Salivation in kids can be due to various reasons ranging from simple oral hygiene issues to complex neurological disorders. Excessive drooling or unintentional leakage of saliva is seen if there is overproduction of saliva or inability to swallow these secretions. Increased salivation is also called sialorrhea, hypersalivation, or ptyalism.
Anterior and posterior drooling is present; this means the excess oral secretions spill from mouth to face or the windpipe (airways). Skin irritation and social stigma can be common problems of children with anterior drooling. In comparison, posterior drooling can cause aspiration pneumonia. Therefore, it is recommended to seek a pediatrician’s attention if your child has excessive drooling.
Read on to know the causes, diagnosis, complications, prevention, and treatment of increased salivation in children.
Symptoms Of Excessive Drooling In Children
Anterior spillage of saliva is visible. You may notice wet clothes and crusts, especially on your child’s face, neck, and chest. A few children drool while sleeping, making the bed and pillows wet (1).
Posterior drooling may not be visible, but children can have choking, coughing, and frequent aspiration pneumonia.
Symptoms of underlying conditions causing sialorrhea may include:
- Motor and sensory dysfunctions in children with central nervous system dysfunction.
- Difficulty in swallowing, painful swallowing, and heartburn are typically associated with oropharyngeal and esophageal problems, which involve the muscles of your gut.
- Jaundice, itching (pruritus), Kayser–Fleischer rings (KF rings, golden brown eye discoloration due to copper deposits) are signs that a child may have a condition called Wilson’s disease.
If you suspect your child has an acute or sudden onset of drooling due to poisoning, chemical or traumatic injuries, or foreign body in the esophagus, then seek immediate medical attention immediately.
When To See A Doctor
You should seek medical attention if you notice chronic excessive drooling, or if the drooling is accompanied by the following symptoms:
- Seizures or loss of consciousness
- Choking and inability to breathe
- Blisters inside the mouth or on the lips
Causes Of Excessive Drooling (Sialorrhea) In Children
Excessive drooling can happen due to any one of the following reasons:
- Excessive production of saliva
- Poor muscle control to contain the saliva
- Failure to swallow saliva before it drools from the mouth
- Reduced sensory and motor functions of the mouth. Various conditions can cause excessive drooling, such as (2):
- Nervous system disorders and injuries, such as cerebral palsy, stroke, traumatic brain injury, and congenital brain abnormalities. These conditions may cause drooling due to poor oral motor skills and sensations. Children with cerebral palsy may have drooling due to poor head control and a lack of facial tone.
- Muscular disorders, such as myasthenia gravis, polymyositis, etc., can cause poor oral motor function.
- Mental retardation and developmental delay may cause ineffective drooling, as well.
- Tongue thrust, that is, reverse or immature swallowing, is commonly seen in a drooling child.
- Lesions or infections in the mouth or throat due to conditions such as gingivostomatitis, epiglottitis, tonsillitis, and tonsillar abscesses.
- Chemical or traumatic injuries of the oropharynx.
- Esophageal injuries or stricture due to trauma, caustic ingestion, etc.
- A foreign body in the esophagus.
- Gastroesophageal problems, such as acid reflux or gastroesophageal reflux disease.
- Some drugs, including clozapine, haloperidol, and morphine, may cause drooling, and poisoning with mercury and organophosphates could lead to increased salivation.
- Teens may be susceptible to drooling due to the abuse of substances, such as cocaine.
- Genetic diseases such as Wilson’s disease, Rett syndrome, and Riley-Day syndrome (familial dysautonomia) can also lead to excessive drooling due to autonomic nervous system dysfunction (sympathetic and parasympathetic nervous system control saliva production and secretion) and oromotor dysfunction.
- Mouth breathing whilst sleeping from nasal congestion/inflammation.
These acute, chronic, or hereditary conditions can lead to changes in body functions, thus resulting in excessive drooling. Seek medical attention to identify the exact cause of sialorrhea and prevent further complications.
Risk And Complications Of Excessive Drooling In Children
Excessive drooling can result in physical, psychological, and social issues, and can result in various side effects, such as (2).
- Damage to the skin around the mouth from saliva (maceration)
- Angular cheilitis that is maceration on the angle of lips
- Dehydration due to fluid loss
- Bacterial infection
- Unpleasant odor
- Social stigma
- Aspiration pneumonia due to inhalation of saliva, food, or drinks to the lungs. Chronic aspiration of saliva may often go undiagnosed in pediatric patients, until the development of significant changes to the lungs.
Sialorrhea could cause emotional problems. Frequent drooling can result in wet clothes, toys, etc. The child may also require clothing changes more frequently.
The social stigmatization and bullying from peers due to frequent drooling may affect the mental wellbeing of young people. This may also cause language and speech delay in some children.
Diagnosing Excessive Drooling In Children
Your child’s pediatrician can diagnose anterior drooling by observation. They may ask for a history of cough, choking, and pneumonia to diagnose posterior sialorrhea.
Doctors may order blood tests to look for infections that may cause increased salivation. Upper gastrointestinal endoscopy and radiography during swallowing may be performed to ellicit the exact cause of excessive drooling. Additional tests, such as brain MRI, CT, etc., may be ordered based on coexisting symptoms (3).
Can Excessive Drooling Be Cured?
Complete elimination of sialorrhea due to neurological problems or chronic conditions may not always be possible. However, treatment measures could reduce excessive drooling. All the treatments for sialorrhea are aimed at minimizing salivary production and thus controlling excessive drooling. Complete removal of glands is not possible since it causes dry mouth, which may result in other problems, including frequent oral infections or ulcers.(1).
However, children with excessive drooling due to acute conditions such as tonsillitis, dental caries, etc., can be completely cured after the resolution of the underlying conditions.
Treating Excessive Drooling In Children
Pharmacologic and non-pharmacologic interventions are recommended for managing excessive drooling in children. If the condition is chronic, then medicines with management procedures would be suggested.
The following non-invasive modalities have not been proven to cure, but can reduce the production of saliva in some cases (4).
- Position training: An appropriate body posture with a good head and trunk control may help to improve drooling and swallowing problems caused by inadequate oral control.
- Eating and drinking skills training: This training is aimed to achieve good eating and drinking skills, with proper lip closing and tongue movements. These may help reduce salivary secretion.
- Oral facial facilitation techniques: These techniques help to control the motor movements and sensation of the oral muscle and swallowing frequency. The training is usually provided by a speech therapist, using hyper and hypotonic muscles. It may include icing, brushing, vibration, or manipulations such as patting or stroking to improve oral awareness and control.
- Speech therapy: This could help improve tongue mobility, strength, and swallowing. It may also help achieve lip closure in a few children. Good results are often seen in children who started training early.
- Behavior therapy: It encourages and teaches children to swallow and wipe excess saliva. It also aims to decrease the sucking of fingers or objects.
- Oral appliances or prosthetic devices: Devices to achieve lip closure and mandibular stability may help reduce drooling. You may discuss with your child’s healthcare provider about a suitable product.
- Oral medicines: These daily medications may help reduce the amount of saliva produced. These are used strictly under the guidance and supervision of your doctor.
- Botox injections: The injection is made from botulinum toxin, and can diminish the saliva production by the salivary gland.
- Salivary gland ablation: It is a percutaneous procedure, injecting agents such as alcohol to the gland to cause the shrinking of the gland. This could lead to a reduction in saliva production and drooling frequency.
- Surgery: Removal of salivary glands (glandular excision) is done to decrease the saliva. The same can be achieved by disconnecting ducts that drain saliva from salivary glands to mouth. It is not recommended, and only done in extreme conditions.
Surgery and salivary gland ablation require anesthesia. Salivary gland ablation is usually given on one side of the face. If there is no reduction in sialorrhea, your child’s doctor may consider injections for the other side of the face during follow up visits. This procedure may often result in painless postoperative facial swelling weeks after the ablation.
Salivary gland ablation with alcohol has the risk of injury to the facial nerves. Rarely, this could complicate into temporary facial muscle paralysis or weakness. There is no evidence that the child suffers from dry mouth after the procedure since the glands produce the required amount of saliva.
The removal of salivary gland may be considered as a last resort. The procedure is likely to be considered when the benefits of the surgery outweigh the potential risks. Your child’s pediatrician may make referrals to a specialist multidisciplinary team for the assessment, management, and treatment of excessive drooling.
Preventing Excessive Drooling In Children
Acute sialorrhea due to inflammation and infections of mouth, throat, and dental problems can be prevented with timely diagnosis and treatment. You can teach the following methods to your child to prevent excessive drooling if possible (6)
- Maintain good oral hygiene.
- If your child can wipe saliva, then you may make them wear an absorbable wristband, like that worn by sportspersons. This can be more effective and acceptable than bibs or handkerchiefs, in older children.
- Ask them to dab saliva instead of wiping it to avoid stimulation of salivary glands.
- Protective clothing and bandanas can be used if there is too much saliva coming from the mouth in older children.
- Provide gloves, elbow splints, or teach not to put fingers or objects in the mouth. This helps to avoid saliva production due to mouthing fingers or objects.
- Avoid sweet fizzy drinks and acidic foods, such as lemon and vinegar, that may stimulate salivary secretion.
These methods do not completely prevent or cure drooling problems, but have an impact of quality of life effects.
How To Prevent Drooling While Sleeping?
It is normal for babies and toddlers to drool while sleeping as they are still todevelop complete control over muscles. Teething is also a common cause of drooling, other than mouth or throat inflammations and infections.
If your child is older, then you can ask them to sleep on their back to reduce drooling during sleep. If it is difficult to sleep on their back, then use wedge pillows that may help reduce drooling while sleeping on the sides (7).
Drinking enough water can reduce the risk for dehydration as well as avoid the production of saliva due to dry mouth. You may also encourage them to use a mandibular device, oral device, or mouthpiece as per the recommendations of a healthcare provider to avoid drooling.
The causes of Sialorrhea or excess salivation in kids include poor oral hygiene, infections, improper oral muscle control, complex disorders of the nervous system such as cerebral palsy, and brain injury. Outward spillage of excess saliva may affect the skin around the mouth, while an inward movement can cause choking or aspiration pneumonia. Drooling
can have a psychosocial effect as well. Treatment aims to reduce excess saliva production, and doctors may suggest techniques such as speech therapy or positional training, prosthetic devices, medical management, or surgical correction depending on the underlying cause. You can help your child by following preventive measures and providing emotional support.
2. Alexander KC Leung and C Pion Kao; Drooling in children; The United States National Library of Medicine
3. Neil G. Hockstein, et al.; Sialorrhea: A Management Challenge; The American Academy of Family Physicians
4. Ganesh Bavikatte, et al.; Management of Drooling of saliva; British Journal of Medical Practitioners
5. Rachael Lawrence and Neil Bateman; Surgical Management of the Drooling Child; The United States National Library of Medicine
6. C B R Fairhurst and H Cockerill; Management of drooling in children; British Medical Journal
7. Drooling in Your Sleep? Here’s Why It Happens and How to Treat It; Sleep Advisor
Dr Bisny T. Joseph
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Dr. Thulja Trikamjee(MD)
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