Impact and management of drooling in children with neurological disorders: an Italian Delphi consensus

Navigating the spectrum of pediatric sialorrhea management: A narrative review

OBJECTIVE

This review summarizes the approaches to pediatric sialorrhea management from least-to-most invasive: non-pharmacological management, anticholinergic medications, botulinum neurotoxin, non-invasive surgery, and invasive surgical intervention.

REVIEW METHODS

An electronic literature review identified English-language articles on sialorrhea management in pediatric patients. Publications between 1982 and 2022 were used, with a focus on articles published from 2012 to 2022. Additional augmentation of pharmacologic information was obtained from the latest editions of medical textbooks supplemented with official package inserts of investigated medications.

CONCLUSIONS

Sialorrhea is abnormal in patients greater than four years of age. Severe cases warrant intervention to improve patient quality of life and reduce caregiver burden. Management starts with conservative approaches. Viable candidates begin with non-pharmacological management options. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus multiple treatments are required. Non-invasive sclerotherapy is an emerging treatment option showing promising results for sialorrhea. In contrast, surgical intervention is reserved as a last-resort treatment for patients with severe symptoms, due to its higher risk for adverse consequences.

IMPLICATIONS FOR PRACTICE

Physicians should be familiar with the different pediatric sialorrhea management options, including advantages and disadvantages, to adequately facilitate shared decision making with caretakers of pediatric patients who require treatment.

Social and emotional impact of anterior drooling in school-age children and young people with neurodevelopmental disabilities

PURPOSE

Anterior drooling is a common comorbidity in children and young people (CYP) with neurodevelopmental disabilities. This study aimed to assess the social and emotional impact of drooling in CYP with a developmental age (DA) of 6 years and older, in whom this impact may differ from those with a lower DA due to their developing sense of self and awareness of their position within social groups.

METHODS

Questionnaire data collected for routine clinical care were used to assess parental perceptions of the impact of drooling on (1) social interaction; (2) satisfaction with social interaction, appearance, family relations and life in general and (3) the way CYP expressed feelings on appearance, acceptance by peers and acceptance by adults. Fisher's exact tests and Mann-Whitney U tests were applied to identify associations between clinical characteristics and the social and emotional impact of drooling.

RESULTS

Seventy-nine CYP with an estimated DA ≥ 6 years were included. The majority experienced frequent to constant (83%) and profuse (61%) drooling. Drooling frequently compromised social interaction with peers (49%) and adults (28%), and cognitive abilities were underestimated in 40%. Dissatisfaction with physical appearance (25%) related to drooling was noted. One-fifth of CYP reportedly expressed negative feelings on acceptance by peers related to drooling.

CONCLUSIONS

These findings underscore the substantial impact of drooling on CYP with a DA of 6 years and older, primarily through avoidance by peers and underestimated cognitive abilities, emphasizing that recognizing and addressing these social-emotional consequences should be integral to clinical care.

WHAT IS KNOWN

• Anterior drooling is common among children and youth with neurodevelopmental disabilities.

WHAT IS NEW

• There seems to be a heightened prevalence of impaired social interaction with peers and underestimation of cognitive abilities due to drooling among children with a developmental age of at least 6 years compared to previous studies with more heterogeneous populations. • The impact of drooling can extend to domains that affect self-esteem, although this may not be fully captured with standardized questions, requiring clinicians to address these consequences in a way that is tailored to the child's experiences.

Outcome of kinesio taping in drooling children: A systematic review

INTRODUCTION

Drooling is a troublesome condition, especially in children with neuromuscular and intellectual disability. Over the past decade, novel interventions have been trialled to alleviate drooling in the affected children. Kinesio tape (KT) application has shown promising results in controlling drooling in children. We reviewed the literature to determine the outcome of KT application in drooling children.

METHODS

A literature search was conducted from January 1, 1990 to March 2024 by searching several databases over a 1-month period (April 2024) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was defined as the success of the intervention determined by the improvement or resolution of symptoms, and the secondary outcome was determined by adjunct or repeated procedures and the presence of complications.

RESULTS

Overall, 172 children from 10 studies were identified. All studies included are retrospective studies (Level III). This review included 172 children, with a mean age of 8.2 years (Male: 58.7 %). All included children had underlying comorbidities (100 %), with neurological disorders (77 %) being the most prevalent. KT application was performed predominantly over the orbicularis oris in 6 studies, 118 children[68.6 %], suprahyoid region in 3 studies, 45 children (26.2 %) and multiregion over the head and neck in 1 study of children (5.2 %). Drooling was assessed subjectively in all 100 % of children with objective measurement performed in 3 studies. KT was the only intervention in 40.7 % of the included children, whereas KT was performed in combination with oromotor therapy in 48 children, speech therapy in 44 children, and manipulation therapy in 10 children. All included children (100 %) reported improvement in drooling. No studies reported adverse reactions to KT application.

CONCLUSIONS

KT application is a safe, effective alternative for drooling children. The effect of KT, however, may be temporary. The quality of the evidence is inadequate to recommend widespread use of the intervention until a better-quality study has been completed. Future randomised controlled studies with a large sample size are warranted to determine the efficacy of this intervention among children.

Glycopyrronium 320 μg/mL in children and adolescents with severe sialorrhoea and neurodisabilities: A randomized, double-blind, placebo-controlled trial

AIM

To investigate the efficacy, safety, and impact on quality of life (QoL) of an oral formulation of 320 μg/mL glycopyrronium designed for children.

METHOD

A double-blind, placebo-controlled SALIVA (Sialanar plus orAl rehabiLitation against placebo plus oral rehabilitation for chIldren and adolescents with seVere sialorrhoeA and neurodisabilities) trial was conducted. Children (3-17 years) with neurodisabilities and severe sialorrhoea (modified Teachers Drooling Scale ≥6) were randomized to 320 μg/mL glycopyrronium or placebo, in addition to non-pharmacological standard care.

RESULTS

Of 87 participants, 44 were aged 10 years or under and 43 had cerebral palsy. The primary endpoint, change in total Drooling Impact Scale (DIS) score from baseline to day 84, was significantly greater (improved) with 320 μg/mL glycopyrronium versus placebo (median [quartile 1, quartile 3] -29.5 [-44.5, 0] vs -1 [-16, 5]; p < 0.001), an effect also observed at day 28 (median - 25 vs -2; p < 0.01). Significant reduction in bibs/clothes used per day was seen with glycopyrronium versus placebo at day 84 (median - 2 vs 0; p < 0.01). Glycopyrronium significantly improved DIS items 9 and 10 related to the extent that drooling affects the child's and family's life (p ≤ 0.03). Adverse events were reported by 77.3% and 69.8% of children with glycopyrronium and placebo respectively; the most common treatment-related adverse event was constipation (20.5% and 16.3%).

INTERPRETATION

The formulation of 320 μg/mL glycopyrronium significantly improved drooling and reduced its impact on QoL, with good tolerability in children with neurodisabilities.

WHAT THIS PAPER ADDS

The formulation of 320 μg/mL glycopyrronium significantly improved Drooling Impact Scale score versus placebo at day 84. The formulation reduced the impact of drooling on the child's and family's quality of life. There were no safety or tolerability concerns with this specific formulation.

Intraoral Acupuncture for Sialorrhea in Stroke Patients: a Study Protocol for a Randomized Controlled Trial

Importance

Post-stroke sialorrhea (PSS) refers to excessive saliva flowing out the lip border after a stroke. PSS negatively affects patient self-image and social communication and may lead to depression. Limited evidence supports the link between excessive salivation and PSS. No large-scale, strictly controlled randomized controlled trials have shown the effectiveness of acupuncture in treating PSS patients.

Objective

We aim to compare the effects of intraoral and sham acupuncture in PSS patients and explore relationships among salivation and drooling severity and frequency and swallowing function in stroke patients.

Design

Clinical study protocol, SPIRIT compliant.

Setting

Prospective, single-center, randomized, and sham-controlled trial.

Population

We will recruit 106 PSS patients to receive 4-week intraoral or sham acupuncture. Additionally, 53 stroke patients without PSS will undergo a conventional 4-week treatment program to compare salivation between PSS and non-PSS patients.

Exposures

Intraoral or sham acupuncture.

Main Outcomes and Measures

The main evaluation index will be the 3-minute saliva weight (3MSW), comparing changes in 3MSW from baseline to weeks 4 and 8. Secondary assessment indices will include the “Drooling Severity and Frequency Scale” and “Functional Oral Intake Scale.”

Results

The results from this study will be published in peer-reviewed journals.

Conclusion

Comparing effects of intraoral and sham acupuncture in PSS patients, this study may contribute important evidence for future PSS treatment and provide valuable insights into whether salivation issues in stroke patients are attributed to heightened salivary secretion or dysphagia.

Pharmacologic Management of Sialorrhea in Neonatal and Pediatric Patients

Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published -human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship.

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.

Safety Profile and Lack of Immunogenicity of IncobotulinumtoxinA in Pediatric Spasticity and Sialorrhea: A Pooled Analysis

IncobotulinumtoxinA, a pure botulinumtoxinA formulation, is free of accessory proteins. This analysis provides pooled safety data from phase 3 trials of children/adolescents (2–17 years), investigating incobotulinumtoxinA for the treatment of spasticity associated with cerebral palsy (at doses ≤20 U/kg (max. 500 U) per injection cycle (IC) for ≤6 ICs; three trials) or sialorrhea associated with neurologic disorders (at total doses of 20–75 U per IC for ≤4 ICs; one trial) for ≤96 weeks. Safety endpoints included the incidences of different types of treatment-emergent adverse events (TEAEs) and immunogenicity. IncobotulinumtoxinA dose groups were combined. Of 1159 patients (mean age 7.3 years, 60.4% males) treated with incobotulinumtoxinA, 3.9% experienced treatment-related TEAEs, with the most common being injection site reactions (1.3%) (both indications), muscular weakness (0.7%) (spasticity), and dysphagia (0.2%) (sialorrhea). Two patients (0.2%) experienced a treatment-related treatment-emergent serious adverse event, and 0.3% discontinued the study due to treatment-related TEAEs. No botulinumtoxinA-naïve patients developed neutralizing antibodies (NAbs) after incobotulinumtoxinA. All children/adolescents with known pre-treatment status and testing positive for Nabs at final visit (n = 7) were previously treated with a botulinumtoxinA other than incobotulinumtoxinA. IncobotulinumtoxinA was shown to be safe, with very few treatment-related TEAEs in a large, diverse cohort of children/adolescents with chronic conditions requiring long-term treatment and was without new NAb formation in treatment-naïve patients.