Authors (including presenting author) :
Ko CH(1), Ng MY(2), Yip CY(2), Lo CH(1)
Affiliation :
(1)Department of Paediatric and Adolescence Medicine
(2) Department of Occupational Therapy
Introduction :
Sialorrhoea beyond the age of 4 years is abnormal and is common problem in children with neurological problems. Underlying risk factors include poor head control, constant open mouth posture, inadequate lip and tongue control, diminished intra-oral sensation and constant tongue thrusting activity. Anterior drooling results in skin excoriation, dehydration and odor, while posterior drooling leads to chronic aspiration pneumonia. Drooling also results in social isolation and embarrassment of the child as well as increased burden of care and psychosocial stress on caregivers. In view of the significant morbidities, the Paediatric Rehabilitation Unit (PRU) of Caritas Medical Centre (CMC) launched a Sialorrhoea Improvement Program in March 2017.
Objectives :
To reduce frequency and severity of drooling by following means:
1. Improve oromotor control and behavioral modification
2. Reduce saliva production by medications, botulinum toxin A injection or surgery.
Methodology :
The program accepts territory-wide referral from Hospital Authority, Department of Health and Education Bureau. Multidisciplinary assessment was performed to ascertain medical condition, functional status and oromotor difficulties of each child. The 10-point visual analogue scale was used to assess the severity of the drooling problem by the caregiver. Interventions included oromotor training, postural control training, application of hyoscine patch, botulinum toxin A injection and referral for ductal relocation surgery. The outcome of oromotor training was assessed by the change in VAS & Drooling Quotient (DQ) from baseline, difference in Drooling Frequency & Severity (DSFS). SPSS version 9.0 was employed for statistical analysis. The changes in aforementioned scores at baseline, 1 month, 3 months and 6 months were analyzed by Friedman test, which is a nonparametric analogue of one-way ANOVA.
Result & Outcome :
Ten children, with a mean age of 12.8 years old (Range: 6-17 years old), had enrolled the 12-months improvement program. All children suffered from cerebral palsy with mild to severe mental retardation. Poor lip closure, inadequate jaw control and delay in swallowing were common oromotor difficulties. All children received oromotor training and home program. Four children underwent botulinum toxin A injection and six children were applied with Hyoscine patch. All ten subjects were followed up for at least six months. Mean drooling severity decreased serially (p<0.001) from 3.8±0.36 (baseline) to 3.1±0.35 (1 month) to 2.6±0.3 (3 months) to 2.4±0.34 (6 months). Mean drooling frequency decreased serially (p=0.006) from 3.1±0.31 (baseline) to 2.4±0.27 (1 month) to 2.2±0.2 (3 months) to 2.0±0.3 (6 months). Mean DQ decreased serially (p=0.001) from 38.5±9.3% (baseline) to 29.8±8.8% (1 month) to 11.0±3.2% (3 months) to 2.410.6±6.0% (6 months). Mean VAS decreased serially (p=0.003) from 6.3±0.7 (baseline) to 5.1±0.8 (1 month) to 4.3±0.9 (3 months) to 4.0±0.9 (6 months). Mean number of bibs used decreased serially (p=0.001) from 5.1±1.4 (baseline) to 3.7±1.4 (1month) to 3.1±1.0 (3months) to 2.5±1.0 (6 months).
Five children completed the 12-months improvement program. They showed sustained reduction of sialorrhoea despite fading botulinum toxin A effect and reduced use of hyoscine patch. Other functional gains, such as improved sucking and swallowing ability, were also identified. Recommendations & Conclusions: Combination pharmacological and oromotor training is proven to be effective to achieve sustained improvement in drooling. We recommend early pharmacological intervention to attain rapid initial response, which is followed by enhanced oromotor training at school and home to sustain the long term effect. Home based oromotor training with higher compliance rate produces significant and sustained reduction in sialorrhoea in this pilot program. Longer follow-up and bigger sample size is required to study the effect on psychosocial and pulmonary morbidities.
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