What is the best course of action for managing a child with a history of oral motor control issues who is experiencing drooling with a stuck object in their mouth?

Management of Child with Drooling and Stuck Object in Mouth

If a child is drooling with a stuck object in the mouth, immediately assess for airway obstruction and remove any visible foreign body that can be easily grasped—but never perform blind finger sweeps as these can impact the object into the larynx. 1

Immediate Assessment and Airway Management

Primary Airway Evaluation

• Check for signs of complete airway obstruction: inability to speak, silent cough, cyanosis, or inability to breathe 1
• Assess breathing by looking for chest/abdominal movement, listening for breath sounds, and feeling for expired air 1
• If the child can cough, speak, or cry, the airway is partially patent—encourage continued coughing and do not interfere 1

Foreign Body Removal Protocol

• Remove only visible foreign bodies that can be easily grasped from the mouth 1
• Never perform blind finger sweeps of the pharynx, as this can impact a foreign body into the larynx 1
• If the object cannot be easily removed and the child shows signs of respiratory distress, proceed with choking management protocols appropriate for the child's age 1

When to Activate Emergency Services

• After one minute of basic life support interventions, activate emergency medical services 1
• Carry infants or small children to the telephone; older children may need to be left briefly 1
• If breathing difficulties persist or worsen, a chest radiograph may be indicated to ensure the object was not aspirated 1

Assessment of Drooling in Context

Distinguishing Acute from Chronic Drooling

The presence of drooling with a stuck object requires differentiation between:

Acute drooling (related to the foreign body):

• Inability to swallow in the absence of excessive oral secretions suggests functional dysphagia from the obstruction 1
• The stuck object may be causing mechanical obstruction or triggering protective reflexes that prevent normal swallowing 1

Pre-existing chronic drooling (from oral motor control issues):

• Drooling or poor weight gain may suggest facial and oral motor weaknesses 1
• In children with neurological conditions, drooling results from impaired swallowing rather than hypersecretion of saliva 2, 3
• Positive signs of functional dysphagia include inability to control anything in the mouth but ability to spit saliva into a cup 1

Post-Removal Management

Oral Examination After Object Removal

Once the foreign body is removed:

• Examine for dental trauma, particularly luxation injuries which are the most common dental injury in primary dentition 1
• Check if the child can bite teeth together properly to ensure occlusion is not affected 1
• Assess for bleeding from the gingival sulcus, which indicates tooth displacement 1
• If a tooth is missing and not found, clinical and radiographic examination can confirm it was not intruded or aspirated 1

Referral Criteria

• Immediate referral to a dentist is indicated for severe tooth displacement, extensive gingival swelling, or suspected root fracture 1
• If the child has pre-existing oral motor difficulties, referral to a feeding team including a speech pathologist is paramount 1

Management of Underlying Oral Motor Issues

For Children with Known Oral Motor Control Problems

Assessment approach:

• Videofluoroscopic swallowing assessment identifies impairments in different phases of swallowing and should be done at baseline in all newly diagnosed cases 1
• Observe for pooling of secretions, "wet" vocal quality, and decreased vigilance with swallowing 1

Conservative management:

• Maximizing clearance of airway secretions should routinely be performed 1
• Modification of dietary texture with commercial thickeners may provide a safe feeding regimen if aspiration risk is identified 1

Medical management for chronic severe drooling:

• Glycopyrrolate oral solution is FDA-approved for children aged 3-16 years with neurologic conditions causing chronic severe drooling 4, 5
• Initiate dosing at 0.02 mg/kg orally three times daily and titrate in increments of 0.02 mg/kg every 5-7 days based on response 5
• Maximum recommended dose is 0.1 mg/kg three times daily, not to exceed 1.5-3 mg per dose based on weight 5
• Administer at least one hour before or two hours after meals, as high-fat food reduces oral bioavailability 5

Key Clinical Pitfalls to Avoid

• Never perform blind finger sweeps—this is the most critical error that can convert a partial obstruction to complete obstruction 1
• Do not assume drooling is always pathologic at age 4; some children have delayed oral motor maturation without underlying disease 4
• Do not miss aspiration risk in children with oral motor difficulties—penetration of liquid into the laryngeal vestibule has been documented as early as 4 months in babies with neuromuscular conditions 1
• Avoid overlooking medication side effects if the child is on aripiprazole or anticonvulsants, which can cause drooling 4
• Do not delay assessment for constipation when initiating glycopyrrolate, particularly within 4-5 days of initial dosing or after dose increase 5