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Drooling

Drooling happens when your child is unable to control what happens to the saliva in the mouth. The problem usually isn't too much saliva, the usual problem is that your child isn't able to control the saliva that is there.

Drooling is common and normal in children under the age 2, because at that stage they have't yet developed sufficiently to learn to control their mouth, tongue and swallowing well enough to control the saliva. Drooling can also affect children with neurological problems such as cerebral palsy, or those with developmental delay.

What should I do if I am concerned about drooling?

In the first instance, talk to your GP or your paediatrician. The important things to determine are:

-Is there an acute problem that has suddenly caused drooling in a child that is unwell (for example, tonsillitis could cause it)

-Is there a cause for drooling (for example delayed development, neuromuscular weakness or coordination problems, inability to close mouth due to blocked nose). Your GP might need to ask a paediatrician to review the child to look for any problems

What treatment is available in children that are otherwise-healthy?

In children that don't have any other health problems to account for long-standing drooling, a period of observation is usually helpful. Drooling usually just settles over time.

Working with a speech and language therapist will be useful. They will assess your child's mouth and tongue movement and swallowing, and provide exercises to teach your child how to gain control over the saliva.

Medication can be used to dry the flow of saliva. However, this can lead to dry mouth, which isn't pleasant for the child. In addition, the antibacterial effectiveness of saliva is then also removed, which may predispose to tooth decay.

Surgery would be considered only in exceptional circumstances. Usually, a major contributing factor for drooling is the presence of large adenoids and tonsils, which interfere with the child's ability to breathe with their mouth closed. If your child constantly has their mouth open because otherwise they can't breathe, then saliva escapes through the mouth. Removal of tonsils and adenoids therefore would be one of the options for drooling management. However, because drooling often just gets better as the child gets older, surgery shouldn't be undertaken lightly. An additional problem is the fact that NHS at present would probably not fund tonsil and adenoid surgery for drooling.

What treatment is available in children with neurological problems?

 

Children with neurological problems may be affected by drooling, which can have a significant impact on their quality of life. Again, working with a speech and language therapist is important. Medication is likely to play a role. It is also worth looking at your child's posture, and seeing whether posture or seating modification could alter how saliva flows.

Removal of tonsils and adenoids may be suitable for some, but there are also other options available to reduce saliva flow, such as botox and surgery.

Botox

Botox injections into saliva glands can reduce the flow of saliva. However, the effect is temporary, and has to be repeated. Many children require a general anaesthetic for the injection, so this would mean repeat general anaesthetics. Botox injections are also not as simple to do as it may seem, and in fact there is the potential for significant problems in swallowing as a result of the injection.

Submandibular duct relocation

If your child has a safe swallow, then submandibular duct relocation would be an option. This operation moves the submandibular gland duct drainage from the front of the mouth to the back of the throat. So instead of saliva appearing at the front, it appears at the back, and the child therefore finds it easier to swallow the saliva rather than drool.

 

The procedure is not suitable for children who aspirate and have an unsafe swallow, because diversion of salivary flow to the back of the throat will increase the risk of aspiration.

 

Also, some surgeons find that operating on the very delicate salivary ducts is a challenge, and believe that in fact all that surgery achieves is to block off the salivary glands. In other words, surgery doesn't work because saliva is diverted, it works because it has closed and blocked the flow of saliva. So those surgeons may suggest that rather than relocating the submandibular ducts, we may as well just stitch them closed. The downside of that is that because we create a block in the flow of saliva the glands swell up after surgery and are painful usually for a week or more.

The benefit of duct relocation is that saliva flow is preserved, so your child keeps the beneficial effects that saliva provides. If you remove the saliva glands, you remove the beneficial effect of saliva.

Submandibular gland excision

Removal of submandibular glands is another option. This is done from the outside, so a scar on each side of the neck will be required. Removal of the submandibular glands reduces the flow of saliva, and aspiration isn't a risk, neither is significant pain. However, this surgery requires external scars, and there is a small chance of injury to the nerves of tongue and mouth.

What about other salivary glands?

You will note that so far we have largely talked about the submandibular glands, but the body has other salivary glands also. The submandibular glands produce the vast bulk of saliva that is present on a constant basis. The parotid glands tend to produce more saliva just in response to feeding. So for drooling, we need to address the salivary flow that is there all the time, and that means focusing on the submandibular glands. We may however also often look at reducing the flow from the parotid glands, which would typically involve blocking off the parotid duct to stop salivary flow. We do not advise surgical removal of the parotid glands because surgery would be unlikely to lead to major reduction in drooling and could lead to weakness of the nerve that moves the face. As you might expect, surgery to block of the parotid salivary ducts is likely to lead to painful swelling for a week or more. 

Keeping some saliva production is a good thing, because saliva serves important functions. So the goal of surgery isn't to completely remove saliva flow, it is to reduce the flow to a manageable level.

You will see that the management of drooling is quite complex. In children that are otherwise-healthy, just waiting for them to get older is usually a good option. For children with neurological problems, working with a multidisciplinary team experienced in drooling management is key.

Section contributor:

Rachael Lawrence MBBS BSc MRCS

ENT Registrar