Drooling outcome measures in paediatric disability: a systematic review.

Drooling, or sialorrhea, is a common condition in patients with cerebral palsy, rare diseases, and neurodevelopmental disorders. The goal of this review was to identify the different properties of sialorrhea outcome measures in children. Four databases were analysed in search of sialorrhea measurement tools, and the review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used for quality appraisal of the outcome measures. The initial search yielded 891 articles, 430 of which were duplicates. Thus, 461 full-text articles were evaluated. Among these, 21 met the inclusion criteria, reporting 19 different outcome measures that encompassed both quantitative measures and parent/proxy questionnaires.   Conclusions: Among the outcome measures found through this review, the 5-min Drooling Quotient can objectively discriminate sialorrhea frequency in patients with developmental disabilities. The Drooling Impact Scale can be used to evaluate changes after treatment. The modified drooling questionnaire can measure sialorrhea severity and its social acceptability. To date, the tests proposed in this review are the only tools displaying adequate measurement properties. The acquisition of new data about reliability, validity, and responsiveness of these tests will confirm our findings. What is Known: • Although sialorrhea is a recognized problem in children with disabilities, especially those with cerebral palsy (CP), there is a lack of confidence among physicians in measuring sialorrhea. What is New: • Few sialorrhea measures are available for clinicians that may guide decision-making and at the same time have strong evidence to provide confidence in the results. • A combination of both quantitative measures and parent/proxy questionnaires might provide an adequate measurement of sialorrhea in children.

SIALORRHEA AND XEROSTOMIA IN PARKINSON'S DISEASE PATIENTS.

Parkinson's disease (PD) is generally considered as a primary movement disorder, but the majority of patients also suffer from non-motor oral, salivary symptoms. The most common salivary symptoms, sialorrhea and xerostomia, have a considerable negative impact on the quality of life. Although these symptoms are completely opposite ones, both significantly impair oral health of patients. Sialorrhea is defined as an increased amount of the retaining saliva. It is related to salivary overproduction, or it may be associated with impaired clearance of saliva. Opposed to sialorrhea, xerostomia is subjectively defined as dryness of mouth and it is related to insufficient salivary secretion. Xerostomia promotes imbalance of oral microflora and oral pathology that often leads to malnutrition in PD patients. It is mostly related to autonomic dysfunction, or it might be considered as a side effect of dopaminergic or anticholinergic medication. In PD, different assessments are used for evaluation of sialorrhea and xerostomia, including validated scales for non-motor symptoms and standardized questionnaires on oral health. Consequently, treatment of salivary symptoms includes pharmacological and nonpharmacological approach, and surgical interventions. A multidisciplinary approach in clinical neurology and dental medicine, which includes accurate evaluation of salivary symptoms and effective treatment, indicates successful management of PD patients.

Stiff Neck and Drooling in a Young Girl.

A 3-year-old girl was brought to the emergency department 4 days after she was playing with a button battery and subsequently had a choking episode. The patient was seen immediately at a different emergency department and was discharged home after a normal chest x-ray finding and able to tolerate an oral challenge with liquids. She was later evaluated by her primary care physician and started on amoxicillin for possible pharyngitis. On examination in our emergency department, the patient had pooling of secretions and was unwilling to range her neck due to pain. Soft tissue neck x-ray confirmed a 20-mm button battery in the esophagus with air lucencies in the prevertebral soft tissues.

Submandibular gland botulinum neurotoxin A injection for predicting the outcome of submandibular duct relocation in drooling: a retrospective cohort study.

AIM: This study evaluated whether the effect of submandibular gland botulinum neurotoxin A (BoNT-A) injection can predict the outcome of submandibular duct relocation with sublingual gland excision (SMDR) in children with drooling. Furthermore, we compared the effectiveness of both procedures. METHOD: A retrospective cohort study was performed in 42 children and adolescents (25 males, 17 females; mean [SD] age at BoNT-A injection 11y [4], range 4-20y; mean [SD] age at SMDR 15y [4], range 7-23y) with cerebral palsy or another non-progressive developmental disability who had undergone both BoNT-A injection and SMDR for drooling. Main outcomes were the drooling quotient and the visual analogue scale (VAS) on drooling severity at 8 weeks and 32 weeks follow-up. RESULTS: Failure or success of previous BoNT-A injections had no influence on success of consecutive SMDR. Relative change in main outcomes showed no significant relation between BoNT-A injection and SMDR for any follow-up measurement. After 8 weeks, SMDR was more successful than BoNT-A injection in diminishing VAS (VAS 80.0% vs 54.3%; drooling quotient 56.2% vs 51.0%). After 32 weeks, both drooling quotient (64.3% vs 29.5%) and VAS (75.7% vs 37.1%) showed significantly higher proportions of success for SMDR. INTERPRETATION: The effect of submandibular BoNT-A injection does not predict subsequent SMDR success in drooling. Furthermore, SMDR has a larger and longer-lasting positive effect on drooling than BoNT-A injections. WHAT THIS PAPER ADDS: Submandibular botulinum neurotoxin A (BoNT-A) injection effect does not predict submandibular duct relocation with sublingual gland excision outcome. Submandibular duct relocation is more effective and more permanent than BoNT-A injection.

INYECCIÓN DE NEUROTOXINA BOTULÍNICA A EN LA GLÁNDULA SUBMANDIBULAR PARA PREDECIR EL RESULTADO DE LA REUBICACIÓN DEL CONDUCTO SUBMANDIBULAR EN BABEO: UN ESTUDIO DE COHORTE RETROSPECTIVO: OBJETIVO: Este estudio evaluó si el efecto de la inyección de neurotoxina A botulínica submandibular (BoNT-A) puede predecir el resultado de la reubicación del conducto submandibular con escisión de la glándula sublingual (SMDR) en niños con babeo. Además, comparamos la efectividad de ambos procedimientos. MÉTODO: Se realizó un estudio de cohorte retrospectivo en 42 niños y adolescentes (25 varones, 17 mujeres; edad media [DE] en la inyección de BoNT-A 11 años [4], rango 4-20 años; edad media [SD] a SMDR 15 años [4] rango 7-23 años) con parálisis cerebral u otra discapacidad del desarrollo no progresiva que se haya sometido a una inyección de BoNT-A y SMDR para babear. Los resultados principales fueron el cociente de babeo y la escala analógica visual (VAS) en la severidad del babeo a las 8 semanas y 32 semanas de seguimiento. RESULTADOS: El fracaso o el éxito de las inyecciones anteriores de BoNT-A no tuvo influencia en el éxito de la SMDR consecutiva. El cambio relativo en los resultados principales no mostró una relación significativa entre la inyección de BoNT-A y SMDR para cualquier medición de seguimiento. Después de 8 semanas, SMDR fue más exitoso que la inyección de BoNT-A en la VAS disminuida (VAS 80,0% vs 54,3%; cociente de babeo 56,2% vs 51,0%). Después de 32 semanas, tanto el cociente de babeo (64,3% vs 29,5%) como el VAS (75,7% vs 37,1%) mostraron proporciones significativamente más altas de éxito para SMDR. INTERPRETACIÓN: El efecto de la inyección submandibular de BoNT-A no predice el éxito posterior de SMDR en el babeo. Además, el SMDR tiene un efecto positivo mayor y más duradero en el babeo que las inyecciones de BoNT-A.

INJEÇÃO DE NEUROTOXINA BOTULÍNICA NA GLÂNDULA SUBMANDIBULAR PARA PREDIÇÃO DO RESULTADO DA RELOCACÃO DO DUCTO SUBMANDIBULAR NA SIALORRÉIA: UM ESTUDO DE COORTE RETROSPECTIVO: OBJETIVO: Este estudo avaliou se o efeito da neurotoxina botulínica A (NTBo-A) na glândula submandibular pode predizer o resultado da relocação do ducto submandibular com excisão sublingual da glândula (RDSM) em crianças com sialorréia. Ainda, comparamos a efetividade de ambos os procedimentos. MÉTODO: Um estudo de coorte retrospectivo foi realizado em 42 crianças e adolescentes (25 do sexo masculino, 17 do sexo feminino; idade média [DP] no momento da injeção de NTBo-A 11a[4], variação de 4-20a; idade média [DP] no momento da RDSM 15a [4], variação de 7-23a) com paralisia cerebral ou outra desordem não-progressiva do desenvolvimento que passaram por injeção de NTBo-A e RDSM para sialorréia. Os principais desfechos foram o quociente de sialorréia e a escala visual análoga (EVA) sobre a severidade da sialorréia no acompanhamento de 8 e 32 semanas. RESULTADOS: A falha ou sucesso da NTBo-A prévia não teve influência no sucesso da RDSM consecutiva. A mudança relativa nos principais desfechos não mostrou nenhuma relação significativa entre a injeção de NTBo-A e a RDSM para nenhuma das medidas no acompanhamento. Após 8 semanas, a RDSM foi mais bem sucedida do que a NTBo-A na redução da EVA (EVA 80,0% vs 54,3%; quociente de sialorréia 56,2% vs 51,0%). Após 32 semanas, tanto o quociente de sialorréia (64,3% vs 29,5%) quanto a EVA (75,7% vs 37,1%) mostram proporções significativamente mais altas de sucesso para a RDSM. INTERPRETAÇÃO: O efeito da injeção submandibular de NTBo-A não prediz o sucesso da RDSM subsequente na sialorréia. Ainda, a RDSM tem efeito maior e mais duradouro na sialorréia do que injeções de NTBo-A.

Characteristics and Outcomes of Ptyalism Gravidarum.

BACKGROUND: Ptyalism gravidarum (PG) is a condition of hypersalivation that affects pregnant women early in gestation. Symptoms include massive saliva volumes (up to 2 liters per day), swollen salivary glands, sleep deprivation, significant emotional distress, and social difficulties. OBJECTIVES: To examine maternal and fetal characteristics and pregnancy outcomes of patients with PG. METHODS: Patients diagnosed with PG in our clinic during the years 2001-2016 were identified and contacted. Demographic data were extracted from patient charts and clinical and outcome data was collected via telephone interviews. RESULTS: The incidence of PG was 1/963 (0.09%) in our sample. Eleven out of 22 women (40%) with PG were also diagnosed with hyperemesis gravidarum. Fetal gender did not increase the risk. Of the mothers presenting with PG, 37% had a positive family history for this condition. There was no associated increase in the rate of fetal or maternal complications. Two women reported a resolution of the symptoms immediately following hypnosis with acupuncture treatment. CONCLUSIONS: Although PG represents an unpleasant mental and physical condition, it does not pose any specific risk to the health of the mother or increase adverse perinatal outcomes for the fetus. Alternative medicine could play a role in the treatment of PG.

Double-Blind, Randomized, Placebo-Controlled Trial of Metoclopramide for Hypersalivation Associated With Clozapine.

Hypersalivation is a frequent, disturbing, and uncomfortable adverse effect of clozapine therapy that frequently leads to noncompliance. The aim of this study was to examine the efficacy of metoclopramide (dopamine D2 antagonist, antiemetic medication) as an option for management of hypersalivation associated with clozapine (HAC). A 3-week, double-blind, placebo-controlled trial was conducted in university-based research clinics from January 2012 to May 2014, on 58 inpatients treated with clozapine who were experiencing hypersalivation. The subjects were randomly divided into placebo and metoclopramide groups. The starting dose was 10 mg/d. Participants who did not respond were up-titrated 10 mg/d weekly to a total of 30 mg/d during the third week. The number of placebo capsules was increased accordingly up to 3 capsules per day. Primary outcome was the change from baseline to the end of study in the severity of hypersalivation as measured with the Nocturnal Hypersalivation Rating Scale and the Drooling Severity Scale. Secondary outcomes included Clinical Global Impression of Improvement scale and adverse effect scales. Significant improvement on the Nocturnal Hypersalivation Rating Scale was demonstrated in the metoclopramide group from the end of the second week (P < 0.004), and on the Drooling Severity Scale (P < 0.02) in the third week. Clinical Global Impression-Improvement scale scores revealed major improvement. Twenty subjects (66.7%) treated with metoclopramide reported significant decline or total disappearance of HAC in comparison to 8 patients (28.6%) who received placebo (P = 0.031). No adverse effects to metoclopramide were reported. Metoclopramide was found to be safe and effective for the treatment of HAC.

Botulinum Toxin Treatment of Autonomic Disorders: Focal Hyperhidrosis and Sialorrhea.

Primary focal hyperhidrosis is a common autonomic disorder that significantly impacts quality of life. It is characterized by excessive sweating confined to circumscribed areas, such as the axillae, palms, soles, and face. Less frequent types of focal hyperhidrosis secondary to underlying causes include gustatory sweating in Frey's syndrome and compensatory sweating in Ross' syndrome and after sympathectomy. Approval of onabotulinumtoxinA for severe primary axillary hyperhidrosis in 2004 has revolutionized the treatment of this indication. Meanwhile further type A botulinum neurotoxins like abobotulinumtoxinA and incobotulinumtoxinA, as well as the type B botulinum neurotoxin rimabotulinumtoxinB are successfully used off-label for axillary and various other types of focal hyperhidrosis. For unexplained reasons, the duration of effect differs considerably at different sites. Beside hyperhidrosis, botulinum neurotoxin is also highly valued for the treatment of sialorrhea affecting patients with Parkinson's disease, cerebral palsy, amyotrophic lateral sclerosis, motor neuron disease, and other neurologic conditions. With correct dosing and application, side effects are manageable and transient.

Profiles of orofacial dysfunction in different diagnostic groups using the Nordic Orofacial Test (NOT-S)--a review.

OBJECTIVE: The Nordic Orofacial Test-Screening (NOT-S) was developed as a comprehensive method to assess orofacial function. Results from the screening protocol have been presented in 11 international publications to date. This study reviewed these publications in order to compile NOT-S screening data and create profiles of orofacial dysfunction that characterize various age groups and disorders. MATERIALS AND METHODS: NOT-S results of nine reports meeting the inclusion criteria were reviewed. Seven of these studies not only provided data on the mean and range of total NOT-S scores, but also on the most common domains of orofacial dysfunction (highest rate of individuals with dysfunction scores), allowing the construction of orofacial dysfunction profiles based on the prevalence of dysfunction in each domain of NOT-S. RESULTS: The compiled data comprised 669 individuals, which included healthy control subjects (n = 333) and various patient groups (n = 336). All studies reported differences between individuals with diagnosed disorders and healthy control subjects. The NOT-S data could measure treatment effects and provided dysfunction profiles characterizing the patterns of orofacial dysfunction in various diagnoses. CONCLUSIONS: This review corroborates previous results that the NOT-S differentiates well between patients and healthy controls and can also show changes in individuals after treatment. NOT-S could be used as a standard instrument to assess orofacial dysfunction, evaluate the outcomes of oral habilitation and rehabilitation and improve comparability in clinical practice and research.

Narrative review of diagnosis, management and treatment of dysphagia and sialorrhea in amyotrophic lateral sclerosis.

The degenerative motor neuron disorder amyotrophic lateral sclerosis (ALS) frequently leads bulbar symptoms like dysarthria, dysphagia, and sialorrhea, in approximately one-third of cases being the initial symptom. Throughout the disease, more than two-thirds of ALS patients experience dysphagia, regardless of the region of onset. In this review, we aimed to offer an updated overview of dysphagia and sialorrhea in ALS, covering its diagnosis, monitoring, and treatment in clinical practice. Regular assessment of dysphagia and sialorrhea during each patient visit is essential and should be a standard aspect of ALS care. Early discussion of potential treatments such as high-calorie diets or percutaneous endoscopic gastrostomy (PEG) is crucial. Furthermore, this review highlights and discusses potential areas for improvement in both clinical practice and research.

[Hypersalivation - inauguration of the S2k Guideline (AWMF) in short form]. / Hypersalivation - Ersterstellung der S2k-Leitlinie (AWMF) in gekürzter Darstellung.

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This reduces social interaction chances and burdens daily care. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, and saliva aspiration. Therefore, a multidisciplinary S2k guideline was developed. Diagnostic tools such as fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing studies generate important data on therapy selection and control. Especially traumatic and oncologic cases profit from swallowing therapy programmes in order to activate compensation mechanisms. In children with hypotonic oral muscles, oralstimulation plates can induce a relevant symptom release because of the improved lip closure. In acute hypersalivation, the pharmacologic treatment with glycopyrrolate and scopolamine in various applications is useful but its value in long-term usage critical. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Surgical treatment should be reserved for isolated cases. External radiation is judged as ultima ratio. Therapy effects and symptom severity has to be followed, especially in neurodegenerative cases. The resulting xerostomia should be critically evaluated by the responsible physician regarding oral and dental hygiene.

Accurate assessment of drooling severity with the 5-minute drooling quotient in children with developmental disabilities.

AIM: The aims of this study were to examine whether objective measurements of the 10-minute drooling quotient (DQ10) and the 5-minute drooling quotient (DQ5) are interchangeable; to assess agreement between the measurements and their accuracy in classifying drooling severity; and to develop a time-efficient clinical assessment. METHOD: The study cohort included 162 children (61 females, 101 males; mean age 11 y 6 mo, SD 4 y 5 mo, range 3 y 9 mo-22 y 1 mo) suffering from moderate to profuse drooling. One hundred and twenty-four had cerebral palsy and 38 had other developmental disabilities. Seventy-four of the participants were ambulant and 88 non-ambulant. The original DQ10 was recalculated into a 5-minute score (DQ5). Assessments were undertaken while the participants were in a rest situation (DQ(R)) and while they were active (DQ(A)). Agreement in scores was quantified using intraclass correlations and Bland-Altman plots. To classify drooling, area under the receiver operating characteristic curve analysis was used to compare accuracy of the DQ10 and DQ5 at rest and during activity. RESULTS: Agreement between DQ10A, and DQ5(A), and between DQ10(R) and DQ5(R) was high (intraclass correlation coefficient >0.90). Moderate agreement existed between DQ(A) and DQ(R). DQ(A) scores were more accurate in classifying children's drooling behaviour. For DQ5(A), a cut-off point of 18 or more (drooling episodes/observation time) might indicate 'constant drooling'. INTERPRETATION: The DQ10 and DQ5 can be used interchangeably. DQ(A) is most discriminative for drooling severity. For evaluating treatment efficiency the cut-off point can be used. For clinical and research purposes, the DQ5 is time efficient and cost saving while validity, and intrarater and interrater reliability are preserved.

[Botulinum toxin A after microvascular ALT flap in a patient with (corrected) squamous cell carcinoma of the tongue]. / Botulinumtoxin A gegen Hypersalivation. Einsatz bei Wundheilung nach Resektion eines Zungenkarzinoms.

We report the case of a 23-year-old man presenting with a cT4 cN1 M0squamous cell carcinoma of the right tongue. After tumor resection and covering of the defect with a microvascular anterolateral thigh (ALT) flap, the patient showed distinct drooling without any substantial regression after anticholinergic therapy. For this reason 75 units of Botox® were injected into the submandibular and parotid glands. After the intraglandular injections, good reduction of saliva secretion was achieved. The treatment improved flap healing, aspiration and patient satisfaction. Injection of botulinum toxin A into the salivary glands is a sufficient therapy for postoperative hypersalivation.

Translation and validation of the drooling impact scale questionnaire into Brazilian Portuguese.

INTRODUCTION: Inadequate drooling can cause serious clinical, functional and social problems. Validated questionnaires to evaluate drooling impact on quality of life are lacking in Brazilian Portuguese. OBJECTIVES: To translate and validate the drooling impact scale to Brazilian Portuguese. METHODS: The drooling impact scale was translated to Brazilian Portuguese and back- translated to English to assess potential conceptual differences. Brazilian Portuguese version of drooling impact scale was applied to a 40 patients' sample of sialorrhea presenting pediatric patients (up to 20 years of age). Chronbach's alpha, exploratory factorial analysis and confirmatory factorial analysis were then proceeded with data collected. RESULTS: The mean drooling impact scale value for the whole population was 51.77 (SD = 16.13). The internal consistency obtained with Cronbach's alpha indicated a value of 0.72 for the entire sample. The Bartlett's test of sphericity was significant (p <  0.0001), confirming correlation among variables tested. Kaiser-Meyer-Olkin measure of sampling adequacy revealed a value of 0.72, indicating that the correlation matrix was reasonably suitable for factor analysis. Regarding exploratory factorial analysis, parallel analysis suggested a two-factor solution that was used for confirmatory factorial analysis. The first factor was responsible for 33.78% of the variance with an Eigenvalue of 3.38. The second factor explained 16.1% of the variance with an Eigenvalue of 1.61. At confirmatory factorial analysis, the two-factor model showed consistently better adjustments parameters than the one-factor model. CONCLUSION: The drooling impact scale has been successfully translated to Brazilian Portuguese language, showing adequate internal validity. Validation of this instrument allows physicians and other personnel involved in the care of these patients to perform a better management of patients experiencing drooling. With this tool, we are now able to guide routines and provide guidelines both before and after the different kinds of treatments in order to improve the general well-being of the patient and his family.

Drooling and Aspiration of Saliva.

Drooling and aspiration of saliva can affect the quality of life and morbidity of patients with neuromuscular diseases. Practitioners must differentiate between drooling with and without aspiration of saliva, as the presence of aspiration affects respiratory health. There are several validated drooling scales, but validated assessments for aspiration of saliva are lacking. Once diagnosed, drooling can be treated with rehabilitative therapy, anticholinergics, botulinum toxin to the salivary glands, and surgery. Drooling with aspiration of saliva often requires multidisciplinary engagement to decrease the risk of respiratory complications.

Silent saliva aspiration in Parkinson's disease.

BACKGROUND: Silent laryngeal penetration and silent aspiration (SLP/SA) are common manifestations in Parkinson's disease (PD) patients and are frequently associated with dysphagia. However, little is known about saliva aspiration in this population. OBJECTIVE: We investigated the frequency and characteristics of saliva SLP/SA in PD patients with daily drooling (Group A) and in individuals without PD or daily drooling (Group B). METHOD: Both groups were evaluated by fiberoptic endoscopic evaluation of swallowing (FEES) after dyeing the oral cavity with blue dye. The oropharynx was assessed for the presence of the stasis of saliva, and sensitivity was tested by direct tactile stimuli. RESULTS: PD patients (n = 28) and controls (n = 18) were evaluated. We observed silent aspiration of saliva in 10.7% and silent laryngeal penetration of saliva near the vocal folds in 28.6% of Group A; however, none of these events was observed in Group B. Sensitivity in the epiglottis and posterior wall of the hypopharynx was decreased in 89.2% of Group A and in 33.3% of Group B, whereas in the aryepiglottic folds and interarytenoid area, a decrease in sensitivity was observed in 92.8% and in 44.4% of Groups A and B, respectively. CONCLUSION: Silent aspiration and laryngeal penetration of saliva are common features in PD patients with daily drooling. The presence of hypoesthesia of the laryngeal structures and the lack of protective reflexes in such patients may play a major role in the mechanisms of SLP/SA.

Amisulpride improved debilitating clozapine-induced sialorrhea.

Clozapine induced sialorrhea is a common and troublesome adverse effect leading to poor treatment compliance. Although there are various treatment options, none has been demonstrated to be superior. In our case study, amisulpride 150 mg/d significantly reduced troublesome daytime sialorrhea along with minimal improvement in nocturnal sialorrhea.

Botox(®) to reduce drooling in a paediatric population with neurological impairments: a Phase I study.

BACKGROUND: The treatment of drooling in a paediatric population with neurological impairments is clinically challenging. Surgery is considered invasive, while behaviour modification techniques, correction of situational factors and oral-motor therapy do not always produce sustained improvement. In recent years the use of Botox® to decrease drooling has been investigated. AIMS: To review the clinical data from a Drooling Treatment Project for children with neurological impairments and to establish the validity of the drooling severity and frequency rating scales, establishing Phase I-level information about the therapeutic use of submandibular salivary gland injections of Botox® in various contexts. METHOD & PROCEDURES: A retrospective, explanatory design was used to review the data. Nine children, seven with cerebral palsy and two with operculum syndrome, ranging in age from 5 to 17 years (mean = 9;3 years) were included. Drooling was assessed by qualified speech-language therapists using drooling rating scales, in five different situations and at different time points pre- and post-Botox® injection up to 6 months. Quantitative and qualitative analyses were computed. Parents'/primary caregivers' perceptions of drooling and treatment with Botox® were also considered using an interview form and a quality of life questionnaire. OUTCOMES & RESULTS: Statistically significant reductions in drooling with large effect sizes were obtained in the communicating and general appearance situations. There was a difference in the pattern of response between the children with cerebral palsy and those with operculum syndrome. Discrepancies between the parents and the speech-language therapists regarding the context of drooling reduction were found. Most parents/primary caregivers felt their children's lives and their own had improved following the Botox® injection and would repeat the treatment. The drooling rating scales were a valid method to assess drooling in a clinical situation. CONCLUSIONS & IMPLICATIONS: In the clinical setting of the Drooling Treatment Project, the results indicated that the context in which drooling occurs is an important factor and suggested the value of considering the situational context when making drooling judgments. Further, there was a difference in the pattern of response between the children with cerebral palsy and those with operculum syndrome, suggesting that aetiology may be involved in the response to Botox®.

Is bib count an accurate quantitative measure of drooling?

BACKGROUND: Bib count is a frequently used measure amongst pediatric otolaryngologists to quantify drooling status. The plethora of bibs used, including important differences in material, size, and shape, makes one question the validity of bib count as an accurate surrogate measure of drooling frequency or severity. To date, no study has addressed this question in the literature. We evaluated the correlation between drooling frequency, drooling severity, and number of bibs changed to better guide clinical practice in saliva management in a large pediatric patient population. METHODS: This was a retrospective cohort study comprising 414 pediatric patients from 2014 to 2019. Patients were included if there was presence of drooling and completed the Daniel Drooling Impact Score Questionnaire. The primary outcome was the severity of drooling, frequency of drooling, and number of bibs changed. Age, sex, feeding type and diagnosis were also data points collected. Pearson's coefficient of correlation and multiple regression analysis were used to analyze association between variables. RESULTS: Bib count, frequency of drooling, and severity of drooling were all positively correlated. The strongest positive correlation was between drooling frequency and drooling severity (r = 0.659; p < 0.01), followed by bib count and drooling severity (r = 0.541; p < 0.01), then bib count and drooling frequency (r = 0.416; p < 0.01). In multivariate regression analysis, only bib count was a statistically significant positive predictor of drooling severity (ß=1.14, p < 0.01). Feeding type and underlying diagnosis also influenced bib count. CONCLUSIONS: The number of bibs changed per day is an accurate predictor of sialorrhea that correlates positively with drooling severity and frequency despite the variability and lack of standardization in bibs. Consistent definitions of what constitutes a bib and its characteristics should be collected during drooling evaluation.