Acute kidney injury in critically ill children with COVID-19 and MIS-C.

BACKGROUND: This study's objective was to investigate the incidence of acute kidney injury (AKI) in children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and multisystem inflammatory syndrome (MIS-C) and to report our clinical experience. METHODS: Acute COVID-19 and MIS-C-diagnosed patients observed in two pediatric intensive care units (PICUs) between 2019 and 2021 were examined for AKI and retrospectively compared to children with AKI. RESULTS: The study comprised 163 children, of whom 98 (60.1%) were diagnosed with acute COVID-19 and 65 (39.9%) with MIS-C. AKI was observed in 40 (40.8%) of the acute COVID-19 patients and 18 (27.7%) of the MIS-C patients. Low calcium level and hypotension were linked with AKI at initial presentation (OR: 0.56, 95% CI: 0.369-0.560, p = 0.006 and OR: 3.64, 95% CI: 1.885-7.152, p = 0.001, respectively). A history of nephrotoxic medication usage played an essential role in the development of AKI in patients who acquired AKI after hospitalization (p = 0.001, odds ratio: 9.32, confidence interval: 3.106-27.973). In clinical practice, individuals with respiratory distress and cough had a high chance of having AKI (OR: 4.47, 95% confidence interval: 2.25-8,892 and OR: 3.48, 95% confidence interval: 1.76-6.88). AKI patients had a greater demand for respiratory assistance and a longer period of stay in the PICU. CONCLUSIONS: AKI in the COVID-19 and MIS-C patient groups is related with increased mortality and extended hospitalization, according to the findings. These statistics imply that identifying and preventing risk factors is necessary. A higher resolution version of the Graphical abstract is available as Supplementary information.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children.

BACKGROUND: We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). METHODS: We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. RESULTS: There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. CONCLUSION: Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Role of Biological Agents in the Treatment of SARS-CoV-2-Associated Multisystem Inflammatory Syndrome in Children.

OBJECTIVES: The aims of this study were to evaluate the role of biological agents in the treatment of severe multisystem inflammatory syndrome in children (MIS-C) and to assess the current application, outcomes, and adverse effects in patients who are followed up in a pediatric intensive care unit (PICU). PATIENTS AND METHODS: This observational, descriptive, medical records review study was performed on patients with MIS-C admitted to the PICU between September 1 and November 1, 2020. Through medical records review, we confirmed that patients were positive for current or recent SARS-CoV-2 infection or for COVID-19 exposure history within the 4 weeks before the onset of symptoms. RESULTS: A total of 33 patients with severe MIS-C were included (21 male) with a median age of 9 years. The most common signs and symptoms during disease course were fever (100%) and abdominal pain (75.5%). Clinical features of 63.6% patients were consistent with Kawasaki disease/Kawasaki disease shock syndrome, and 36.4% were consistent with secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. Myocardial dysfunction and/or coronary artery abnormalities were detected in 18 patients during the PICU stay. Intravenous immunoglobulin and corticosteroids were given to 33 patients. Anakinra was administered to 23 patients (69.6%). There was a significant increase in lymphocyte and platelet counts and a significant decrease in ferritin, B-type natriuretic peptide, and troponin levels at the end of the first week of treatment in patients who were given biological therapy. Two patients were switched to tocilizumab because of an insufficient response to anakinra. The mortality rate of MIS-C patients admitted in PICU was 6.0%. CONCLUSIONS: Management of systemic inflammation and shock is important to decrease mortality and the development of persistent cardiac dysfunction in MIS-C. The aggressive treatment approach, including biological agents, may be required in patients with severe symptoms and cardiac dysfunction.

Crimean-Congo hemorrhagic fever: A pediatric case responding to plasmapheresis treatment.

Crimean-Congo hemorrhagic fever (CCHF) is a life-threatening tick-borne viral infection. The most important step in the treatment of CCHF is supportive therapy. Ribavirin is the recommended antiviral agent for infected patients. We present a case of a child who presented to our pediatric intensive care unit due to CCHF and was treated with plasmapheresis and ribavirin. A previously healthy seven-month-old male infant presented to the emergency room with a fever of 39.5 °C, nosebleed, cough, vomiting, and weakness. We decided to apply plasmapheresis treatment due to multiple organ failure associated with thrombocytopenia, acute liver failure, and a family history of death from the disease. Plasmapheresis was performed in three sessions. By the sixth day of his admission to the intensive care unit, the patient's clinical condition had improved and his laboratory values had returned to normal, so he was transferred to the infectious diseases service in stable condition.

Overlap Stevens Johnson Syndrome/Toxic Epidermal Necrolysis developed due to the use of toxic-dose vinblastine in case of Langerhans Cell Histiocytosis(Letterer-Siwe).

Except for side effects expected standart dose use of the chemotherapeutics agents, toxic effects (poisoning) may occur if high doses of are mistakenly used in the treatment of haemato-oncological diseases and these toxic doses are usually fatal. Here, we report a case of Stevens Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN) following administration of toxic dose of vinblastine by mistake. A 20-month-old male patient with a diagnosis of Langerhans Cell Histiocytosis (Letterer-Siwe) at the pediatric oncology department was admitted to intensive care unit, after having received treatment protocol consisting of vinblastine, etoposide and prednisolone, with fever, altered consciousness and decompensated shock findings. Skin biopsy which performed from bullous lesions in the perianal, neck and axillary regions was resulted compatible with SJS / TEN in the patient with multiple organ failure, at 48 h of admission. It was later determined that the patient has been mistakenly given 10 times the normal dose of vinblastine he needed (60 mg/m2), which was 6 mg/m2. Plasma exchange was performed 3 times for vinblastine toxicity, intravenous immunoglobulin was administered for SJS / TEN therapy and phenobarbital was initiated to increase drug metabolism. The patient whose clinical picture fully improved, was transferred to the oncology department on the 30th day of intensive care hospitalization. Vinblastine toxicity is a life-threatening condition that can cause multiple organ failure, SJS / TEN. Plasma exchange is an effective treatment method for the removal of vinblastine from the body and in these cases of toxicity.

Therapeutic plasma exchange: A potential management strategy for critically ill MIS-C patients in the pediatric intensive care unit.

This study aimed to evaluate the effectiveness and the role of therapeutic plasma exchange (TPE) in treatment of children with severe MIS-C. In addition, we assessed demographic data, clinical features, laboratory abnormalities, underlying conditions, treatments, and outcomes. Patients with severe MIS-C who were admitted to the pediatric intensive care unit (PICU) between September 01 and October 05, 2020 were included in this observational, descriptive, retrospective study. The data collected included the patients' demographic data, presenting symptoms, clinical features, laboratory parameters, diagnostic investigations, and medications. Of 27 children with MIS-C, 63 % were male. The median age of the patients was nine years. Intravenous immunoglobulin and corticosteroids were used for treatment in 100 % of the patients, anakinra in 51.8 %, vasopressors in 85.1 %, noninvasive mechanical ventilation in 25.9 %, and invasive mechanical ventilation in 18.5 %. Ten of the 27 patients (37 %) underwent TPE. In the patients who underwent TPE, the median PELOD score was 21 (IQR: 11-30.25) before TPE and 10 (IQR: 10-11) after TPE (p < 0.001). Moreover, their median left ventricular ejection fraction (LVEF) was 52 % (IQR: 49.25 %-55 %) before TPE and median LVEF was 66.5 (IQR: 58 %-68.5 %) after TPE (p = 0.012). The median number of TPE sessions was three (IQR: 2-4.75). The mortality rate of the patients with severe MIS-C admitted to the PICU was 7.4 %. We suggest that TPE should be considered as a therapeutic option in children with severe MIS-C. Early initiation of TPE followed by immunomodulatory therapy in critically ill children with MIS-C may help improve clinical and laboratory outcomes.

Algorithm for the diagnosis and management of the multisystem inflammatory syndrome in children associated with COVID-19.

OBJECTIVE: Although the initial reports of COVID-19 cases in children described that children were largely protected from severe manifestations, clusters of paediatric cases of severe systemic hyperinflammation and shock related to severe acute respiratory syndrome coronavirus 2 infection began to be reported in the latter half of April 2020. A novel syndrome called "multisystem inflammatory syndrome in children" (MIS-C) shares common clinical features with other well-defined syndromes, including Kawasaki disease, toxic shock syndrome and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. Our objective was to develop a protocol for the evaluation, treatment and follow-up of patients with MIS-C. METHODS: The protocol was developed by a multidisciplinary team. We convened a multidisciplinary working group with representation from the departments of paediatric critical care, cardiology, rheumatology, surgery, gastroenterology, haematology, immunology, infectious disease and neurology. Our protocol and recommendations were based on the literature and our experiences with multisystem inflammatory syndrome in children. After an agreement was reached and the protocol was implemented, revisions were made on the basis of expert feedback. CONCLUSION: Children may experience acute cardiac decompensation or other organ system failure due to this severe inflammatory condition. Therefore, patients with severe symptoms of MIS-C should be managed in a paediatric intensive care setting, as rapid clinical deterioration may occur. Therapeutic approaches for MIS-C should be tailored depending on the patients' phenotypes. Plasmapheresis may be useful as a standard treatment to control hypercytokinemia in cases of MIS-C with severe symptoms. Long-term follow-up of patients with cardiac involvement is required to identify any sequelae of MIS-C.

Severe Coronavirus Disease Pneumonia in Pediatric Patients in a Referral Hospital.

OBJECTIVE: We aimed to evaluate the characteristics and outcomes of critically ill children managed in an intensive care unit because of coronavirus disease (COVID-19) pneumonia with respiratory support requirements. METHODS: We performed a single-center retrospective observational study in a pediatric intensive care unit (PICU) with 32 beds in Ankara City Hospital, Ankara, Turkey, from 13 March 2020 to 31 December 2020. Patients who needed positive-pressure ventilation (PPV) therapy for COVID-19 pneumonia were included in the study. Demographic, clinical and laboratory data were extracted from the patients' electronic medical records. As outcomes, the hospitalization rate of all pediatric patients diagnosed as having with COVID-19 by Polymerase Chain Reaction(PCR), PICU admission rate for COVID-19 pneumonia among all hospitalized patients, PPV support rate, intensive care hospitalization duration (days), total hospitalization duration (days), survival rate and tracheotomy requirement were evaluated. RESULTS: During the study period, 7033 children tested positive for COVID-19 in PCR tests. Of these patients, 1219 were hospitalized for COVID-19. Seventeen patients needed PPV support because of COVID-19 pneumonia. High proportion (65%) of patients admitted to the PICU had comorbid diseases. Noninvasive ventilation was applied in 15 patients (88%). The hospitalization rate among the children with COVID-19 was 17%, of whom 1.6% were admitted to the PICU. Mortality rates were 0.056% of all the cases and 0.32% of the hospitalized patients in our hospital. CONCLUSION: The presence of a comorbid disease could be a sign of severe disease in children with higher lethality. Very few children required PPV support because of severe COVID-19 pneumonia.

Coronavirus disease (COVID-19) spread from Wuhan, China, and caused an outbreak that threatened human health globally. Reports worldwide have shown that the outbreak mainly affected the adult population. Data about severe COVID-19 pneumonia in children are limited. Treatment interventions for the adult population have been adapted for children. Our article was aimed at building an opinion about this patient group. We found that severe COVID-19 pneumonia occurred in only a small population. Cardiac and neurological comorbidities are associated with higher mortality rates. Only a few patients with COVID-19 required mechanical ventilation support.

Comparison of Clinical Findings in SARS-CoV-2 with Other Respiratory Viruses in Critically Ill Children during the COVID-19 Pandemic.

OBJECTIVES: The aim of this study was to compare the clinical and laboratory findings in SARS-CoV-2 (COVID-19) with those of other respiratory viruses in critically ill children. METHODS: It is a single center retrospective descriptive study conducted in a 32-bed pediatric intensive care unit (PICU). Our study was performed in Ankara City Hospital, Ankara, Turkey, between 1 March 2020, and 1 March 2021. Demographic and clinical characteristics of the patients were collected and we recorded the antibiotic use, antiviral treatments, respiratory and extracorporeal supports, PICU stay and survival rates. RESULTS: A total of 202 pediatric patients who tested positive for either COVID-19 or for another respiratory virus panel (RVP) were included in the study. Seventy-two patients were COVID-19 positive. The median age of COVID-19 positive patients and RVP positive patients was 97 and 17 months, respectively. Hypoxia was much more common in patients with RVP than in COVID-19 patients. Low oxygen saturation in arterial blood (SaO2), increased oxygen saturation index (OSI) and fraction of inspired oxygen (FiO2) needs were more significant in RVP patients than in COVID-19 patients. Respiratory support therapies, such as high-flow nasal cannula and non-invasive ventilation (NIV), were used more frequently in RVP patients than in COVID-19 patients. CONCLUSION: It is important to distinguish between COVID-19 and RVP cases in order to prioritize intensive care needs in these patients. In addition, non-Covid diseases should not be left aside in the pandemic and appropriate care should be provided to them.

COVID-19 originated in Wuhan, China, at the end of 2019 and has since spread around the world. During the key period of the pandemic from 1 March 2020, to 1 March 2021, the pediatric intensive care unit registered a total of 72 patients testing positive for SARS-CoV-2 and 130 patients positive for RVP on the respiratory virus panel. In this single-center study, we compared the clinical differences and course of the disease in pediatric intensive care patients infected with SARS-CoV-2 with patients diagnosed with respiratory tract viruses during the COVID-19 outbreak. Unlike previous studies, this is the first to compare the clinical manifestations of COVID-19 with other respiratory pathogens requiring intensive care. Respiratory support therapy, such as high-flow nasal cannula (HFNC) and NIV, was prescribed more frequently in RVP patients than in COVID-19 patients. In our study, low oxygen saturation in the arterial blood (SaO2), increased OSI and increased fraction of inspired oxygen (FiO2) requirements were more significant in RVP patients than in COVID-19 patients. In parallel, the need for mechanical ventilation was higher in RVP patients than in COVID-19 patients. Therefore, we believe that RVP patients should be followed more carefully during this pandemic period.

Continuous venovenous hemodiafiltration in the treatment of newborns with an inborn metabolic disease: a single center experience

Background/aim: Most inborn metabolic diseases are diagnosed during the neonatal period. The accumulation of toxic metabolites may cause acute metabolic crisis with long-term neurological dysfunction and death. Renal replacement therapy (RRT) modalities allow the efficient removal of toxic metabolites. In this study, we reviewed our experience with continuous venovenous hemodiafiltration (CVVHDF) as RRT for newborns with an inborn metabolic disease. Materials and methods: Patients diagnosed with an inborn metabolic disease and who received CVVHDF treatment at our neonatal intensive care unit between January 2014 and December 2017 were included in this study. Their demographic and clinical data were collected, and the efficacy and safety of CVVHDF was evaluated. Results: A total of nine continuous RRT (CRRT) sessions as CVVHDF were performed in eight newborns with a diagnosis of urea cycle defect (n = 5), maple syrup urine disease (n = 2), or methylmalonic acidemia (n = 1). The mean age at admission was 10 ± 8.6 days (range: 3­28 days). The mean plasma levels of ammonium were 1120 ± 512.6 mg/dL and 227.5 ± 141.6 mg/dL before and at the end of the treatment, respectively. Plasma levels of leucine were 2053.5 ± 1282 µmol/L and 473.5 ± 7.8 µmol/L before and at the end of the treatment, respectively. The CVVHDF duration was 32.3 ± 11.1 h (median: 37 h; range: 16­44 h), and the mean length of hospitalization was 14.6 ± 12.9 days. The mean duration of CVVHDF was 32.3 ± 11.1 h (range: 16­44 h). Circuit clotting was the most common observed complication (37.5%) and the survival rate was 50%. Among surviving patients, two developed severe and two developed mild mental and motor retardation. Conclusion: CVVHDF is a CRRT modality that can be used to treat newborns with an inborn metabolic disease. Early diagnosis, commencement of specific medical therapy, diet, and extracorporeal support, if needed, are likely to result in improved short and long- term outcomes.

Fatal Refractory Ventricular Fibrillation Due to Ingestion of Hydrofluoric Acid.

Hydrofluoric acid (HF) is a colorless and odorless solution of the hydrogen fluoride in water. It is used in some household products. The rapid onset of severe toxicity and death after the ingestion of HF is not reported often. Also, there is no reported fatal pediatric case after HF ingestion. In this case report, we present a 3.5-year-old girls who unintentionally drunk a rust remover that contained 8% HF. She died in a short period as a result of refractory ventricular fibrillation, which was developed due to fluoride intoxication.

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey.

OBJECTIVES: To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey. MATERIALS AND METHODS: It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions. RESULTS: Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO2 ≥60 mm Hg. CONCLUSION: Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them. HOW TO CITE THIS ARTICLE: Kockuzu E, Bayrakci B, Kesici S, Citak A, Karapinar K, Emeksiz S, et al. Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs During the Winter Season in Turkey. Indian J Crit Care Med 2019;23(6):263-269.

Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey.

Introduction: Malnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies. Material and Method: In this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined. Results: Of the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024). Conclusion: Timely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score.

Comparison of pre-PICU and per-PICU interventions, clinical features and neurologic outcomes of motor vehicle collision trauma and other mechanisms of trauma in children.

BACKGROUND: Motor vehicle collisions (MVCs) are the number one cause of death in the pediatric age group. The aim of this study was to determine the differences between MVCs and other trauma mechanisms (OTMs) in patients who were followed up at a pediatric intensive care unit (PICU). METHODS: Data were retrospectively collected for pediatric trauma patients hospitalized at a third level PICU between 2014 and 2018. Patients have been divided into two groups as MVC and OTM. Demographic data, pre-PICU interventions (cardiopulmonary resuscitation, intubation, injury severity scores, time period before intensive care), intensive care interventions (invasive mechanical ventilation, non-invasive mechanical ventilation, need for surgery, type of surgery, need for transfusion, and inotrope therapy) were compared between two groups. Outcomes were evaluated by survival, discharge from hospital, Pediatric Cerebral Performance Cate-gory (PCPC) at discharge, tracheotomy presence, and amputation performed. RESULTS: During the 5-year study period, 135 patients were hospitalized for trauma. The injured body regions were the head and neck (61.5%), abdomen and lumbar spine (39.4%), and extremities and pelvis (36.3%). Multiple trauma was mostly seen in the MVC trauma group (p=0.001). The need for invasive mechanical ventilation and inotrope therapy was greater in the MVC group (p=0.002, 0.001 respectively). One hundred and twenty-three patients (91.1%) survived. The mortality rate was higher in the MVC group (p=0.026). The PCPC results were better in the OTM group (p=0.017). CONCLUSION: MVCs lead to more multiple trauma cases than OTMs. Invasive mechanical ventilation, inotropes, and other inten-sive care interventions were necessary much more often in MVC victims than in OTM patients.

Sublingual Atropine Sulfate Use for Sialorrhea in Pediatric Patients.

Sialorrhea is a frequent problem and may lead to aspiration in patients with swallowing dysfunction. We aimed to assess the effectiveness and safety of sublingual atropine sulfate treatment in pediatric patients with sialorrhea. The medical records of patients who had received sublingual atropine sulfate between January 2015 and January 2016 were reviewed retrospectively. The demographic properties, diagnosis, invasive or noninvasive mechanical ventilation need, and the presence of tracheotomy were assessed. Response rates to sublingual atropine were measured using the Teacher Drooling Scale (TDS). Pre and post-treatment drooling scores were compared. Atropine sulfate ampoule was administered at 20 µg/kg/dose. Minimum dose was 0.25 mg, while maximum dose was 0.03 mg/kg.Thirty-five pediatric patients with sialorrhea who had received sublingual atropine sulfate were identified; however, TDS scores had been recorded in only 20 of them. The median age of the patients was 25 months (3-78 months; 7 girls, 13 boys). Sixteen (80%) patients were on invasive mechanical ventilation and seven (30%) had tracheotomy. Nineteen patients had a neurodevelopmental disorder and only one patient had oral and esophageal lesions due to corrosive material intake. The median TDS score prior to sublingual atropine sulfate treatment was 5, and it decreased to 3 on the second day of treatment, a change that was statistically significant ( p < 0.001). No side effects were observed. Sublingual atropine sulfate is safe and effective in the short-term treatment of sialorrhea; however, randomized placebo controlled and long-term follow-up studies are necessary.