Drooling: Always Gooey, But When Is It Abnormal In Kids?

At some point, all of us drool–especially when we are babies. It isn’t hard to miss, this unintentional waterfalling of saliva out the front of our mouths, and most parents in clinic observe their babies’ drooling with a mixture of amusement and concern.  Sure, drooling may be an associated with teething, but there’s much more to it.  The phenomena reflects the complex interplay of anatomy, neurology, behavior, development, and really good bibs. Which begs the questions: how long do kids normally drool for? (longer than you think) What does it mean if a child drools past a certain age?  (Depends) Are there treatments for children who have pathologic amounts of drool? (Read on and find out!).

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 cascades out.  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.  And, out they come. 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. It really ranges in amount and duration. 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. Past that birthday, persistent drooling is considered abnormal.

Drool is saliva (aka spit, slaver, slobber or spittle). Saliva is a remarkable cocktail 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. No wonder it gets wet in there.

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 drugs or tranquilizers. 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. Whammo: Drooling happens.

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. Do you have a full term child? (preemies have higher rates of oromotor problems) Is there a known neurologic or developmental issue? (rates of drooling can run extremely high in certain populations, such as children with cognitive delay or cerebral palsy, or “CP.” Listen: up to 37% of kids with CP have significant and persistent drooling problems). From a physical exam, a primary care provide can further discern if there are any there any contributing anatomical problems or other related issues.

Acute vs. Chronic: There’s a difference

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.

A trip to the primary care clinic may be in order if the pain is eluding ‘comfort measures’.  In littler children or children with delays who may be less verbal, one must be sure that drooling has not been triggered by a swallowed, or half-swallowed object. Any perception that something may be stuck in the back of the throat or blocking the airway needs to be evaluated immediately. If a child is having trouble breathing, 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. In some children with neurologic impairment, excessive drooling may pose additional risks for aspiration and pneumonia. In short, drooling can greatly impair a child and family’s quality of life. I encourage families to convey this concern and not let it be displaced by attention to other issues (braces? wheelchair? growth?) if their child has a lot going on developmentally or medically. It all matters!

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. Is it abnormal? It’s worth finding out if therapies can help. After all, not knowing ain’t worth spit.

Photo above by myklang (http://media.photobucket.com/image/drooling%20baby/myklang/drooling.jpg?o=2).

Cartoon below by me.

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