Upper airway secretion management in children with neurodisability

Introduction

This leaflet is for parents and carers of children and young people who are being treated under the complex chest service and who are suffering with chronic drooling. Hyper salivation (sialorrhoea) is the excessive production of saliva that can cause chronic drooling.

It presents as drooling in some children and young people with a neurological condition, such as cerebral palsy because they have a poor ability to swallow, altered tone and sometimes an ineffective cough. Chronic drooling is defined as the unintentional loss of saliva from the mouth. Drooling is normal in infants. It usually stops by 15 - 18 months of age, but if it is persistent after four years it is considered chronic.

This page gives information on medication control for chronic drooling.

Possible effects of chronic drooling of saliva

• Skin cracking and bacterial infection of skin
• Dehydration
• Halitosis (bad breath)
• Aspiration leading to pneumonia
• Feeding difficulties

Two main approaches for chronic drooling

• Non-invasive - pharmacological (controlled by medication)
• Invasive - surgery

Non medication approaches

Good posture with good trunk and head support can help in oral control of drooling and swallowing. If your child is able to, encouraging them to swallow their own secretions is useful. Otherwise wiping your child's mouth or using oral suction (if advised) can help reduce the side effects of chronic drooling. Behaviour therapy such as positive reinforcement can help to reduce drooling. This includes encouraging swallowing and mouth wiping.

Behaviour therapy and positive reinforcement can help to reduce drooling Try to encourage a good posture including keeping their body straight. If your child is able to, encourage them to swallow their own secretions and wipe their own mouth .If necessary, wiping your child’s mouth or using oral suction can also help reduce the side effects of chronic drooling.

Medication options

Glycopyrronium bromide 1mg / 5ml oral solution

Glycopyrronium bromide is licensed for symptomatic treatment of severe sialorrhoea (chronic drooling) in children and adolescents aged 3 years and older with chronic neurological disorders.

Dose

The dosing schedule is based on the weight of the child with small initial dosing to be taken up to three times daily and titrate (increase dose) in increments every 5 to 7 days based on the child’s therapeutic response i.e how effectively the medication helps control your child's drooling.

The advantage of glycopyrronium

It should be started at the smallest dose in the range prescribed and increased upwards in small increments to assess the effectiveness of salivation. Glycopyrronium is felt to be useful as each dose will begin to wear off after about 4 hours and therefore small alterations to dose will be noticeable within a few hours and should be regularly assessed for effectiveness.

Possible side effects

The most commonly reported adverse effects are: dry mouth, vomiting, constipation, flushing and nasal congestion, behavioural changes (drowsiness, restlessness, hyperactivity and irritability) and urinary retention. Side effects such as urinary retention, constipation and overheating due to inhibition of sweating are dose dependent.

Transdermal hyoscine hydrobromide

These are small plaster like patches which are applied as a patch (or a proportion of a patch) to a hairless area of skin behind the ear; If less than a whole patch is required either cut with scissors along the full thickness ensuring the membrane is not peeled away or cover a portion to prevent contact with the skin. This is an alternative treatment for drooling.

Transdermal patches (1.5mg / 2.5cm2) offer several advantages over other treatments including ease of administration, maintenance of steady state concentrations and a lower incidence of side effects.

Side-effects

• Confusion
• Constipation
• Dizziness
• Drowsiness
• Dry mouth
• Dyspepsia
• Flushing;
• Headache
• Nausea
• Palpitations
• Skin reactions
• Tachycardia
• Urinary disorders
• Vision disorders
• Vomiting
• Eyelid irritation

When your child is unwell with a cough, cold / chest infection

Your child's secretions will automatically become thicker. We would therefore recommend that at the start of a cold any secretion management medication be stopped or reduced. If your child is using glycopyrronium you should reduce or omit one or more doses depending on the thickness of your child's secretions, to allow them to become loose enough to cough and clear easily. If your child uses a hyoscine patch , you may wish to remove the patch for the duration of the illness, noting it may take 24 to 48 hours before this is fully effective.

Contacts / further information

The complex chest service: 01223 348067