Drooling of Saliva in Children: Clinical Evaluation Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with drooling of saliva
Physical Examination Guide
Systematic approach to examining a child with drooling of saliva
Diagnostic Approach
Initial Assessment
For a child presenting with drooling, the initial assessment should include:
- Detailed history focusing on onset, duration, and severity of drooling
- Assessment of developmental milestones
- Complete physical examination with focus on oral cavity and neurological status
- Evaluation of impact on daily functioning and quality of life
- Differentiation between physiologic and pathologic drooling
Understanding Drooling in Children
Drooling can be classified as:
| Type | Definition | Key Features |
|---|---|---|
| Physiologic Drooling | Normal developmental phenomenon in young children | Typically resolves by 18-24 months, associated with teething, occurs during concentration |
| Pathologic Drooling (Anterior) | Unintentional loss of saliva from the mouth | Visible drooling, wet clothes/toys, skin irritation, older children (>4 years) |
| Pathologic Drooling (Posterior) | Flow of saliva over the tongue through the oropharynx | Coughing, choking, aspiration pneumonia, less visible external drooling |
Drooling Severity and Frequency Assessment
| Thomas-Stonell and Greenberg Scale | Description |
|---|---|
| Severity Scale |
1 = Dry (never drools) 2 = Mild (wet lips only) 3 = Moderate (wet lips and chin) 4 = Severe (clothing becomes damp) 5 = Profuse (clothing, hands, tray, objects become wet) |
| Frequency Scale |
1 = Never drools 2 = Occasionally drools (not every day) 3 = Frequently drools (every day but not all the time) 4 = Constantly drools |
Differential Diagnosis
| System | Conditions | Red Flags |
|---|---|---|
| Neurological |
- Cerebral palsy - Parkinson's disease (juvenile) - Stroke/brain injury - Neuromuscular disorders - Pseudobulbar palsy |
- Motor delays/abnormalities - Associated neurological symptoms - Dysphagia/swallowing difficulties - Loss of previously acquired skills - Asymmetric drooling |
| Anatomical |
- Macroglossia - Oral/dental malocclusion - Cleft lip/palate - Adenoid/tonsillar hypertrophy - Nasal obstruction |
- Abnormal facial/oral appearance - Dental abnormalities - Mouth breathing - Sleep-disordered breathing - Difficulty closing mouth |
| Hypersalivation |
- Teething - Oral infection/stomatitis - Gastroesophageal reflux disease - Medication side effects - Heavy metal poisoning |
- Recent medication changes - Oral pain/lesions - Concurrent GI symptoms - Systemic symptoms - Environmental exposures |
| Developmental |
- Intellectual disability - Autism spectrum disorder - Developmental delay - Down syndrome |
- Global developmental delays - Social/communication concerns - Syndromic features - Abnormal behaviors - Learning difficulties |
| Miscellaneous |
- Hypohydrosis syndrome (Riley-Day) - Angioedema - Foreign body - Rabies (extremely rare) - Childhood dystonias |
- Autonomic dysfunction - Acute onset of symptoms - Pain with swallowing - Facial or oral swelling - Animal exposure (rabies) |
Laboratory Studies
Consider these studies when red flags are present:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Sialometry | Quantitative measurement of saliva production | Suspected hypersalivation vs. dysphagia/oral motor dysfunction |
| Swallowing Assessment | Evaluate swallowing mechanism and aspiration risk | Suspected dysphagia, choking, recurrent pneumonia |
| Drooling Impact Scale | Assess quality of life impact and severity | Considering interventional treatment, monitoring progress |
| pH Monitoring | Evaluate for gastroesophageal reflux | Concurrent reflux symptoms, posterior drooling, recurrent pneumonia |
Advanced Studies
Reserve for concerning presentations or refractory cases:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| MRI Brain | Evaluate for structural abnormalities | Neurological signs, developmental regression, focal findings |
| Video Fluoroscopic Swallow Study | Assess swallowing mechanism and aspiration | Suspected aspiration, posterior drooling, recurrent pneumonia |
| Electromyography | Evaluate motor function of oral muscles | Suspected neuromuscular disorders, asymmetric findings |
| Genetic Testing | Identify underlying genetic disorders | Syndromic features, developmental delays, family history |
| Salivary Gland Imaging | Identify salivary gland abnormalities | Suspected structural issues, unilateral drooling, masses |
Diagnostic Algorithm
A stepwise approach to diagnosing drooling in children:
- Determine physiologic vs. pathologic based on age and developmental stage
- Assess severity and frequency using standardized scales
- Comprehensive oral-motor examination including tonsillar assessment
- Evaluate neurological status including cranial nerves and motor function
- Consider underlying causes based on associated symptoms and findings
- Assess impact on quality of life, social functioning, and respiratory health
- Targeted investigations based on suspected etiology
- Multidisciplinary assessment for complex or severe cases
Management Strategies
General Approach to Management
Key principles in managing drooling in children:
- Identify and treat underlying cause: Address primary factors when possible
- Individualized approach: Consider age, severity, etiology, and impact on quality of life
- Multidisciplinary team: May include pediatrician, neurologist, ENT, dentist, speech therapist, occupational therapist
- Progressive management: Start with conservative measures before more invasive approaches
- Regular reassessment: Monitor for changes in severity and impact
Non-Pharmacological Interventions
| Intervention | Description | Evidence Level |
|---|---|---|
| Oral Motor Therapy |
- Exercises to improve lip closure - Jaw stability training - Tongue control exercises - Sensory stimulation techniques |
Moderate; effective for children with mild to moderate neuromotor dysfunction |
| Positioning Techniques |
- Proper head/neck alignment - Upright seated position - Optimization of trunk support - Specialized seating devices |
Moderate; particularly important for children with neuromotor impairments |
| Behavioral Approaches |
- Self-awareness training - Swallow reminders - Positive reinforcement - Biofeedback techniques |
Moderate; effective for cognitively able children without severe motor impairment |
| Intraoral Devices |
- Palatal training appliances - Orthodontic devices - Customized oral prosthetics |
Low to moderate; limited long-term studies, but promising short-term results |
| Adaptive Equipment |
- Absorbent scarves/bandanas - Silicone neck collars - Specialized clothing - Portable suction devices |
Low; primarily manages consequences rather than underlying cause, but improves quality of life |
Pharmacological Interventions
| Medication | Mechanism | Evidence and Considerations |
|---|---|---|
| Anticholinergic Agents |
- Glycopyrrolate (0.04-0.1 mg/kg/dose) - Scopolamine transdermal patch - Benztropine - Trihexyphenidyl |
- Moderate to high evidence for glycopyrrolate - Side effects: constipation, urinary retention, blurred vision, flushing - Contraindicated in narrow-angle glaucoma, GI obstruction - Monitor for CNS side effects, especially in young children |
| Botulinum Toxin |
- Injection into salivary glands - Typically parotid and submandibular - Effects last 3-6 months - Ultrasound-guided techniques preferred |
- High evidence for effectiveness - Temporary solution requiring repeat treatments - Side effects: dry mouth, swallowing difficulties, pain at injection site - Consider for moderate to severe drooling |
| Other Medications |
- Beta-blockers (propranolol) - Alpha-2 agonists (clonidine) - Modafinil - Amitriptyline |
- Limited evidence for drooling management - Generally third-line options - Consider for specific underlying conditions - Careful monitoring for side effects required |
Surgical Interventions
Consider for severe, refractory cases:
| Procedure | Description | Evidence and Considerations |
|---|---|---|
| Salivary Duct Relocation |
- Submandibular ducts redirected posteriorly - Redirects saliva flow toward oropharynx - Maintains salivary production |
- Moderate evidence for effectiveness - Risk of ranula formation, duct stenosis - Careful patient selection required - May increase aspiration risk |
| Salivary Duct Ligation |
- Ligation of submandibular or parotid ducts - Reduces overall saliva production - Can be performed with botulinum toxin injection |
- Moderate evidence base - Risk of sialadenitis, xerostomia - Often produces only partial improvement - Usually performed bilaterally |
| Salivary Gland Excision |
- Removal of submandibular glands - Sometimes with parotid duct ligation - Permanent reduction in saliva |
- High evidence for effectiveness - Most invasive option - Irreversible procedure - Risks: xerostomia, facial nerve injury, wound infection - Last resort for severe cases |
| Tympanic Neurectomy |
- Transection of chorda tympani nerve - Reduces parasympathetic stimulation to glands - Less commonly performed |
- Limited evidence - Potential taste disturbance - Variable effectiveness - Rarely performed as primary procedure |
Management by Specific Etiology
| Underlying Cause | Management Approach | Follow-up Recommendations |
|---|---|---|
| Physiologic Drooling in Young Children |
- Reassurance and education - Bibs and absorbent clothing - Regular wiping - Avoid intervention |
- Routine pediatric visits - Reassess if persists beyond 4 years of age - Monitor dental health |
| Cerebral Palsy |
- Multidisciplinary approach - Positioning and oral motor therapy - Consider botulinum toxin - Surgical options for severe cases |
- Regular assessment by team - Monitor for aspiration - Assess impact on quality of life - Stepwise progression of interventions |
| Adenotonsillar Hypertrophy |
- ENT referral - Consider adenotonsillectomy - Treat allergies if contributing - Assess for sleep-disordered breathing |
- Post-surgical follow-up - Reassess drooling after recovery - Monitor for recurrence |
| Gastroesophageal Reflux |
- Acid suppression therapy - Dietary modification - Positional therapy - Consider prokinetic agents |
- Follow-up in 4-6 weeks - Monitor for improvement - Consider pH study if refractory |
| Medication-Induced |
- Medication review - Consider dose reduction - Alternative medications - Symptom management |
- Follow-up after medication adjustment - Monitor for improvement - Balance primary condition treatment with side effects |
Parent Support and Education
- Education: Causes of drooling and expected timeline for physiologic drooling
- Practical management: Clothing protection, skin care, hydration
- Psychosocial impact: Addressing stigma, social challenges, school integration
- Expectations: Realistic outcomes based on etiology and severity
- Resources: Support groups, disability services, financial assistance for equipment
When to Refer
- Speech Therapy: Oral-motor dysfunction, swallowing concerns
- Neurology: Suspected neurological causes, abnormal movements, developmental regression
- ENT: Adenotonsillar hypertrophy, anatomical concerns, consideration of surgical approaches
- Dentistry/Orthodontics: Malocclusion, intraoral appliances, dental complications
- Gastroenterology: Significant GERD, swallowing dysfunction, aspiration concerns
- Multidisciplinary Drooling Clinic: Severe or refractory drooling, consideration of invasive treatments
- Genetics: Multiple congenital anomalies, suspected genetic syndrome
