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Paeds ENT | The Drooling Child | Dr Charlie Fairhurst

1K views|3 years ago
💫 Short Summary

Dr. Dribble discusses his interest and experience in saliva control in children with neurodisabilities, highlighting the societal challenges and the need for proper assessment and management. He explains the physiological aspects of saliva production and the potential causes of saliva control difficulties, focusing on children with cerebral palsy and other neurodisabilities.Dr. Richard discusses the use of botulinum toxin injections to manage drooling in children with profound neurological disabilities. He emphasizes the importance of safety, accurate administration, and collaboration with other medical professionals. The injections have been shown to have a positive impact on reducing drooling and improving the quality of life for the children and their families. Referral to a tertiary saliva control service is recommended for cases where healthcare providers are uncomfortable with managing the treatment.

✨ Highlights
📊 Transcript
Dr. Dribble discusses the importance of saliva control in children with disabilities.
00:08
He mentions the establishment of a saliva control clinic in the early 2000s.
Families have reported significant physical and psychological issues associated with saliva control difficulties in children.
Society's perception and treatment of children with saliva control difficulties is still a challenge.
Research and development of knowledge in the area of saliva control have been ongoing for the past 20 years.
The speaker was involved in leading the cerebral palsy guideline that focused on comorbid challenges, including saliva control.
The speaker discusses the assessment and management of saliva control difficulties in children with neurodisability.
04:25
Saliva is produced under the autonomic nervous system and is controlled by the parasympathetic system.
Children with neurodisability may experience challenges with saliva control due to problems with swallowing and postural issues.
The prevalence of saliva control difficulties is significant in children with cerebral palsy, ranging from 10 to 37 percent.
Assessment tools include the drooling impact scale and modified drooling rating scale to measure the frequency, severity, and impact of saliva loss.
The video discusses the challenges and causes of saliva loss in children with neurological problems.
08:29
The main population with saliva control difficulties are children who cannot swallow properly due to postural problems.
Problems with saliva control are also associated with upper airway issues and gastroesophageal reflux.
Children with cerebral palsy often experience hypersalivation due to the use of certain medications.
Children with cerebral palsy also have a high prevalence of gastroesophageal reflux, which can lead to hypersalivation.
The speaker discusses the assessment of saliva control and the focus on qualitative measures in clinical practice.
14:11
Quantifying qualitative problems for the child and the family using the drooling impact scale and modified drooling rating scale.
Assessment of neurological and other clinical factors including posture, communication, and oral health.
Management options include anticholinergic medications, behavioral treatment, and conservative measures such as dabbing saliva away and using toweling wristbands.
The speaker talks about the children referred to their saliva control clinic and the approaches to management.
20:32
A small population of children can consider oral motor exercises with the help of a speech and language therapist.
Behavioral treatment and cognitive abilities play a significant role in the management of drooling.
Conservative measures such as dabbing saliva away and using toweling wristbands are recommended for dealing with drooling.
Alternative therapies like acupuncture and taping are also of interest but lack clear evidence base.
The video discusses the limited function but potential usefulness of intraoral devices in managing saliva control.
26:16
Intraoral devices are a modified brace with ridges and bumps over the palate to stimulate a normal swallow.
There are anecdotal reports of the usefulness of intraoral devices in some children.
Historically, there was a focus on anti-reflux medications for the treatment of saliva loss.
Untreated gastroesophageal reflux can increase saliva production, so the cause of the problem needs to be addressed.
The speaker discusses the effectiveness of different treatment options for saliva control, including oral medications, inhaled agents, and myofunctional therapy.
32:00
Oral medications improved the drilling impact scale by around a factor of minus 20, twice as good as the inhaled and myofunctional therapy.
Botulinum toxin injections are another option for reducing saliva production, particularly useful for children with epilepsy.
Dr. Richard is a pediatric neurologist who specializes in managing drooling in children with profound neurological disabilities.
00:00
He uses botulinum toxin injections to treat drooling in children who cannot manage their saliva.
Dr. Richard values the input and collaboration of the ENT team and prefers to avoid sedation, especially for children with autism.
He emphasizes the importance of safety and provides details about his approach, including using ultrasound scans to locate saliva glands and administering low doses of botulinum toxin.
Dr. Richard also discusses the rare need for general anesthesia, the potential side effects of thickened saliva and swallowing difficulties, and the positive effects of botulinum toxin injections on reducing drooling and chest infections.
Botulinum toxin injections are effective in reducing excessive drooling in children with neurodisabilities.
10:19
In a five-year period, 551 courses of injections were given to 186 children, resulting in a significant improvement in the drooling impact scale and the quality of life.
The injections also led to a marked reduction in chest infections post-procedure, indicating a decrease in aspiration.
The average duration of benefit from the injections ranged from six to nine months, with some children experiencing benefits for up to 18 months.
Surgical options, such as duct ligation and gland removal, are considered in collaboration with ENT specialists for cases where botulinum toxin injections are not sufficiently effective.
Botulinum toxin injections and surgical interventions are compared for their effects on drooling in children with neurodisabilities.
20:29
Botulinum toxin injections have a quicker onset of action, typically within a week, and are less invasive than surgery.
The injections are administered into the salivary glands using ultrasound guidance, and the effects can last for about three to four months.
Surgical interventions, such as duct ligation and gland removal, have a longer duration of action but are more invasive.
The decision to use botulinum toxin injections or surgery depends on the individual child's needs and the response to previous treatments.
Combining botulinum toxin injections with oral medications or surgical interventions may be necessary for some children with more severe drooling.
Dr. Richard discusses the use of botulinum toxin injections for managing drooling in children with neurological disabilities, emphasizing the importance of accurate and safe administration.
30:53
He mentions the challenge of administering injections to children with profound disabilities, such as autism, who may not cooperate without sedation.
Dr. Richard highlights the use of ultrasound guidance and low doses of botulinum toxin to ensure safety and effectiveness.
The injection is targeted at the saliva glands, and Dr. Richard suggests using ultrasound to visualize the needle placement.
He also discusses the potential side effects of thickened saliva and swallowing difficulties, emphasizing the need for a comprehensive approach to managing drooling in these children.
Surgical approaches for managing drooling are discussed, including duct ligation, duct transposition, and gland removal, with a focus on the duration and effectiveness of the interventions.
42:03
Surgical interventions for managing drooling include duct ligation, duct transposition, and gland removal.
The results of these surgical interventions can be variable, with some meta-analyses highlighting their effectiveness and potential complications.
Recommendations suggest not to perform these surgeries before puberty, as the condition may settle down with age.
The presentation shows the changes in drooling impact scale before and after surgery, indicating a significant improvement in quality of life for the child and the family.
The speaker discusses the administration of glycopyrrolate and the criteria for referral to the tertiary saliva control service.
53:27
Glycopyrrolate can be given orally or through a gastrostomy tube.
Referral to the tertiary saliva control service is recommended when the healthcare provider is uncomfortable with managing the case.
The service accepts referrals from general practitioners, pediatricians, and ENT specialists for a second opinion and support.
Botulinum toxin injections for drooling should not be done more often than every three months, and in some cases, the effect can last up to six to nine months.
The speaker has experience in using botulinum toxin injections for children as young as 18 months, but with clear parental consent and documentation.
💫 FAQs about This YouTube Video

1. What are the main challenges and consequences of saliva control difficulties in children with neurodisabilities?

Children with neurodisabilities may experience challenges with saliva control, leading to medical and social consequences such as skin breakdown, irritation, and problems with seizure control. These difficulties can also affect the child's quality of life and result in social isolation.

2. How is the assessment of saliva control difficulties in children with neurodisabilities conducted?

The assessment of saliva control difficulties in children with neurodisabilities involves the evaluation of neurological and clinical factors, including head and trunk position, oral health, and dentition. The safety of swallow is also carefully considered by the speech and language therapy team.

3. What treatment options are available for managing saliva control difficulties in children with neurodisabilities?

There are various treatment options for managing saliva control difficulties in children with neurodisabilities, including anticholinergic medications, behavioral treatments, and conservative measures. In some cases, botulinum toxin injections may be considered to reduce the frequency and severity of saliva control.

4. How are botulinum toxin injections used to manage drooling in children with profound neurological disabilities?

Botulinum toxin injections are used to manage drooling in children with profound neurological disabilities, such as those with cerebral palsy, by targeting the salivary glands to reduce excessive saliva production. This treatment is particularly beneficial for children who have difficulty swallowing and managing their saliva due to their neurological condition.

5. What are the key considerations when using botulinum toxin injections to treat drooling in children with profound neurological disabilities?

The key considerations when using botulinum toxin injections to treat drooling in children with profound neurological disabilities include the need for careful dosing and administration to prevent potential side effects, the use of ultrasound guidance to ensure the injections are targeted effectively, and the importance of a multidisciplinary approach involving speech and language therapists and ENT specialists.

6. How do botulinum toxin injections improve the quality of life for children with profound neurological disabilities?

Botulinum toxin injections can significantly improve the quality of life for children with profound neurological disabilities by reducing drooling, which can lead to enhanced social interaction, decreased risk of skin irritation, and improved comfort and confidence for the child and their family in daily activities and public settings.

7. What is the duration of the effect of botulinum toxin injections for managing drooling in children with profound neurological disabilities?

The duration of the effect of botulinum toxin injections for managing drooling in children with profound neurological disabilities varies but is generally observed to last for several months, with some children experiencing benefits for up to 18 months. The injections may need to be repeated periodically to maintain their effectiveness.

8. When is referral to a tertiary saliva control service recommended for children with profound neurological disabilities experiencing drooling?

Referral to a tertiary saliva control service is recommended for children with profound neurological disabilities experiencing drooling when healthcare providers are uncomfortable with managing the treatment or when a second opinion and specialized support are needed. The referral allows for a comprehensive evaluation and tailored treatment plan by experts in saliva control.