Columnists :: Kids Health With Dr Jack
Drooling: Always gooey by Jack Maypole, MD
MySouthEnd.com ContributorThursday May 10, 2012 But when is it abnormal?
Drooling-he unintentional waterfall of saliva from the front of our mouths-isn’t hard to miss. In clinic, parents observe their babies’ drooling with a mixture of amusement and concern. Sure, drooling may be an associated with teething, there’s much more to it.
By the fourth month of life, the salivary glands in the infant undergo a rapid phase of growth, with a corresponding increased output of saliva (once again in medicine, we dignify a condition with a horrible name, "sialorrhea"). While most babies swallow a healthy fraction of this volume, a fair share of slobber tends to cascade out the mouth. As any caretaker of a child who drools knows: chins, and necks, and neck folds tend to be constantly moist and gooey places. Failure to dab or wipe or bib these areas with some regularity can result in the skin becoming irritated and rashy.
Developmentally, healthy children from 4 to 18 months have not yet developed the oral and lip muscles ability to manage all of these secretions. This problem is magnified by infant’ and toddlers’ tendency to grasp, mouth, and slime whatever graspable object is within their reach. Cute they are, but gooey!
Drooling is considered a normal finding in children up until the age of 2. Some kids drool more (several bibs or costume changes a day!), some less (an occasional swipe will do). Otherwise healthy children who persist in drooling after their second birthday may be simply observed with an expectation that they’ll grow out of it by the age of four. For children four and older, persistent drooling is considered abnormal.
Drool is saliva, a remarkable cocktail of comprised mostly of water, antibodies and digestive enzymes. Saliva serves a crucial role in moisturizing and protecting the oral cavity from infection, cleansing the teeth, preventing foul breath, assisting in swallowing by moistening foods, and digesting carbohydrates and proteins. Saliva is produced by a network of three paired glands embedded in the lining of the walls and floor of the mouth, with additional spit factories in the tongue and roof of the mouth.
Ideally, children and adults make the saliva they need. Too little saliva ain’t good: children and adults without enough may develop painful mouth infections and sores, suffer increased rates of cavities, and have difficulty eating.
Too much saliva, known as hypersecretion, is relatively rare and is most associated as a side effect of meds, such as seizure medications or tranquilizing drugs. In older kids who have a drooling problem, the issue is not so much that they produce excessive amounts of saliva, but rather that they are having trouble managing the secretions they produce.
For parents, consulting with their child’s health care provider is key. Each child needs to be considered holistically in such cases, and the evaluation begins with careful history. From a physical exam, a primary care provide can further discern if there are any there any contributing anatomical problems or other related issues.
Children of any age may experience ’sudden onset’ cases of drooling (or worsening of drooling that they already have)if they develop mouth pain. Oral infections, canker sores, cavities, tooth eruption may underlie a child’s new unwillingness to swallow. A peek inside the mouth by a sunny window is a good idea to see what gives. Any perception that something may be blocking or stuck in the back of the throat call 911. STAT.
Chronic drooling may impose a significant challenge to families, careproviders, and educators. In these instances, children and teens may develop hard-to-treat breakdown of the skin on their faces and necks, soaking of their clothes, communication equipment, and isolation or self-consciousness that makes it difficult for them to connect socially with their peers
Generally, the best approach to abnormal drooling for a child of any age involves a team effort. Consultations may involve the work of specialists, such as pediatric neurologists, dentists, and/or ear, nose and throat surgeons where appropriate. Further, speech pathologists, physical therapists, and occupational therapists collaborate to understand a child’s level of function, and how to optimize it. Oral training and rehabilitation to improve drooling tend to be more effective for children with higher levels of perception and motivation. It can be slow going but well worth it.
Medications offer limited results for children with chronic, excessive drooling. At best, medications lessen the amounts of secretions produced. Unfortunately, many of these meds (e.g. Robinul) come with significant side effects, including making saliva ropey and hard to swallow. Botox (aka botulinum toxin) has gained attention and renown recently for being effective when injected into the major salivary glands.. In studies of treatments applied on kids with drooling results showed some improvement in some of the children-but should be considered as a temporary measure and not a cure. Radiation and surgical approaches to overactive salivary glands may also be used in grownup populations, but are virtually unheardof in children.
And so, for any parent with an infant, toddler or child who drools a little or a lot: check in with your child’s primary care provider if you are concerned or have questions. Not knowing ain’t worth spit.
Jack Maypole, MD is director of Pediatrics at the South End Community Health Center, and Director of the Comprehensive Care Program at Boston Medical Center, a clinic for children with complex and chronic illness. Portions of his articles are drawn from his blog found at thefastertimes.com/pediatrics.