Dr.ª Maria Luisa Oliveira

Paediatric Surgeon

Pediatric Surgery for the neurologically compromised child

HPA Magazine 8

Sialorrhoea, also known as drooling, is characterized by the involuntary loss of saliva, either by excessive production or incapacity in swallowing and consequent control.

The situation is considered normal in children up to the age of 2 or 3, but in neurologically compromised infants (NCI) it causes family and social instability.
The efforts to integrate the NCI made by the parents and the whole team of health care providers, as well as school activities, are strongly affected by the drooling.
The most common cause in children and adolescents is cerebral palsy, although other compromising causes of the swallowing function can be involved, such as chromosome disorders, neuromuscular dystrophy and others. It is characterised by the spilling of saliva over the lower lip and neuromuscular dysfunction makes saliva swallowing difficult, even if produced in normal amounts.
Saliva is produced by the major salivary glands (parotid, submandibular and sublingual) and minor salivary glands (present throughout the oral cavity). As the first enzyme of the digestive tract, it contains properties that help maintain oral health, especially dental health.
Drooling therapy consists firstly of training sensory awareness and oral motor skills. In a second phase, or concomitantly with the first, pharmacological therapy with anticholinergics and intra-glandular injection of botulinum toxin may be indicated.
The multidisciplinary approach of these patients is essential not only for their motivation but also for the understanding that the NCI deserves. Parental presence is indispensable in the evaluation of serious cases (wet clothing) and severe (wet clothing, hands and objects). Should these treatments fail, surgery will be the last resource, as the result is definitive. 
Our experience, in terms of the surgical approach, consists of the excision of the submandibular glands, which produce baseline salivation. It requires admission in the day hospital, general anaesthesia and two cervical incisions parallel to the mandibular arch. The complication rate is less than 5% and can be resolved.
The level of short, medium and long term satisfaction of the parents and caregivers has already produced significantly positive results, and proves that we can and should offer these children the possibility of surgical treatment.
Paediatric Surgery is a medical speciality dedicated to the diagnosis and surgical treatment of disease, injuries or deformities from the foetal period until the start of adulthood. Paediatric surgeons integrate on a permanent basis with a wide team of paediatricians and neonatologists, anaesthesiologists, imagiologists and other professionals with vast experience, devoted to treating children and young adults in a paediatric setting. Paediatric surgery is a wide-ranging speciality, which includes the general and neonatal pathology, cancer surgery, general surgery, urology and paediatric gynaecology.