If you have a child who has difficulty managing his or her saliva, you know how difficult this can make day-to-day life. It can cause milder issues such as changing clothes multiple times a day and rashes from constantly wet skin, to more serious issues like aspiration pneumonia and atelectasis.
There are a number of conditions that can cause a child to have severe dysphagia, which is the inability to swallow properly, or at all, resulting in issues with saliva management. Many are neurological, some are structural, but they all lead back to the same issue, which I think most parents with children like mine agree can best be described in one sentence: “How are you making this much and where is it coming from!?”
While it can seem like your child has too much spit, he likely has a normal amount and simply can’t handle it due to swallowing issues. This can often cause respiratory problems from choking to micro-aspiration. Every time your child swallows, but doesn’t manage it properly, there is a risk of inhaling saliva right into the lungs. If your child has no swallow at all, her saliva will pool, and then enter into her lungs. Either way, this spells bad news.
Aspiration pneumonia is one of the more severe complications of dysphagia. This is, of course, pneumonia cause by aspiration or inhaling liquid into the lungs, and it is life threatening. Atelectasis is another complication. It is the complete or partial collapse of a lung or section of a lung and can also be life threatening.
Keeping your child’s lungs healthy can seem like an impossible task sometimes, but there are many, many options out there that can help you achieve this, through secretion management.
I’m going to start with the least invasive management techniques and progress to more medically invasive solutions. Hopefully you can find something that helps!
The first thing to try is changing your child’s positioning. Some kids manage to swallow better in a good positioning chair. Some do best on their bellies or sides so their saliva can drain. See what works for your child. If you have a young infant or an immobile child, make sure to monitor her either visually or with a pulse oximeter or apnea monitor when she is in a position that could compromise the airway.
If your child has some head control and good cognitive function, you may be able to teach him to drop his head down to let the saliva drain, then pick it back up again to protect the airway. As long as you have an abundance of very absorbent cloths or bibs (I recommend good quality pre fold cloth diapers, personally), this can be an excellent solution. I might never have thought to teach my daughter this, but she started doing it on her own at a young age. Unfortunately, she did NOT have good head control so the second part of the solution didn’t work so well. I had to keep pushing her head back for her until she finally gained some head control around age five. Even if you think your child might not understand, give it a shot…you might be surprised!
Speech therapists may know techniques to help your child initiate and follow through on or improve the swallow. Even if your child doesn’t have the ability to speak, speech therapy can benefit him or her. There is also a therapy called VitalStim that might help. It combines neuromuscular electrical stimulation (which is painless) with swallowing exercises to improve a person’s swallow. These therapies don’t always help, but if they are accessible to you, they are worth a try.
You may need to orally or nasally suction out your child’s secretions to help manage them. This won’t completely prevent complications, but it can help considerably. A pulmonary doctor or ENT can assess your child’s needs and order a suction machine if it is necessary. If they don’t feel it’s necessary, but you do, don’t be afraid to push for it or even buy your own if you are able to. Some doctors believe that suctioning can cause a person to secrete more than a normal amount, but if your child’s life is at risk, this should not be considered a valid reason to refuse suctioning. Suctioning your child can seem overwhelming at first, but like everything else, you get the hang of it and it becomes easy and routine.
There are several medications that can decrease the amount of saliva your child has. Robinul is a very popular medication, but some people don’t tolerate it well, because of side effects such as thick saliva and slowed gastric motility.
Scopolamine patches (used for motion sickness/nausea) have the side effect of dry mouth that works well for saliva management. It’s a small patch placed behind the ear that is generally changed every 72 hours. Some people report skin irritation with it. In our case, my daughter had some irritation, but she adjusted to it and the irritation went away, so if the irritation isn’t too severe, it may be worth it to stick it out and see if it goes away.
Another medication that can be used is atropine drops. These drops are normally used to dilate your pupils at eye doctor appointments, but when placed under the tongue (sublingually) they can decrease saliva production. They are used every 4-6 hours as needed.
It is possible to use more than one medication at a time if one doesn’t quite cut it. Ask your child’s doctor about all of your options.
Botox and Surgery
There are some procedures that can help considerably. Botox in the salivary glands every few months can make a big difference for some kids. Surgery to remove or tie off the salivary glands is a more permanent solution. An ENT doctor can help you determine which procedure might be best for your child.
If your child continues to struggle despite your best efforts, a tracheostomy may be something to consider. A trach itself doesn’t prevent saliva issues, but it can make airway management easier. If your child requires BiPAP, a trach will make her more comfortable since she would no longer have to wear a mask on her face. A tracheostomy can seem horribly invasive, and many parents resist the idea, often because they worry it could negatively impact their child’s quality of life, having yet another medical device to deal with. But a trach can actually improve a child’s quality of life considerably. Most parents I’ve talked to who initially resisted the trach and later consented to the surgery only regret not doing it sooner, which is exactly how it happened in our situation.
Aside from saliva management, there are things you can do to help prevent aspiration pneumonia. A good oral care routine can reduce the risk of pneumonia. Aerosol medications generally used to treat asthma, like Albuterol, Pulmicort, Atrovent, and Flovent, can strengthen the lungs and help keep them clear of mucus. Another way to clear your child’s lungs is with chest percussions or an airway clearance system. The general idea is to use a physical motion to shake the mucus in the lungs loose so it can be coughed up. If your child has a poor cough or no cough, a cough assist machine can be helpful. Oxygen therapy, BiPAP, or ventilation can be used if your child doesn’t oxygenate well due to micro-aspiration.
Hopefully this list gives you plenty of ideas to work with. It’s not an entirely comprehensive list, but it covers many of the options available.