Management of Excessive Salivation in Infants
The first-line approach for managing excessive salivation (sialorrhea) in infants should focus on identifying and treating the underlying cause, with conservative measures being the initial treatment of choice before considering pharmacologic interventions.
Causes of Excessive Salivation in Infants
- Physiologic causes - normal developmental process in infants, particularly during teething 1
- Oral motor dysfunction - poor oral and facial muscle control is the most common cause of pathologic sialorrhea 1, 2
- Neurological disorders - cerebral palsy, mental retardation, and other neurologic impairments 1
- Gastroesophageal reflux disease (GERD) - can cause increased salivary flow as a response to acid reflux, known as "water brash" 3, 4, 2
- Oral infections or inflammation 2
- Anatomical abnormalities - such as those seen in syndromes like 22q11.2 deletion syndrome 3
- Medication side effects - certain drugs with cholinergic effects can induce sialorrhea 2
Initial Assessment
- Evaluate for signs of GERD, including regurgitation, irritability, feeding problems, and arching 3, 4
- Assess for oral motor function and control 1
- Check for signs of oral infection or inflammation 2
- Evaluate swallowing function if dysphagia is suspected 5
- Consider transnasal swallowing endoscopy in cases where aspiration is a concern 5
Conservative Management Approaches
For Physiologic Drooling
- Reassurance to parents that excessive salivation is often normal in infants, especially during teething 1
- Use of absorbent bibs to keep clothing dry 1
- Regular wiping of the mouth area to prevent skin irritation 1
For GERD-Related Excessive Salivation
- Feeding modifications:
- Smaller, more frequent feedings to reduce gastric distension 3, 4
- Thickened feedings (adding up to 1 tablespoon of dry rice cereal per 1 oz of formula) for formula-fed infants 3
- For breastfed infants, a 2-4 week maternal elimination diet restricting at least milk and egg 3, 6
- For formula-fed infants with suspected milk protein allergy, switching to extensively hydrolyzed protein or amino acid-based formula 3, 6
- Positioning:
- Proper burping techniques after feedings 6
For Oral Motor Dysfunction
- Referral to speech-language pathology for oral motor therapy 1, 5
- Positioning techniques to improve head control and oral motor function 1
Pharmacologic Management
If conservative measures fail and sialorrhea is causing significant complications (such as skin breakdown, social issues, or aspiration):
- Glycopyrrolate bromide - approved for children and adolescents with pathologic sialorrhea, reduces saliva flow with limited risk 5
- Anticholinergic medications - such as scopolamine, but use may be limited by side effects 1
- Atropine or glycopyrrolate may be used to prevent increased salivation in specific clinical scenarios 3
Invasive Interventions (rarely indicated in infants)
- Botulinum toxin type A injections into salivary glands - generally reserved for older children with chronic neurologic conditions 1, 5, 7
- Surgical interventions - including salivary duct ligation, rerouting, or gland excision, are rarely indicated in infants and reserved for severe cases unresponsive to other treatments 1, 7
Multidisciplinary Approach
- Treatment is best managed by a clinical team that may include 1, 7:
- Primary care provider
- Speech-language pathologist
- Occupational therapist
- Dentist
- Otolaryngologist
- Neurologist (if neurological issues are present)
- Gastroenterologist (if GERD is suspected)
Monitoring and Follow-up
- Regular monitoring of weight gain and nutritional status 3
- Assessment of skin integrity around the mouth 1
- Evaluation for signs of aspiration or respiratory complications 5
- Adjustment of treatment plan based on response 5