportions of success for SMDR.

INTERPRETATION

The effect of submandibular BoNT-A injection does not predict subsequent SMDR success in drooling. Furthermore, SMDR has a larger and longer-lasting positive effect on drooling than BoNT-A injections.

WHAT THIS PAPER ADDS

Submandibular botulinum neurotoxin A (BoNT-A) injection effect does not predict submandibular duct relocation with sublingual gland excision outcome. Submandibular duct relocation is more effective and more permanent than BoNT-A injection.

Effects of salivary gland botulinum Toxin-A on drooling and respiratory morbidity in children with neurological dysfunction

OBJECTIVE

To describe the effects of salivary gland Botulinum Toxin-A (SG BoNT-A) on children with drooling due to neurological dysfunction.

METHODS

This was a 3½-year prospective observational case series design of children referred for SG BoNT-A injections at a pediatric hospital (2010-2014). Outcomes were parent-reported severity, frequency, impact of drooling, and respiratory morbidity; and, from hospital records, number of respiratory hospital admissions.

RESULTS

Out of 17 children treated, complete data were available for 15 (including 8 boys) aged 3-14 years (Mean = 9.9 years; SD = 3.4), with a combined total of 71 injections. Most had cerebral palsy (n = 11), classified as Level V (n = 10) or IV (n = 1) on the Gross Motor Function Classification Scale (GMFCS). In almost all instances, parents reported reductions in severity, frequency, and impact of drooling, and parent-reported respiratory morbidity. Among those with posterior drooling (n = 12), most children (n = 10) did not have advanced respiratory disease. A trend towards reduced respiratory-related hospital admissions was observed during SG BoNT-A treatment periods.

CONCLUSION

SG BoNT-A can improve severity, frequency, and impact of drooling. It can also reduce respiratory-related hospital admissions in children with posterior drooling without advanced respiratory disease. For children with advanced respiratory disease, it may reduce severity and impact of drooling.

Unsuccessful submandibular duct surgery for anterior drooling: Surgical failure or parotid gland salivation?

OBJECTIVES

To evaluate if drooling recurrence after surgery of the submandibular ducts is due to surgical failure or other variables.

METHODS

Historic cohort with prospective collected data of all patients with severe drooling who underwent unsuccessful submandibular duct surgery with subsequent re-intervention between 2003 and 2018. A reference cohort was used for comparison of clinical variables.

RESULTS

Six males and 4 females were included (cerebral palsy n = 8, neurodevelopmental disorders n = 2). All patients underwent submandibular gland surgery as a primary intervention (duct ligation n = 8, submandibular duct relocation n = 2) followed by re-intervention (submandibular gland excision n = 7, parotid duct ligation n = 3). One patient underwent tertiary surgery (parotid duct ligation after re-intervention by submandibular gland excision). Three patients were successful after re-intervention. No difference was found between both re-intervention techniques. There was significantly more severe dental malocclusion (50% vs. 21%, P value = 0.047) and severe speech disorders (80% vs. 42%, P value = 0.042) in the current cohort when compared to the reference cohort.

CONCLUSION

Recurrence of drooling surgery is most likely not caused by surgical failure of the primary intervention, because re-intervention (submandibular gland excision) did not lead to more success. Dysarthria and dental malocclusion might negatively influence treatment outcome.

Can muscle vibration be the future in the treatment of cerebral palsy-related drooling? A feasibility study

Background: Drooling is an involuntary loss of saliva from the mouth, and it is a common problem for children with cerebral palsy (CP). The treatment may be pharmacological, surgical, or speech-related. Repeated Muscle Vibration (rMV) is a proprioceptive impulse that activates fibers Ia reaching the somatosensory and motor cortex. Aim: The aim of the study is to evaluate the effectiveness of rMV in the treatment of drooling in CP. Design, setting and population: This was a rater blinded prospective feasibility study, performed at the "Gli Angeli di Padre Pio" Foundation, Rehabilitation Centers (Foggia, Italy), involving twenty-two CP patients affected by drooling (aged 5-15, mean 9,28 ± 3,62). Children were evaluated at baseline (T0), 10 days (T1), 1 month (T2) and 3 months (T3) after the treatment. Methods: The degree and impact of drooling was assessed by using the Drooling Impact Scale (DIS), the Drooling Frequency and Severity Scale (DFSS), Visual Analogue Scale (VAS) and Drooling Quotient (DQ). An rMV stimulus under the chin symphysis was applied with a 30 min protocol for 3 consecutive days. Results: The statistical analysis shows that DIS, DFSS, VAS, DQ improved with significant differences in the multiple comparisons between T1 vs T2, T1 vs T3 and T1 vs T4 (p≤0.001). Conclusion This study demonstrates that rMV might be a safe and effective tool in reducing drooling in patients with CP. The vibrations can improve the swallowing mechanisms and favor the acquisition of the maturity of the oral motor control in children with CP.

Pediatric Sialorrhea: Submandibular Duct Rerouting and Intraparotid Botulinum Toxin A Injection With Literature Review

OBJECTIVES:

The aim of this study was to assess the effectiveness of bilateral submandibular duct relocation and bilateral sublingual gland excision in combination with botulinum toxin A injection into the parotid glands in children with sialorrhea. Previously in the literature, either surgery or botulinum toxin injection but not their combination has been reported.

METHODS:

Preoperative and at least 6-month postoperative assessments using the Drooling Severity Scale and Drooling Frequency Scale (Thomas-Stonell and Greenberg classification) and the Teacher Drooling Scale and by interviewing parents and caregivers face to face or via telephone were performed. Also, decreases in the daily number of bib changes and hourly frequency of saliva wiping were recorded as success. Complications were recorded.

RESULTS:

The Drooling Frequency and Severity Scale, the Teacher Drooling Scale, daily number of bib changes, and hourly frequency of saliva wiping decreased significantly in 21 patients (95.5%) and remained unchanged in 1 patient (4.5%). Postoperative bleeding was observed in 1 patient (4.5%).

CONCLUSIONS:

Drooling is a complex problem that benefits from a multidisciplinary approach. Many treatment methods exist, each with advantages and disadvantages. In this study botulinum toxin A injection was applied in conjunction with bilateral submandibular duct relocation and bilateral sublingual gland excision surgery, achieving a success rate of 95.5%. Moreover, minimal complications and no recurrence after at least 6-month follow-up were observed. The authors therefore recommend further use of this combination treatment. Larger and longer term studies may also help clarify its effectiveness.

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.

Negative effects of submandibular botulinum neurotoxin A injections on oral motor function in children with drooling due to central nervous system disorders

AIM

The aims of this study were: (1) to determine the incidence and nature of adverse effects on oral motor function after first injections of botulinum neurotoxin A (BoNT-A) in submandibular glands for excessive drooling in children with central nervous system disorders; and (2) to identify independent predictors of these adverse effects.

METHOD

A cohort study involved 209 children (123 males, 86 females, aged 4-27y, median 8y 4mo), who received submandibular BoNT-A injections for drooling. Adverse effects were categorized into swallowing, eating, drinking, articulation, and other problems. Univariable logistic regression was used to study differences in patients with and without adverse effects. Possible predictors were identified using multivariable logistic regression.

RESULTS

Transient adverse effects occurred in 33% of the 209 BoNT-A treatments. Almost 80% of these were mild, versus 8.7% severe. Approximately 54% of the adverse effects spontaneously resolved within 4 weeks; 3% still existed after 32 weeks. A diagnosis of cerebral palsy, higher range of BoNT-A dosage, and a pre-treatment drooling quotient <18% were found to be independent predictors of adverse effects.

INTERPRETATION

Before using submandibular BoNT-A injections for drooling, potential adverse effects should be discussed. Oral motor function needs to be monitored, because existing dysphagia may be worsened. The identified clinical predictors could be helpful to optimize patient selection.

Treatment of drooling with sublingual atropine sulfate in children and adolescents with cerebral palsy

ABSTRACT Atropine sulfate blocks the muscarinic receptors in the salivary glands and leads to reduced saliva production. There are no published studies about its use in children with cerebral palsy. Objective To report the effect of sublingual atropine sulfate to treat drooling in children with cerebral palsy by comparing the results of the Drooling Impact Scale in a non-controlled open clinical trial. Results Twenty-five children were assessed. The difference in the mean scores of the pre- and post-treatment scales reached statistical significance. There was a low frequency of side effects compared to studies with other anticholinergics. Conclusion The use of sublingual atropine sulfate seems to be safe and there is a reduction in the Drooling Impact Scale score, which suggests efficacy in the treatment of drooling in children and adolescents with cerebral palsy. Our results should be replicated in randomized, placebo-controlled studies with larger numbers of participants.

Sublingual administration of atropine eyedrops in children with excessive drooling - a pilot study

BACKGROUND

Drooling can be a severe disability and have high impact on daily life. Reversible treatment is preferable.

AIM

To analyse whether sublingual administration of atropine eyedrops is a useful reversible treatment option for severe drooling in children with disabilities.

DESIGN

The study had a prospective, single-system research design. The participants served as their own controls. The study period was 3 weeks without treatment, 4 weeks with atropine eyedrop solution 10 mg/mL one drop a day followed by 4 weeks of one drop twice a day. Parents' rating of their child's drooling was assessed on a 100-mm VAS, and unstimulated salivary secretion rate measurement was performed together with notations about side effects and practicality.

RESULTS

Parents' VAS assessment of drooling decreased from a median (range) of 74 (40-98) at baseline to 48 (18-88) (P = 0.05) and 32 (12-85) (P = 0.004) after 4 weeks of atropine once a day and another 4 weeks of atropine twice a day, respectively (n = 11). Unstimulated salivary secretion rates decreased from baseline to end of study (P = 0.032). Several parents complained about difficult administration. No irreversible side effects were noted.

CONCLUSIONS

Sublingual atropine eyedrops may be an alternative for treatment of severe drooling in children with disabilities.

Sialorrhea in children with cerebral palsy

OBJECTIVE

To review the literature on sialorrhea in children with cerebral palsy.

SOURCE OF DATA

Non-systematic review using the keywords "sialorrhea" and "child" carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed.

DATA SYNTHESIS

The prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment.

CONCLUSIONS

The most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.

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.

Effects of Neuromuscular Electrical Stimulation on Swallowing Functions in Children with Cerebral Palsy: A Pilot Randomised Controlled Trial

Objective/Background

Oral-motor and sensory dysfunctions are primary reasons for difficulties with swallowing in children with cerebral palsy (CP). Neuromuscular electrical stimulation (NMES) has been shown to provide positive effects on the swallowing function in adult populations with various neurological disorders. However, there is a lack of studies regarding the effects of NMES in children with dysphagia. The aim of the present study was to investigate the effects of NMES and oral sensorimotor treatment (OST) by occupational therapists in children with CP and dysphagia.

Methods

The present study was a two-group experimental design. Participants were randomly assigned to either the experimental group (n = 10) or the control group (n = 10). The NMES group received both NMES and OST, with NMES on the pharyngeal level for 20 minutes after OST, while the control group received OST and sham–-NMES only. The treatment sessions occurred twice a week for 8 weeks.

Results

The experimental group demonstrated a significant improvement in: lip closure while swallowing, ability to swallow food without excess loss, ability to sip liquid, ability to swallow liquid without excess loss, and ability to swallow without cough (p < .05).

Conclusion

This study demonstrated that OST and NMES facilitated swallowing functions than OST and sham–-NMES in children with CP and dysphagia. Future studies need to utilise video fluoroscopy swallowing study for outcome measurements in a large participant group.

An investigation of the relationship of drooling with nutrition and head control in individuals with quadriparetic cerebral palsy

[Purpose] The aim of the present study was to investigate the relationship of drooling, nutrition, and head control in individuals with quadriparetic cerebral palsy. [Subjects and Methods] Fifty-six individuals between the ages 2 and 15 diagnosed with spastic quadriparetic cerebral palsy and their families/caretakers were included in the study. Drooling severity and frequency of individuals was evaluated by using the scale developed by Thomas-Stonell and Greenberg (Drooling Severity and Frequency Scale). Individuals having a drooling severity value of 1 were included in the not drooling group (group 2) (n=27). Individuals having a drooling severity of 2, 3, 4, or 5 were included in the drooling group (group 1) (n=29). The evaluations were applied to both groups. [Results] There were significant differences between the two groups in terms of gestational age, nutrition behavior, eating abilities, head control, gagging, nutritional status (inadequate nutrition, normal nutrition, over weight-obese), and low weight. It was established that as head control increased, drooling severity diminished, and as drooling severity increased, BMI index decreased. Independence of eating ability was found to be greater in the group having better drooling control. [Conclusion] In the present study, it was determined that drooling control affected nutritional functions and that drooling control was affected by head control.

Feeding and Swallowing Disorders in Pediatric Neuromuscular Diseases: An Overview

Feeding and swallowing problems in infants and children have a great impact on health and wellbeing. The aim of this study was to provide an overview of recognized feeding and swallowing problems in different groups of children with neuromuscular diseases, based on relevant literature and expert opinion, and to propose recommendations for the assessment and treatment of these problems. Almost all pediatric neuromuscular diseases are accompanied by feeding and swallowing problems during the different phases of deglutition, problems that give rise to a wide variety of signs and symptoms, which emphasizes the importance of a comprehensive feeding and swallowing assessment by a speech and language therapist.

Nonspeech Oral Movements and Oral Motor Disorders: A Narrative Review

PURPOSE

Speech and other oral functions such as swallowing have been compared and contrasted with oral behaviors variously labeled quasispeech, paraspeech, speechlike, and nonspeech, all of which overlap to some degree in neural control, muscles deployed, and movements performed. Efforts to understand the relationships among these behaviors are hindered by the lack of explicit and widely accepted definitions. This review article offers definitions and taxonomies for nonspeech oral movements and for diverse speaking tasks, both overt and covert.

METHOD

Review of the literature included searches of Medline, Google Scholar, HighWire Press, and various online sources. Search terms pertained to speech, quasispeech, paraspeech, speechlike, and nonspeech oral movements. Searches also were carried out for associated terms in oral biology, craniofacial physiology, and motor control.

RESULTS AND CONCLUSIONS

Nonspeech movements have a broad spectrum of clinical applications, including developmental speech and language disorders, motor speech disorders, feeding and swallowing difficulties, obstructive sleep apnea syndrome, trismus, and tardive stereotypies. The role and benefit of nonspeech oral movements are controversial in many oral motor disorders. It is argued that the clinical value of these movements can be elucidated through careful definitions and task descriptions such as those proposed in this review article.

Evaluation of the efficacy of cervical perivascular sympathectomy on drooling in children with athetoid cerebral palsy

OBJECTIVE

To evaluate the efficacy of cervical perivascular sympathectomy (CPVS) for drooling in children with athetoid cerebral palsy (ACP).

METHODS

The severity and frequency of drooling and the amount of salivation of 32 ACP children with drooling were evaluated before CPVS and at 4th, 12th and 24 weeks postoperatively by the teacher drooling scale (TDS) and salivary flow rate (SFR).

RESULTS

Fifteen children exhibited improvements on drooling according to the TDS score at 4th week after surgery (P < 0.05). Later, the number of children decreased to 10 at 12th week (P < 0.05) and to 8 at 24 week after surgery (P < 0.05). SFR was 0.67 mg/min at baseline, which decreased to 0.58 mg/min (P < 0.05) at 4th week after surgery. However, SFR showed a gradual increase at 12th week and 24 week with no significant difference.

CONCLUSIONS

Although CPVS was effective in improving drooling in some children with ACP, the results were not satisfactory. Thus, CPVS still needs to be cautiously used. Furthermore, more rigorous clinical studies should be performed to detect the effectiveness and safety of this procedure.

Relevance of intraglandular injections of Botulinum toxin for the treatment of sialorrhea in children with cerebral palsy: a review

BACKGROUND

After the age of 4 years, drooling becomes pathological and impacts the quality of life of children with cerebral palsy. Intraglandular injection of Botulinum toxin is one of the treatments available to limit this phenomenon.

AIMS

The objectives of this review were to validate the efficacy of Botulinum toxin injections for drooling in children with cerebral palsy, determine recommendations and identify potential side effects.

METHODS

We conducted a literature review from 2001 in the following databases: Embase, Pubmed and Cochrane using the keywords: sialorrhea, drooling, hypersalivation, Botulinum toxin, cerebral palsy and children. Only the articles evaluating the efficacy of Botulinum toxin in children with cerebral palsy over the age of 4 were researched.

RESULTS

Eight studies were found: 2 case studies, 3 open and non-controlled studies and 3 randomized controlled trials. Efficacy results in this indication are quite encouraging and the use of BTX injections is safe but the overall level of evidence of these studies was quite low.

CONCLUSION

However, intraglandular injection of Botulinum toxin has a place among the therapeutic array available for the management of sialorrhea in this population even if no standardized protocol is available yet.