How to manage excessive salivation in children during sleep?

Management of Excessive Salivation in Children During Sleep

For children with excessive salivation during sleep, the most effective approach is to evaluate for and treat underlying obstructive sleep-disordered breathing, particularly adenotonsillar hypertrophy or laryngomalacia, as these are the most common causes of nighttime drooling in otherwise healthy children.

Evaluation for Underlying Causes

1. Assess for signs of obstructive sleep-disordered breathing (oSDB):

   • Snoring
   • Struggling to breathe during sleep
   • Restless sleep
   • Mouth breathing
   • Daytime sleepiness or behavioral issues

2. Physical examination focus points:

   • Enlarged tonsils and adenoids
   • Signs of upper airway obstruction
   • Craniofacial abnormalities
   • Evidence of nasal obstruction

Treatment Algorithm

First-line approach:

1. For children with enlarged tonsils and adenoids:

   • Tonsillectomy and adenoidectomy is recommended as first-line surgical treatment for oSDB 1
   • Success rates for resolving oSDB are approximately 80% in normal-weight, younger children 1
   • Lower success rates (less than 50%) in obese children 1

2. For children with laryngomalacia:

   • Flexible laryngoscopy for diagnosis (preferably during sleep or under light sedation) 2
   • For mild cases: conservative management with positioning strategies:
     • Prone or side-lying position during sleep
     • Elevating head of bed 30 degrees 2
   • For severe cases: supraglottoplasty may be indicated, which can improve AHI, oxygen saturation, and resolve symptoms in up to 86% of children 2, 1

Conservative measures while awaiting definitive treatment:

• Positioning strategies:

  • Sleep with head elevated
  • Side-lying position to prevent pooling of saliva
  • Avoid supine sleeping position

• Environmental modifications:

  • Use of waterproof pillowcases
  • Absorbent cloths under the head during sleep

Special Considerations

For children with neurological impairment:

Excessive salivation may be due to poor oral and facial muscle control rather than increased production 3. Consider:

• Speech therapy and occupational therapy for improving oral motor control
• Anticholinergic medications (used cautiously due to side effects) 3

For medication-induced sialorrhea:

Review medications that may cause excessive salivation 4, 5:

• Sedatives such as benzodiazepines
• Neuroleptics
• Cholinesterase inhibitors
• Pilocarpine

Follow-up and Monitoring

• Regular assessment of symptoms after intervention
• Polysomnography (sleep study) may be needed to document presence and severity of obstructive sleep apnea before and after treatment 2
• For persistent symptoms despite initial management, investigate for concomitant conditions or other airway abnormalities 2

Caution

• Medications for reducing salivation (anticholinergics) should be used cautiously in children due to potential side effects
• Parents should be counseled that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1
• Children with obesity may require additional interventions beyond surgical management of the airway 1

By addressing the underlying cause of excessive salivation during sleep, particularly obstructive sleep disorders, most children will experience significant improvement in symptoms and quality of life.