Diagnosis of sialorrhea in children with cerebral palsy (a review)

The review covers a comprehensive assessment of reliable measurement of salivation in children: clinical, scale and instrumental.

In our study, we used only systematic reviews with a high level of evidence and evaluated their real potential for implementation in practical medicine. Based on various sources with a high level of evidence and a large sample of patients, the strengths and weaknesses of each scale used in the diagnosis of sialorrhea in children, their validity and the need for combination in clinical practice were evaluated. It should be noted that there are few publications on pediatric sialorrhea; most reviews address salivation in Parkinson’s disease. We conducted an electronic searching of PubMed, Web of Science, Scopus, Cochrane Library, eLIBRARY databases and bibliographies of key articles with evidence levels 1a, b, c, 2a and recommendation levels A. Inclusion criteria were the follosing: systematic reviews, randomized controlled trials, multicenter cohort studies with evidence levels 1a, b, c, 2a and recommendation levels A, children aged 4 to 18 years with sialorrhea. Exclusion criteria were the following: thematic articles, case reports, observations, cohort uncontrolled studies, experimental studies, reports, articles with evidence levels 2b, c, 3a, b, 4, 5 and recommendation levels B, C, D, adult age of patients, Parkinson’s disease, neonatal pathology, Huntington’s chorea. Based on our review, it was concluded that many studies of salivation are limited by the inaccuracy of using standardized quantitative methods for evaluation treatment effi  cacy and the need to combine scales for comprehensive study of this disease. The severity of sialorrhea varies daily, and sometimes hourly, or depending on everyday life circumstances. In clinical practice, it is necessary to quantify the frequency of sialorrhea and its impact on the quality of life of children and their social environment, as well as the dynamics and eff ectiveness of treatment. Incorrect assessment of the severity of sialorrhea can worsen the results of treatment and distort conclusions about the eff ectiveness of the applied therapies.

Based on a literature review, recommendations are made for a comprehensive assessment of salivation in pediatric sialorrhea.

1. Zakharov DV, Kokareva DD. Comorbidity of sialorrhea and depression in patients with Parkinson’s disease, their mutual infl uence on the severity of symptoms and the success of therapy. Neurology, Neuropsychiatry, Psychosomatics. 2024;16(6):105–111]. doi: 10.14412/2074-2711-2024-6-105-111 EDN: BQRNUM

2. Van der Burg JJ, Didden R, Jongerius PH, Rotteveel JJ. Behavioral treatment of drooling: a methodological critique of the literature with clinical guidelines and suggestions for future research. Behav Modif. 2007;31(5):573–94. doi: 10.1177/0145445506298723

3. Jost WH, Steff en A, Berweck S. A critical review of incobotulinumtoxin A in the treatment of chronic sialorrhea in pediatric patients. Exp Rev Neurother. 2021;21(10):1059–1068. doi: 10.1080/14737175.2021.1979959

4. Heikel T, Patel S, Ziai K, et al. Botulinum toxin A in the management of pediatric sialorrhea: a systematic review. Ann Otolog Rhinolog Laryngolog. 2023;132(2):200–206. doi: 10.1177/00034894221078365

5. Zerchaninova EI, Gagarina EM, Evdokimov VV. Physiology of the maxillofacial region: a textbook on normal physiology. Bankov VI, editor. Ekaterinburg; 2009. 136 p. (In Russ.)]

6. Klochkova OA, Kurenkov AL, Kharimova HM, et al. Drooling in patients with cerebral palsy: the effectiveness of botulinum toxin A treatment. Pediatric pharmacology. 2015;12(4):398–406]. doi: 10.15690/pf.v12i4.1420 EDN: UMTZNZ

7. Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database Syst Rev. 2012;11(11):CD008624. doi: 10.1002/14651858.CD008624

8. Oad H, Maltezeanu A, da Silva SD, Daniel SJ. Onabotulinum toxin A (BoNT-A) for drooling in children: a systematic review and meta-analysis. Laryngoscope. 2024;134(7):3012–3017. doi: 10.1002/lary.31277

9. Lang IM. Coordination of pharyngeal and esophageal phases of swallowing. J Neurogastroenterol Motil. 2024;30(4):397–406. doi: 10.5056/jnm24003

10. Roehm CE, Schoem SR. Drooling and salivary aspiration. In book: Pediatric otolaryngology for primary care. 2020. P. 409‒422. doi: 10.1542/9781610024013-part05-ch20

11. Wahyuni LK. Multisystem compensations and consequences in spastic quadriplegic cerebral palsy children. Front Neurol. 2023;13:1076316. doi: 10.3389/fneur.2022.1076316

12. Unes S, Tuncdemir M, Ozal C, et al. Relationship among four functional classifi cation systems and parent interpredicted intelligence level in children with diff erent clinical types of cerebral palsy. Dev Neurorehabil. 2022;25(6):410–416. doi: 10.1080/17518423.2022.2051629

13. Rashnoo P, Daniel SJ. Drooling quantifi cation: correlation of diff erent techniques. Int J Pediatr Otorhinolaryngol. 2015;79(8):1201–1205. doi: 10.1016/j.ij porl.2015.05.010

14. Riva A, Federici C, Piccolo G, et al. Exploring treatments for drooling in children with neurological disorders. Expert Rev Neurother. 2021;21(2):179–187. doi: 10.1080/14737175.2021.1855146

15. Reid SM, McCutcheon J, Reddihough DS, Johnson H. Prevalence and predictors of drooling in 7- to 14-year-old children with cerebral palsy: a population study. Dev Med Child Neurol. 2012;54(11):1032–1036. doi: 10.1111/j.1469-8749.2012.04382.x

16. Kurenkov AL, Klochkova OA, Zmanovskaya VA, et al. Updated and revised Russian consensus on the use of multilevel injections of abobotulinumtoxin A in children. Neurology, Neuropsychiatry, Psychosomatics. 2024;16(6):125–133]. doi: 10.14412/2074-2711-2024-6-125-133 EDN: WTYXEP

17. Olsson SE, Chorney SR, Brown AT, et al. The role of speech therapy in sialorrhea management and quality of life: a retrospective study. Laryngoscope Investig Otolaryngol. 2025;10(1):e70105. doi: 10.1002/lio2.70105

18. Blasco P. Prevalence and predictors of drooling. Dev Med Child Neurol. 2012;54(11):970. doi: 10.1111/j.1469-8749.2012.04412.x

19. Boaden E, Nightingale J, Bradbury C, et al. Clinical practice guidelines for videofl uoroscopic swallowing studies: a systematic review. Radiography (Lond). 2020;26(2):154–162. doi: 10.1016/j.radi.2019.10.011

20. Jongerius PH, Rotteveel JJ, van Limbeek J, et al. Botulinum toxin eff ect on salivary fl ow rate in children with cerebral palsy. Neurology. 2004;63(8):1371–5137. doi: 10.1212/01.wnl.0000142040.57474.a6

21. Mailly M, Rebours C, Koskas P, et al. Interests of the ultrasoundguidance in the treatment of drooling through botulinum toxin injections, our experience over 10 years. J Stomatol Oral Maxillofac Surg. 2017;118(1):5–10. (In French). doi: 10.1016/j.jormas.2016.12

22. Dogu O, Apaydin D, Sevim S, et al. Ultrasound-guided versus ‘blind’ intraparotid injections of botulinum toxin-A for the treatment of sialorrhoea in patients with Parkinson’s disease. Clin Neurol Neurosurg. 2004;106(2):93–96. doi: 10.1016/j.clineuro.2003.10.012

23. Hong J, Rha DW, Cha JM. Ultrasound-guided salivary gland interventions: clinical application of intraglandular botulinum toxin injections. Clin Pain. 2025;24(1):68–74. doi: 10.35827/cp.2025.24.1.68

24. Cardona I, Saint-Martin C, Daniel SJ. Eff ect of recurrent onabotulinum toxin A injection into the salivary glands: an ultrasound measurement. Laryngoscope. 2015;125(10):E328–32. doi: 10.1002/lary.25222

25. Scott K, Shannon R, Roche-Green A. Management of sialorrhea in amyotrophic lateral sclerosis. J Palliat Med. 2016;19(1):110–111. doi: 10.1089/jpm.2015.0360

26. Bard-Pondarré R, Roumenoff F, Julien C, et al. Validity, reliability and responsiveness to change of the French version of the drooling impact scale. Disabil Rehabil. 2022;44(5):788–794. doi: 10.1080/09638288.2020.1777471

27. Thomas-Stonell N, Oddson B, Robertson B, Rosenbaum P. Validation of the focus on the outcomes of communication under six outcome measure. Dev Med Child Neurol. 2013;55(6):546–552. doi: 10.1111/dmcn.12123

28. McInerney M, Reddihough DS, Carding PN, Imms C. Drooling in children with neurodisability: a survey of Australian speech-language pathologists’ practice. 2020;22(5):601–609. doi: 10.1080/17549507.2020.1729860

29. Navazesh M, Kumar SK; University of Southern California School of Dentistry. Measuring salivary fl ow: challenges and opportunities. J Am Dent Assoc. 2008;139(Suppl):35S–40S. doi: 10.14219/jada.archive.2008.0353

30. Zamani SM, Naderifar E, Torabi MH, Kamali M. Non-medical treatments of drooling by speech and language pathologists in cerebral palsy children: a systematic review. J Iranian Medical Council. 2024. doi: 10.18502/jimc.v7i4.16622

31. Perinelli MG, Riva A, Federici C, et al. Comparing subjective scales for rating drooling: a pilot, bicentric study. Int J Neurorehabil. 2022;9(8):2‒6. doi: 10.37421/2376-0281.2022.9.478

32. Sforza E, Onesimo R, Leoni C, et al. Drooling outcome measures in paediatric disability: a systematic review. Eur J Pediatr. 2022;181(7):2575–2592. doi: 10.1007/s00431-022-04460-5

33. Olsson SE, Chorney SR, Brown AT, et al. The role of speech therapy in sialorrhea management and quality of life: a retrospective study. Laryngoscope Investig Otolaryngol. 2025;10(1):e70105. doi: 10.1002/lio2.70105

34. Ghezzi EM, Lange LA, Ship JA. Determination of variation of stimulated salivary fl ow rates. J Dent Res. 2000;79(11):1874–1878. doi: 10.1177/00220345000790111001