The proposed algorithm for the assessment and treatment of anterior and posterior drooling in children and youth with neurodevelopmental disabilities is detailed in Fig. 1.

Comprehensive flowchart representing the treatment approach for children and youth with anterior or posterior drooling secondary to neurodevelopmental disabilities

Children with a need for care regarding drooling are referred to our saliva control clinic by a physician. All information guiding treatment decisions is subsequently collected during a baseline assessment when the child, together with their parent(s)/caregiver(s) (referred to as ‘caregivers’ throughout this paper), visits our clinic. The assessment comprises three sequential components.

First, a medical assessment, an evaluation of the child’s learning abilities, self-management skills and social functioning (e.g. interaction with social environment, self-awareness, and response to negative reactions on drooling), and an oral motor assessment are conducted, in line with recommendations [1, 3]. Through these assessments, it is deduced whether the child has anterior drooling, posterior drooling, or both [8], and factors that influence and perpetuate drooling are identified. For example, anterior drooling may be influenced by frequent mouthing behaviour, poor oral health, suboptimal posture, and ear-nose-throat pathology [9]. Additionally, gastro-oesophageal reflux disease or medication use may contribute to excessive salivary flow [8]. In children with posterior drooling, the condition may be negatively influenced by—among other things—a reclined sitting position, poor oral health, compromised respiratory health, and dysmotility of the gastrointestinal tract [4]. This approach is rooted in considering the autonomic nervous system, including the neurological pathways that influence saliva production [8].

Second, the severity, frequency, and impact of drooling are quantified. Anterior drooling is assessed through a combination of (semi-)objective and caregiver-reported measures [3], including the drooling quotient, a verbal numerical rating scale reflecting drooling severity, and the Drooling Severity and Frequency Scale (DSFS). Furthermore, the impact of drooling in daily life is discussed and quantified [5]. This discussion includes an inventory of the child’s social context at home and at school, to estimate the extent to which drooling affects social interaction and well-being, and the extent to which the child and parents/caregivers are able to follow through with recommendations. Caregiver-involvement in these assessments (and child-involvement, if possible) is considered essential, as they hold the key to understanding the true extent of the severity and impact of drooling in daily life. For children up to 4 years old, the Drooling Infants and Pre-schoolers Scale (DRIPS) is administered to quantify the child’s severity and frequency of drooling relative to their typically developing peers.

For posterior drooling, clinical history taking is used to assess saliva aspiration risk, for example with regard to repeated episodes of aspiration pneumonia and need for antibiotics, need for suctioning, deteriorating pulmonary condition, and choking incidents [3]. While no recommendations are available on the (non-invasive) quantification of posterior drooling [3], the assessment in our centre is supplemented by caregiver-reported severity of posterior drooling symptoms and cervical auscultation to assess the pharyngeal phase of swallowing. The presence and severity of posterior drooling can subsequently be quantified using the Paediatric Posterior Drooling Scale (PPDS), a 5-point classification ranging from clear to wet breathing before and after swallowing.

Third, treatment goals are established and child and caregiver preferences for treatment are identified. As a shared decision-making process between caregivers and healthcare professionals, it is discussed whether these goals are attainable. If possible—taking age, cognition, self-awareness and communicative abilities into account—the child is directly involved in this process. Otherwise, caregivers are considered advocates for their child.

During an interdisciplinary consultation, the saliva control team discusses and interprets all information collected at the baseline assessment to reach consensus on a recommended treatment approach. This decision-making process consists of three phases, which are summarised in Table 3 and explained in detail in the Appendix.

First, the team determines whether it is necessary to initiate saliva control treatment, which is generally based on three main characteristics: (1) the type of drooling, (2) the (chronological) age of the child, and (3) the severity, frequency, and impact of drooling.

Second, if saliva control treatment is indicated, the team decides on the most suitable treatment option. This may involve improving the child’s saliva management (e.g. oral sensorimotor training, self-management training), reducing the volume of saliva (e.g. pharmacological treatment, salivary duct ligation, or submandibular gland excision) or rerouting the salivary flow (e.g. submandibular duct relocation). Regardless of which treatment option is decided on, our team recommends intermittent oral sensorimotor therapy as an add-on treatment.

In a third phase, comprehensive (telephone) follow-up is ensured, either to evaluate effectiveness and potential side effects of treatment, or to re-evaluate the need for care and provide additional advice when no saliva control treatment was initiated.