Comparison of factors associated with drooling between intractable neuromuscular disease and cerebral palsy.

Drooling represents a common and noteworthy symptom in patients with intractable neuromuscular disease (IND) and cerebral palsy (CP) and can lead to poor quality of life (QOL) and higher incidence of death due to aspiration of saliva. Identifying the factors affecting drooling is crucial to improving QOL and improving the poor prognosis of patients with IND and CP. This study sought to assess the prevalence of drooling and to elucidate the associated factors, drugs, and differences between patients with IND and CP. We included hospitalized patients with IND and CP. Among the 269 patients, 69 of 162 patients with IND (42.6%) and 75 of 107 patients with CP (70.1%) exhibited drooling. Drooling in IND was significantly higher in patients with tube feeding and those who had a previous stroke than in patients with potential oral intake and those having no history of stroke. In individuals with CP, drooling was significantly negatively associated with age. Taltirelin in patients with IND had a significant positive association with drooling, and antipsychotics and centrally acting muscle relaxants in those with CP had a significant negative association with drooling. Our results suggest that the factors associated with frequent drooling differ between IND and CP cases, and patients who should be screened for drooling are those with decreased swallowing function, those with IND who have had a previous stroke, and young patients with CP. Moreover, clinicians should consider the impact of drugs on drooling in IND and CP cases.

Prevalence of clozapine-induced sialorrhea and its effect on quality of life.

RATIONALE: Clozapine has proven to be superior to other antipsychotic drugs in the treatment of schizophrenia but is under-prescribed due to its potentially severe side effects. Clozapine-induced sialorrhea (CIS) is a frequent and extremely uncomfortable side effect, which remains understudied. OBJECTIVES: To examine the prevalence of diurnal and nocturnal CIS in a sample of patients treated with clozapine, and to evaluate its impact on quality of life. METHODS: We conducted a cross-sectional, observational study of 130 patients with schizophrenia spectrum disorders treated with clozapine. The prevalence of CIS was evaluated via specific sialorrhea scales. None of the patients included in the study was receiving a specific treatment for hypersalivation during the study period. Possible associations between sialorrhea and clinical and quality of life variables were analyzed. RESULTS: Of 130 subjects, 120 (92.3%) suffered from CIS. Eighty-one (62.31%) suffered from diurnal CIS, 115 (88.56%) from nocturnal CIS, and 85 (65.38%) suffered from both. Significant positive associations between quality of life and diurnal CIS (B = 0.417; p = 2.1e - 6, R2 = 0.156) and nocturnal CIS (B = 0.411; p = 7.7e - 6, R2 = 0.139) were detected. Thirty per cent of the subjects reported a moderate to severe negative impact of sialorrhea on their quality of life. CONCLUSIONS: The present study suggests that CIS is highly prevalent in patients with schizophrenia and has an important impact on quality of life in one-third of our sample. Therefore, the inclusion of a systematic evaluation and treatment of CIS in standard clinical practice is highly recommended. TRIAL REGISTRATION: Clinical Trials ( https://clinicaltrials.gov ) under reference NCT04197037.

Acute infectious supraglottitis in adult population: epidemiology, management, outcomes and predictors of airway intervention.

PURPOSE: The purpose is to analyze the incidence of acute infectious supraglottitis in our center between 2010 and 2020, define the characteristics and trends of those patients and identify factors associated with the need of airway intervention. METHODS: A retrospective single-center observational study of a cohort of patients diagnosed with acute infectious supraglottitis between January 2010 and December 2020. Patients were stratified according to airway management. RESULTS: Eighty eight patients were included: 59 men (67%) and 29 women (33%). A significant upward trend of 9% in the annual incidence rate of supraglottitis was seen during 2010-2020, with an important increase in cases during 2019. Muffled voice (41%) and respiratory distress (38%) were the most common presenting symptoms; and the median duration of symptoms before hospital admission was 2 days [IQR 1; 3]. Airway intervention was performed in fifteen patients (17%). Nine patients (10%) were intubated and six required tracheotomy (7%). Comparing the patients who required airway intervention with those who received a conservative treatment, younger patients (p < 0.01) were more likely to need airway intervention. In logistic regression analysis, we found that epiglottic abscess (p = 0.015), hypersalivation (p = 0.027) and smoking (p = 0.036) were independent factors with a significant association with airway intervention. CONCLUSION: There was an important increase in cases and its severity in 2019, but due to COVID-19 pandemic, it was not possible to define if it was an isolate event or an upward trend. Epiglottic abscess, hypersalivation and smoking could be possible risk factors for airway intervention.

Prevalence of Sialorrhea Among Amyotrophic Lateral Sclerosis Patients: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative motor neuron disease (MND), and sialorrhea is a known symptom in patients with ALS, which may cause a social embarrassment and discomfort. However, people do not pay attention to sialorrhea up to now. This study is aimed at conducting a systematic review and meta-analysis of the pooled prevalence of sialorrhea in ALS patients all around the world and raising awareness of salivation. METHODS: We searched PubMed and EMBASE databases to obtain the comprehensive literatures which reported the prevalence of sialorrhea. We used AHRQ and NOS to evaluate the literature quality. Subgroup analyses were performed based on screening instruments and severity of sialorrhea. At the meantime, sensitivity analyses was also conducted to identify the source of heterogeneity. RESULTS: A total of 17 eligible studies which included 21 groups of data reported prevalence of sialorrhea. The pooled prevalence of sialorrhea among ALS patients was 30.8% (95% CI: 20.0%-44.2%). For studies using ALSFRS-R, direct questioning, postal survey, and ALSSoL average and ALSFRS-R, the pooled prevalence of sialorrhea was 22.7%, 25.8%, 29.8% and 52.0% respectively. According to the severity of sialorrhea, the prevalence of mild, moderate, and severe sialorrhea were 25.1%, 11.2%, and 10.5%, respectively. And none of the studies alone had a significant effect on the overall prevalence of sialorrhea after we eliminated each study separately in sensitivity analyses. CONCLUSIONS: Sialorrhea is a relatively common symptom in ALS patients with a comparatively high prevalence. In our study, we found that the prevalence of sialorrhea in ALS patients is relatively higher than the results based on direct questioning or postal survey. Therefore, we deduced that sialorrhea should be evaluated by more complex professional assessment scales to improve the quality of life and improve early prognosis of disease.

Drooling, Swallowing Difficulties and Health Related Quality of Life in Parkinson's Disease Patients.

BACKGROUND: Parkinson's disease (PD) is the most common neurodegenerative disorder associated with motor and nonmotor symptoms. Drooling, one of the nonmotor symptoms, can be present in 70-80% of patients with PD. The aim of this paper is to study the characteristics of PD patients with drooling compared to those without in terms of age, gender, disease duration, stage of the disease, swallowing difficulties, and health-related quality of life; methods: a cross-sectional study was conducted. The sample was divided into two groups: PD with drooling (n = 32) and PD without drooling (n = 30). Age, gender, disease duration and Hoehn & Yahr (H & Y) stage, Sialorrhea Clinical Scale for Parkinson's Disease (SCS-PD), the 10-item Eating Assessment Tool (EAT-10), and the 39-item Parkinson's Disease Questionnaire (PDQ-39) were compared between groups; Results: 62 individuals with PD, 40 men and 22 women (mean age 73 ± 8 years), were included. Overall, 32 patients reported drooling, and 30 did not exhibit it. The ANCOVA found significant differences between groups for the EAT-10 score (0.83, 95% CI = 5.62-9.03; p = 0.016) and SCS-PD score (1.48, 95% CI = 0.86-6.81; p < 0.001). Analysis of the PDQ-39 scores revealed no significant differences between groups for the PDQ-39 total score (p > 0.057) and in all subscales. The inclusion of gender, age, disease duration, and H & Y as covariates did not influence the results (all p > 0.05). CONCLUSIONS: drooling is related to swallowing difficulties assessed with EAT-10 but not with health-related quality of life assessed with PDQ-39 in PD patients with drooling compared to PD patients without it. Age, gender, duration of the disease, and the H & Y state of PD patients with and without drooling seem to be similar.

Acupuncture for drooling in children with cerebral palsy: A protocol for systematic review.

BACKGROUND: The aim of this study is to provide the methods used to evaluate the effectiveness and safety of acupuncture therapy for treating drooling in children with cerebral palsy. METHODS AND ANALYSIS: A comprehensive search of Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, 4 Chinese databases (China National Knowledge Infrastructure, Chinese Biomedical Literatures database, Wan-Fang Database and Chinese Science and Technology Periodicals will be conducted to identify randomized controlled trials of acupuncture for treating children with cerebral palsy salivation with no restriction on time or language. The primary outcome of this systematic review will be the effective rate. The risk of bias will be implemented according to Cochrane Handbook for Systematic Reviews of Interventions. We will conduct the meta-analysis to synthesize the evidence for each outcome, if possible. The heterogeneity will be evaluated statistically using the χ2 test and the I2 statistic. The random-effect model will be used to provide more conservative results, if significant heterogeneity is identified (I2 > 50% or P < .10). ETHICS/DISSEMINATION: Our findings will be disseminated in a peer-reviewed journal and at conference meetings. It is not necessary for formal ethical approval as no primary data are collected. TRIAL REGISTRATION NUMBER: INPLASY2020110024.

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.

Clinical features associated with drooling in Parkinson's disease.

INTRODUCTION: Drooling is characterized by an excessive pooling of saliva in the oral cavity. The exact pathophysiological mechanism of drooling in Parkinson's disease (PD) is not yet fully understood. OBJECTIVE: To identify the relationship between drooling and other clinical features in people diagnosed with PD. METHOD: Research on the topic was carried out on the PubMed and ScienceDirect electronic databases. Articles published between March 2015 and March 2020 were selected. Search terms and inclusion and exclusion criteria were previously defined. The articles included met those requirements. RESULTS: Sixteen articles were included for analysis. The prevalence of drooling varies between 9.26 and 70% and can occur at any stage of the disease. Higher prevalence of drooling is related to disease duration, disease severity, older age, male, levodopa equivalent dose, hypomimia, dysphagia, dysarthria, cognition, sleep, non-dominant tremor, motor fluctuations, bradykinesia, more symmetric pattern, gastrointestinal and urinary problems, sexual dysfunction, obstipation, and orthostatic hypotension. However, it is not related to hallucinations, rapid eye movement sleep behavior disorder, akinetic-rigid PD, mixed, nor dyskinesias. CONCLUSION: Drooling is not caused by a single factor; it is influenced and related to several clinical features. Some clinical factors participate in the onset of drooling while others are concomitant.

A Cross-Sectional Study of Nemaline Myopathy.

OBJECTIVE: Nemaline myopathy (NM) is a rare neuromuscular condition with clinical and genetic heterogeneity. To establish disease natural history, we performed a cross-sectional study of NM, complemented by longitudinal assessment and exploration of pilot outcome measures. METHODS: Fifty-seven individuals with NM were recruited at 2 family workshops, including 16 examined at both time points. Participants were evaluated by clinical history and physical examination. Functional outcome measures included the Motor Function Measure (MFM), pulmonary function tests (PFTs), myometry, goniometry, and bulbar assessments. RESULTS: The most common clinical classification was typical congenital (54%), whereas 42% had more severe presentations. Fifty-eight percent of individuals needed mechanical support, with 26% requiring wheelchair, tracheostomy, and feeding tube. The MFM scale was performed in 44 of 57 participants and showed reduced scores in most with little floor/ceiling effect. Of the 27 individuals completing PFTs, abnormal values were observed in 65%. Last, bulbar function was abnormal in all patients examined, as determined with a novel outcome measure. Genotypes included mutations in ACTA1 (18), NEB (20), and TPM2 (2). Seventeen individuals were genetically unresolved. Patients with pathogenic ACTA1 and NEB variants were largely similar in clinical phenotype. Patients without genetic resolution had more severe disease. CONCLUSION: We present a comprehensive cross-sectional study of NM. Our data identify significant disabilities and support a relatively stable disease course. We identify a need for further diagnostic investigation for the genetically unresolved group. MFM, PFTs, and the slurp test were identified as promising outcome measures for future clinical trials.

Excessive buccal saliva in patients with Parkinson's disease of the French COPARK cohort.

We describe excessive buccal saliva (EBS) prevalence in patients with Parkinson's Disease (PD) and controls of the COPARK study, its changes between "ON" and OFF" conditions and over time, its impact on Health-related Quality of life (HRQoL), and factors associated with this condition. We studied 671 ambulatory PD patients and 177 age/sex-matched controls. We defined "sialorrhea" as UPDRS item #6 (salivation) = 1 or 2; and "drooling" as item #6 = 3 or 4. SCOPA-Aut drooling score (item #2) was also available in a subset (45%) of the cohort. HRQoL was assessed by the PDQ-39 and SF-36 scales. Twenty-four months' follow-up data were available in 401/671 patients. EBS as assessed by UPDRS was present in 38% of PD patients in the "ON" condition ("Sialorrhea": 35%; "drooling": 3%). There were also more PD patients reporting "drooling" than controls according to the SCOPA-Aut (49% vs 19%, p < 0.01). UPDRS salivation score was worse in the "OFF" vs "ON" condition in PD patients with motor fluctuations (0.90 ± 0.94 vs 0.54 ± 0.79, p < 0.01). UPDRS salivation score worsened after ~ 24 months of follow-up (0.47 ± 0.70 vs 0.64 ± 0.81, p < 0.01). Worse PDQ-39 scores were observed in PD patients with EBS in bivariate but not in multivariate analyses. EBS was directly related to PD duration and severity, male gender, dysphagia, hypomimia, and autonomic dysfunction (logistic regression). EBS was more frequent in PD patients than controls, worsened in the "OFF" condition and after ~ 24 months of follow-up, moderately affected HRQoL, and was correlated with indices of bradykinesia, dysphagia, and autonomic dysfunction.

Reporting Patterns of Sialorrhea Comparing Users of Clozapine to Users of Other Antipsychotics: A Disproportionality Analysis Using VigiBase.

BACKGROUND: Sialorrhea is a non-life-threatening, but potentially invalidating adverse drug reaction (ADR) in patients using clozapine. In light of the very serious ADRs (agranulocytosis and myocarditis), sialorrhea is at risk to be overlooked by health care professionals. In this study, the sialorrhea reporting patterns of clozapine compared with other antipsychotics were assessed by evaluating differences in relative reporting frequency and reporter type. METHODS: A case/noncase disproportionality analysis using data from VigiBase (1968-2016) was performed. Reports of antipsychotics with "salivary hypersecretion" as ADR were considered as cases, and those with ADRs other than salivary hypersecretion were defined as noncases. Relative reporting frequencies were expressed as reporting odds ratios (RORs), and multivariate logistic regression was performed with the drug-ADR pair as unit of analysis to estimate RORs with 95% confidence intervals (CIs). RESULTS: A total of 1,169,254 drug-ADR pairs from 425,304 unique Individual Case Safety Reports were identified. Sialorrhea was relatively more frequently reported in clozapine (n = 2732 [1.1%]) compared with other antipsychotics (n = 2911 [0.31%]; ROR, 3.60; 95% CI, 3.41-3.79) and was reported relatively more often by consumers (ROR, 19.8; 95% CI, 15.1-25.9) compared with health care professionals (ROR, 2.44; 95% CI, 2.27-2.63). CONCLUSIONS: Sialorrhea was reported almost 4 times more often with clozapine use than with other antipsychotic use and was reported 8 times more often by patients than by health care professionals. This provides a signal of disproportion in sialorrhea occurrence among clozapine compared with other antipsychotics and in light of the disproportionality between reporter and an underreporting by health care professionals, underlining the importance to incorporate sialorrhea into the shared decision process when commencing clozapine therapy.

Drooling in Parkinson's Disease: Prevalence and Progression from the Non-motor International Longitudinal Study.

Sialorrhoea in Parkinson's disease (PD) is an often neglected yet key non-motor symptom with impact on patient quality of life. However, previous studies have shown a broad range of prevalence figures. To assess prevalence of drooling in PD and its relationship to quality of life, we performed a retrospective analysis of 728 consecutive PD patients who had a baseline and follow-up assessment as part of the Non-motor International Longitudinal Study (NILS), and for whom drooling presence and severity were available, assessed through the Non-Motor Symptoms Scale (NMSS). In addition, we analysed the prevalence of associated dysphagia through self-reported outcomes. Quality of life was assessed through the PDQ-8 scale. Baseline (disease duration 5.6 years) prevalence of drooling was 37.2% (score ≥ 1 NMSS question 19), and after 3.27 ± 1.74 years follow-up, this was 40.1% (p = 0.17). The prevalence of drooling increased with age (p < 0.001). The severity of drooling, however, did not change (p = 0.12). While in 456 patients without drooling at baseline, only 16% (n = 73) had dysphagia (question 20 of the NMSS), in those with drooling this was 34.3% (p < 0.001). At follow-up, the number of patients with dysphagia had increased, 20.4% with no drooling had dysphagia, and 43.6% with drooling had dysphagia. Both at baseline and follow-up, drooling severity was significantly positively associated with quality of life (PDQ-8; r = 0.199; p < 0.001). In moderately advanced PD patients, subjective drooling occurs in over one-third of patients and was significantly associated with decreased quality of life. Dysphagia occurred significantly more often in patients with drooling.

Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: a systematic review and meta-analyses.

AIM: To determine the prevalence of drooling, swallowing, and feeding problems in persons with cerebral palsy (CP) across the lifespan. METHOD: A systematic review was conducted using five different databases (AMED, CINAHL, Embase, MEDLINE, and PubMed). The selection process was completed by two independent researchers and the methodological quality of included studies was assessed using the STROBE and AXIS guidelines. Meta-analyses were conducted to determine pooled prevalence estimates of drooling, swallowing, and feeding problems with stratified group analyses by type of assessment and Gross Motor Function Classification System level. RESULTS: A total of 42 studies were included. Substantial variations in selected outcome measures and variables were observed, and data on adults were limited. Pooled prevalence estimates determined by meta-analyses were as high as 44.0% (95% confidence interval [CI] 35.6-52.7) for drooling, 50.4% (95% CI 36.0-64.8) for swallowing problems, and 53.5% (95% CI 40.7-65.9) for feeding problems. Group analyses for type of assessments were non-significant; however, more severely impaired functioning in CP was associated with concomitant problems of increased drooling, swallowing, and feeding. INTERPRETATION: Drooling, swallowing, and feeding problems are very common in people with CP. Consequently, they experience increased risks of malnutrition and dehydration, aspiration pneumonia, and poor quality of life. WHAT THIS PAPER ADDS: Drooling, swallowing, and feeding problems are very common in persons with cerebral palsy (CP). The prevalence of drooling, swallowing, and feeding problems is 44.0%, 50.4%, and 53.5% respectively. There are limited data on the prevalence of drooling, swallowing, and feeding problems in adults. Higher Gross Motor Function Classification System levels are associated with higher prevalence of drooling, swallowing, and feeding problems. There is increased risk for malnutrition, dehydration, aspiration pneumonia, and poor quality of life in CP.

PREVALENCIA DE PROBLEMAS DE SIALORREA, DEGLUCIÓN Y ALIMENTACIÓN EN PARÁLISIS CEREBRAL A LO LARGO DE LA VIDA: UNA REVISIÓN SISTEMÁTICA Y METAANÁLISIS: OBJETIVO: Determinar la prevalencia de problemas de sialorrea/babeo, deglución y alimentación en personas con parálisis cerebral (PC) a lo largo de la vida MÉTODO: Se llevó a cabo una revisión sistemática utilizando cinco bases de datos diferentes (AMED, CINAHL, Embase, MEDLINE y PubMed). El proceso de selección fue completado por dos investigadores independientes y la calidad metodológica de los estudios incluidos se evaluó utilizando las directrices STROBE y AXIS. Se realizó un metaanálisis para determinar las estimaciones de prevalencia agrupadas en problemas de babeo, deglución y alimentación con análisis de grupos estratificados por tipo de evaluación y nivel del Sistema de Clasificación de la Función Motora Gruesa. RESULTADOS: Se incluyeron un total de 42 estudios. Se observaron variaciones sustanciales en las medidas y variables de resultados seleccionadas, y los datos sobre adultos fueron limitados. Las estimaciones de prevalencia agrupadas determinadas por metaanálisis fueron tan altas como 44,0% (intervalo de confianza [IC] del 95% 35,6-52,7) para babeo, 50,4% (IC 95% 36,0-64,8) para problemas de deglución y 53,5 % (IC 95% 40,7-65,9) para problemas de alimentación. Los análisis de grupo para el tipo de evaluaciones no fueron significativos; sin embargo, el funcionamiento más severo en PC se asoció con problemas concomitantes de aumento de sialorrea, deglución y de la alimentación. INTERPRETACIÓN: Problemas relacionados con sialorrea, tragar, y de alimentación son muy comunes en personas con PC. En consecuencia, ellos experimentan mayores riesgos de desnutrición y deshidratación, neumonía por aspiración y mala calidad de vida.

PREVALÊNCIA DE PROBLEMAS COM SIALORRÉIA, DEGLUTIÇÃO E ALIMENTAÇÃO EM PARALISIA CEREBRAL AO LONGO DA VIDA: UMA REVISÃO SISTEMÁTICA E METANÁLISE: OBJETIVO: Determinar a prevalência de problemas com sialorréia, deglutição e alimentação em pessoas com paralisia cerebral (PC) ao longo da vida. MÉTODO: Uma revisão sistemática foi realizada utilizando cinco bases de dados diferentes (AMED, CINAHL, Embase, MEDLINE, e PubMed). O processo de seleção foi realizado por dois pesquisadores independentes e a qualidade metodológica dos estudos incluídos foi avaliada usando as diretrizes STROBE e AXIS. Metanálises foram realizadas para determinar as estimativas de prevalência agrupada de problemas de sialorréia, deglutição e alimentação, com análises estratificadas por tipo de avaliação e nível do Sistema de Classificação da Função Motora Grossa. RESULTADOS: Um total de 42 estudos foram incluídos. Variações substanciais nas medidas de resultado e variáveis selecionadas foram observadas, e dados em adultos são limitados. As estimativas de prevalência agrupada determiadas pela metanálise chegaram a 44,0% (intervalo de confiança [IC] 95% 35,6-52,7) para sialorréia, 50,4% (IC 95% 36,0-64,8) para problemas com deglutição, e 53,5% (IC 95% 40,7-65,9) para problemas de alimentação. Análises agrupadas por tipo de avaliação não foram significativas; no entanto, comprometimento funcional mais severo em PC foi associado com mais problemas concomitantes de salivação deglutição e alimentação. INTERPRETAÇÃO: Problemas de sialorréia, deglutição e alimentação são muito comuns em pessoas com PC. Consequentemente, elas apresentam risco aumentado de malnutrição e desidratação, pneumonia por aspiração e pior qualidade de vida.

Oral habits in Children with Cleft (Lip and) Palate: A Pilot Study.

BACKGROUND/AIMS: This pilot study aimed to evaluate the occurrence of oral habits and non-nutritive sucking habits in children with cleft (lip and) palate (CL/P) between 0-12 years, compared to peers without CL/P. METHODS: Children with CL/P (mean age 6.0 years, SD 2.80) were recruited from the Ghent University Hospital and compared to gender- and age-matched children without CL/P (mean age 5.8 years, SD 3.09). A self-report questionnaire was developed and given to the caregivers. To compare the occurrence of oral habits and non-nutritive sucking habits in children with and without CL/P, χ2 tests or Fisher's exact tests were used. RESULTS: The present study revealed a significantly lower occurrence of non-nutritive sucking habits in children with CL/P. These children showed significantly less pacifier sucking; no significant difference was found regarding thumb or finger sucking nor regarding sucking on other objects. Additionally, the results showed that the occurrence of snoring was statistically significantly higher in children with CL/P. CONCLUSION: Children with CL/P show less non-nutritive sucking habits, but more snoring compared to a control group without CL/P. Although further research regarding the oral habits in children with CL/P is necessary, cleft teams should give attention to the occurrence of oral habits.

Treatment Strategies for Clozapine-Induced Sialorrhea: A Systematic Review and Meta-analysis.

BACKGROUND: Clozapine is the most effective medication for treatment-refractory schizophrenia. However, it has a high burden of adverse events, including common adverse events such as sialorrhea. Sialorrhea can lead to severe physical complications such as aspiration pneumonia, as well as psychological complications including embarrassment and low self-esteem. Compromised adherence and treatment discontinuation can occur due to intolerability. There have been no meta-analyses examining strategies to mitigate clozapine-induced sialorrhea. METHODS: We systematically searched Chinese and Western research databases for randomised controlled trials examining agents for clozapine-induced sialorrhea. No limit to language or date were applied to the search. Where sufficient data for individual agents was available, pairwise meta-analyses were conducted. Results were provided as risk ratios and number needed to treat. Sensitivity analysis was conducted by study quality. Adverse events were provided as number needed to harm. RESULTS: 19 studies provided data for use in the meta-analysis. Improvement in clozapine-induced sialorrhea was seen in meta-analyses of propantheline (studies = 6, risk ratio [RR] 2.38, 95% confidence interval [CI] 1.52-3.73; number needed to treat [NNT] 3, 95% CI 1.9-2.7), diphenhydramine (studies = 5, RR 3.09, 95% CI 2.36-4.03; NNT 2, 95% CI 1.5-2.0), chlorpheniramine (studies = 2, RR 2.37, 95% CI 1.59-3.55; NNT 3, 95% CI 1.6-3.5), and benzamide derivatives (odds ratio [OR] 6.93, 95% CI 3.03-15.86). When meta-analyses were limited to high-quality studies, all these results remained significant. Single studies of benzhexol, cyproheptadine, doxepin and Kongyan Tang showed promise. Propantheline increased rates of constipation with a number needed to harm (NNH) of 9 (95% CI 4.2-204.1). CONCLUSION: Clozapine-induced sialorrhea is a potentially serious adverse event. Included studies in this meta-analysis were limited by poor study quality. Diphenhydramine, chlorpheniramine and benzamide derivatives appear to have the best supporting evidence and lowest reported adverse events. Caution should be exercised when using propantheline given its increased risk of constipation.

Development of the Drooling Infants and Preschoolers Scale (DRIPS) and reference charts for monitoring saliva control in children aged 0-4 years.

OBJECTIVES: To develop and validate a parent questionnaire to quantify drooling severity and frequency in young children (the Drooling Infants and Preschoolers Scale - the DRIPS). To investigate development of saliva control in typically developing young children in the age of 0-4 years. To construct sex-specific reference charts presenting percentile curves for drooling plotted for age to monitor the development of saliva control in infancy and preschool age. STUDY DESIGN: The DRIPS was developed consisting of 20 items to identify severity and frequency of drooling during meaningful daily activities. Factor analysis was performed to test construct validity. A piecewise logistic regression was followed by a piecewise linear regression to construct sex-specific reference charts. RESULTS: We obtained 652 completed questionnaires from parents of typically developing children. The factor analysis revealed four discriminating components: drooling during Activities, Feeding, Non nutritive sucking, and Sleep. To illustrate the development of saliva control, eight sex-specific reference curves were constructed to plot the scores of the DRIPS by age group, at the 15th, 50th, 85th and 97th percentile. About 3-15% of the preschoolers in our cohort did not acquire full saliva control at the age of 4 years. CONCLUSIONS: With the DRIPS it is possible to validly compare and visualize the development of saliva control in an individual infant or preschooler and allow clinicians to timely initiate individually targeted interventions if children outperform.

Pilocarpine and artificial saliva for the treatment of xerostomia and xerophthalmia in Sjögren syndrome: a double-blind randomized controlled trial.

BACKGROUND: Sjögren syndrome (SS) is associated with xerostomia and xerophthalmia. Pilocarpine has been shown to stimulate the secretion of saliva. OBJECTIVES: To investigate and compare the efficacy of pilocarpine and artificial saliva as symptomatic treatments for xerostomia and xerophthalmia in patients with SS. METHODS: A double-blind randomized controlled study was performed. A total of 72 patients with SS were assigned randomly to receive 10 drops of pilocarpine (5 mg) or 10 drops of artificial saliva orally, three times daily for 12 weeks. Whole saliva and tear flow were evaluated at baseline and periodically throughout the study to provide a global assessment of dryness and to report any adverse effects. RESULTS: Patients receiving pilocarpine had a statistically significant improvement in their salivary flow (P < 0·001), lacrimal flow (P < 0·001) and their subjective global assessment (P < 0·001), compared with patients who received artificial saliva. The most common side-effects were sialorrhoea and nausea. CONCLUSIONS: Pilocarpine is more effective than artificial saliva for enhancing salivary and lacrimal secretion in patients with SS. This is the first study to compare the efficacy of pilocarpine and artificial saliva for the treatment of xerostomia and xerophthalmia in SS.

Motor subtypes and other risk factors associated with drooling in Parkinson's disease patients.

OBJECTIVE: To explore the relationship between motor subtypes and drooling, and other risk factors associated with drooling in a large cohort of Chinese patients with Parkinson's disease (PD). METHODS: A total of 586 PD patients were enrolled in this study. Unified Parkinson's disease rating scale (UPDRS) and Hoehn & Yahr stage (H & Y stage) scale, Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Hamilton Rating Scale for Depression-24 item (HRSD), and Mini-Mental State Examination (MMSE) were applied to all subjects. Salivary subscores of UPDRS part II were used to evaluate drooling. Constipation was diagnosed using the Rome III criteria. RESULTS: The prevalence of drooling in this cohort is 54.6% (320/586). Non-TD subtype PD patients tend to have higher daily levodopa-equivalent dose (LED), H & Y stage, UPDRS I, UPDRS II, and UPDRS III scores, HRSD score and ESS score, a higher percentage of levodopa treatment, drooling, dyskinesia, and constipation. After adjusting for confounders, non-TD subtype, male sex, UPDRS III score, ESS and PSQI scores, and constipation were still associated with drooling, with corresponding Odds ratios and 95% confidence intervals (95% CIs) were 1.865 (95% CI, 1.137-3.060), 1. 951 (95% CI, 1.326-2.869), 1.024 (95% CI, 1.002-1.046), 1.064 (95% CI, 1.024-1.105), 1.058 (95% CI, 1.000-1.119), and 1.603 (95% CI, 1.092-2.353), respectively. CONCLUSION: Drooling is common, even in mild-to-moderate PD patients. PD patients with non-TD subtype are at a higher risk of drooling. Male sex, motor severity, excessive daytime sleepiness, poor nighttime sleep, and constipation are also associated with drooling in patients with PD.

Drooling is no early sign of dysphagia in Parkinson's disease.

BACKGROUND: Dysphagia is frequent and clinically highly relevant in Parkinson's disease (PD). For a rational dysphagia screening predictors are required. Previous investigations suggested that drooling correlates with dysphagia and may serve as its early sign. The aim of this study was to clarify the interrelationship of drooling and dysphagia. METHODS: In a controlled, cross-sectional, observational study, a total of 119 Parkinson outpatients and 32 controls were examined clinically and by flexible-endoscopic evaluation of swallowing (FEES). Drooling, dysphagia including retained pharyngeal secretions, and cognitive function were assessed by established evaluation scales. KEY RESULTS: Fifty percent of all PD patients but only 9% of controls had drooling (P < .001). Drooling and dysphagia were related in PD (P = .027) but the data do not support to view drooling as a hallmark symptom for critical dysphagia. Thirty-nine percent of the patients with critical aspiration had no drooling. In contrast, 41% of the patients with severe drooling had no clinically relevant dysphagia in FEES. The oral, but not the pharyngeal secretion management was impaired in PD patients and there was no clear association between drooling and pharyngeal secretion accumulation. Cognitive impaired patients had significantly more drooling (P = .005). CONCLUSIONS & INFERENCES: Although frequent in PD, drooling and dysphagia are only weakly related and drooling cannot be viewed as an early sign of dysphagia. Our data further suggest that the underlying cause of drooling is located in the voluntary oral phase, which is negatively influenced by cognitive deficits.

Botulinum Toxin Therapy for Nonmotor Aspects of Parkinson's Disease.

The medical treatment of Parkinson's disease (PD) is symptomatic both in terms of motor and nonmotor aspects. The nonmotor symptoms therapy should be taken into account as many of them negatively influence the quality of life and are treatable. Botulinum neurotoxin (BoNT) offers effective treatment for drooling and bladder dysfunctions and alternative treatment for constipation and pain related to parkinsonism. BoNT for drooling is probably the best-documented therapy for nonmotor symptoms by clinical trials. Ultrasound-guided injections into parotid and submandibular glands can be recommended as the first line treatment, especially when anticholinergic oral medications are not indicated due to the risk of confusion, cognitive decline, or psychosis. BoNT therapy of constipation and neurogenic bladder is not so well evidenced and the latter indication is based on positive effects in clinical trials in multiple sclerosis and posttraumatic spine injuries. BoNT injections into the salivary glands or bladder are effective and safe with relatively low risk of complications. Authors reviewed the literature on the use of BoNT for all nonmotor aspects of PD, showed their position in guidelines and systematic reviews and gave the practical remarks on injection techniques and dosing.