Today’s “Got Questions?” answer is by behavior analyst Kara Reagon, Autism Speaks associate director for dissemination science.
Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional.
Everybody drools – at least to start. Typically developing infants start to gain control of their swallowing and mouth muscles between 18 and 24 months of age. But it’s common for children with developmental disorders to drool excessively and for longer than is typical with other children. This includes children with autism, many of whom have delays and difficulties with muscle control and sensitivity.
What causes excessive drooling?
Typically, drooling involves low muscle tone, a lack of sensitivity around the lips and face, difficulty swallowing and/or excessive production of saliva. A variety of neurological and attention deficits can contribute to these issues – as is often the case among children – and sometimes adults – who have autism.
You are right to be concerned. Drooling becomes socially stigmatizing when it continues beyond infancy. It’s also unhygienic – an important issue as your son enters group settings such as preschool.
That said, drooling in some situations – for instance, while sleeping – is generally harmless unless it’s so excessive that your child is inhaling saliva.
So let’s focus on your son’s tendency to drool during the day.
Evaluation and treatment options
First, it’s important to discuss your son’s drooling with his pediatrician or a pediatric ear-nose-throat specialist to address or rule out serious underlying medical conditions. This will likely involve an examination of his tonsils, sinuses, and salivary glands. Also, certain medications can worsen drooling – another issue to discuss with your son’s doctor. In addition, the doctor should evaluate whether your son’s drooling is resulting in his inhaling saliva into his lungs – putting him at risk for pneumonia.
Treatment options should be tailored to your son’s needs and may require further evaluation – for instance by a speech-language pathologist or occupational therapist experienced in oral-sensitivity and muscle tone issues.
Speech and occupational therapists can help your son improve his oral muscle tone, lip closure and swallowing. In some cases, the therapist may suggest a dental appliance or chin cup to assist in lip closure, tongue positioning and swallowing.
It may also help to reduce the amount of acidic foods your son is eating – as they can trigger the production of excessive saliva. But it’s important to work with a dietician before introducing any significant change to your son’s diet – particularly if he’s already a picky eater.
The goals of therapy
Generally drooling can be addressed through occupational and/or speech therapy that focuses on the following:
1. Develop good posture and positioning
Sometimes, poor muscle control of the trunk, neck and head results in the head tilting downward. In this position, saliva tends to pool at the front of the mouth and spill from parted lips. The therapist can help you position your child in ways that encourage proper trunk control and head support.
2. Build oral muscle strength and control.
Therapists use a variety of playful oral-motor exercises to help children build muscle tone around the mouth. For instance, the therapist may have your son practice closing his lips around a straw, spoon or a piece of food and/or practice pronouncing closed-lip speech sounds such as “p,” “b” and “m.” The therapist will show you how to continue these exercises at home, with lots of encouragement in the form of praise and/or small rewards.
3. Increase oral sensitivity. Similarly, therapists have a variety of tactile exercises that can help your child develop sensitivity in the lips, tongue, mouth and chin. This includes building awareness of dryness versus wetness – so your child becomes aware when he’s drooling. Playful oral-sensitivity exercises can include blowing bubbles, making exaggerated sounds involving the lips such as “oooo,” “eeee” and “puh-puh-puh.” Again the therapist will give you guidance on how to practice these exercises at home.
4. Practice proper chewing and swallowing. Does your child drool excessively while eating? If so, you and the therapist can work with your child to master the steps of proper chewing and swallowing. It’s helpful to practice these exercises when your child is hungry enough to enjoy a snack but not ravenous. In general, the therapist will show you how to model, or exaggerate, appropriate chewing motions (closing the teeth and then the lips, etc.) and encourage your child to do the same. It can help to give your son a hand-held mirror so he can watch himself perform these steps. As always, remember to encourage and praise, as in:
“That’s great. You’re chewing your cracker. Awesome, you swallowed the cracker! Good eating.”
5. Practice wiping with a napkin or handkerchief. While your child is learning to become aware of wetness on his face, it’s important to encourage the socially appropriate practice of wiping with a napkin or handkerchief. For mealtimes, I suggest teaching him the habit of “wipe, wipe, swallow” – wiping one side of the mouth and then the other before swallowing. Consider attaching the napkin to a wristband during meals to encourage this habit.
You mention that your son drools continuously. So you’ll also want to teach him the habit of wiping with a handkerchief when not at the dinner table. This includes helping him learn to keep a clean handkerchief handy in a pocket. Another option is have your son wear wrist sweatbands and encourage him to use them to wipe each side of his face regularly.
Both at the dinner table and away, you’ll want to cue your child – perhaps by properly wiping your own mouth – when you see him drooling.
6. Put it all together with rewards.
Be sure to create a reward system to reinforce each step your child takes with chewing, swallowing, wiping and most importantly keeping a clean, dry face. At age 3, you may want to keep this simple – with lots of praise and small rewards. But your son may be old enough to enjoy a token system that involves earning larger rewards such as a favorite activity with you.
One of my favorite resources is How to Stop Drooling, by speech-language pathologist Pam Marshalla.
What is drooling?
Drooling is defined as saliva flowing outside of your mouth unintentionally. It’s often a result of weak or underdeveloped muscles around your mouth, or having too much saliva.
The glands that make your saliva are called the salivary glands. You have six of these glands, located on the bottom of your mouth, in your cheeks, and near your front teeth. These glands typically make 2 to 4 pints of saliva a day. When these glands make too much saliva, you may experience drooling.
Drooling is normal in the first two years of life. Infants don’t often develop full control of swallowing and the muscles of the mouth until they are between 18 and 24 months old. Babies might also drool when they’re teething.
Drooling is also normal during sleep.
Drooling can occur in people who have other medical conditions or neurological conditions, such as cerebral palsy.
Drooling can be a symptom of a medical condition or developmental delay, or a result of taking certain medications. Anything that leads to excessive saliva production, difficulty swallowing, or problems with muscle control may lead to drooling.
Age
Drooling begins after birth and peaks between three and six months as infants become more active. This is normal, especially when going through the teething process.
Diet
Diets high in acidic content often cause excessive saliva production.
Neurological disorders
Certain medical conditions can put you at risk for drooling, particularly if they cause a loss of control of facial muscles. Neurologic conditions, such as cerebral palsy, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), or stroke may cause muscle weakness that affects the ability to close the mouth and swallow saliva.
Other conditions
Drooling is usually caused by excess saliva in the mouth. Medical conditions such as acid reflux and pregnancy can increase saliva production. Allergies, tumors, and above-the-neck infections such as strep throat, tonsil infection, and sinusitis can all impair swallowing.
Drooling isn’t always treated. Doctors usually won’t recommend any treatment for someone under the age of 4 or who drools during sleep.
Treatment may be recommended when drooling is severe. Drooling may be considered severe if saliva drips from your lip to your clothing or your drooling interferes with your daily activities and creates social problems.
Excessive drooling can also lead to inhaling saliva into the lungs, which can cause pneumonia.
Treatment options are looked at on a case-by-case basis, but generally your doctor will perform an assessment and come up with the management plan that works best for you.
The noninvasive approach includes trying things such as medication and oral motor therapy. In more serious cases, you and your doctor may consider a more invasive approach, including treatment options such as surgery and radiotherapy.
Therapy
Speech and occupational therapists teach positioning and posture control to help improve lip closure and swallowing. Your therapist will work with you on improving muscle tone and saliva control.
Therapists may also suggest that you see a dietitian to modify the amount of acidic foods in your diet.
Appliance or dental device
A special device placed in the mouth helps with lip closure during swallowing. An oral prosthetic device, such as a chin cup or dental appliances, may help with lip closure as well as tongue position and swallowing. This option works best if you have some swallowing control.
Medications
Certain medications help reduce saliva production. These include:
- Scopolamine (Transderm Scop), which comes as a patch and is placed on your skin to deliver the medication slowly throughout the day. Each patch lasts for 72 hours.
- Glycopyrrolate (Robinul), which is given as an injection or in the form of a pill. This medication decreases your saliva production but can cause dry mouth as a result.
- Atropine sulfate, given as drops in the mouth. This is usually used for people during end-of-life care.
Botox injections
Botox injections may help reduce symptoms of drooling by tightening facial muscles.
Surgical treatment
Several procedures are approved for the treatment of drooling. The most common reroutes the salivary ducts to the back of the mouth to prevent drooling outside of the mouth. Another procedure removes your salivary glands completely.
In children, drooling is a normal part of development. But if you notice excessive drooling or have any other concerns, consult your child’s doctor.
There are many medical conditions that cause drooling, so you should consult your doctor if you notice that you’re drooling excessively or uncontrollably. Many problems can be easily controlled with therapy or medication, but some conditions may require more serious treatment and highlight a more serious medical condition.
Following a healthy diet and listening to your body can help to alleviate some problems. For anything serious, your doctor can help you develop a treatment plan.