Sialorrhea In Children Research Articles

Management of paediatric sialorrhea

Purpose of review To summarize current understanding of and recent literature on the management of sialorrhea in children. Recent findings Sialorrhea is a symptom of oropharyngeal dysphagia and reduced clearance. Sialorrhea can be anterior, with forward overflow of saliva, causing skin rash, social embarrassment and spillage on communication devices; or posterior, where there is pharyngeal pooling of saliva, which may cause aspiration. Assessment of sialorrhea involves a clinical evaluation, focusing on the individual's age, development, underlying medical condition and whether the sialorrhea is anterior, posterior or both. Craniomaxillofacial structure, posture, airway patency, neuromotor control, level of social awareness, motivation and caregiver concerns are assessed. To manage sialorrhea, integration of multiple strategies is usually needed. There is good evidence for behavioral intervention, oral appliances, anticholinergic medications, botulinum toxin injection and surgery. The role of various options of surgery in providing a longer lasting effect is supported. Adjunctive airway and craniomaxillofacial surgery may be indicated. Summary Sialorrhea is a modifiable condition with multifactorial causes requiring multimodal therapy by an inter-disciplinary team. There is increasing evidence on the role of saliva surgery in improving the quality of life for the person with sialorrhea and their caregivers.

Does injection of botulinum toxin to salivary glands require ultrasound guidance?

IntroductionInjection of botulinum toxin into salivary glands is a well-established treatment for sialorrhea in children, but the absolute need for radiological guidance has not been tested. MethodsSingle-centre study in which clinicians of varying seniority attempted blind injection of salivary glands, after which their position within or outside the gland was confirmed by ultrasound guidance before the injection is administered. Results117 patients underwent botulinum toxin of salivary glands between November 2008 and August 2023, with 459 glands injected in total. 24 (5 %) glands were injected by medical students, 32 (7 %) by junior trainees (foundation doctors or senior house officers), 343 (75 %) by registrars or senior fellows and 36 (8 %) by consultants. 160 (68 %) of injections to the parotid gland were on target, and 74 (32 %) submandibular gland were on target (P < 0.01). No differences were detected on likelihood of success depending on seniority of practitioner, age of patient or hand dominance. ConclusionUltrasound guidance ought to be recommended for injection of botulinum toxin into salivary glands regardless of the seniority of the practitioner.

Ultrasound-guided botulinum toxin injections of salivary glands in cerebral palsy children with sialorrhea

Objective: Excessive salivation and drooling are distressing problems that affect both children and their families. Salivary gland botulinum toxin injection is a widely studied therapeutic method for treating sialorrhea. The proper protocol for such treatment modality is an area of interest for researchers. This study set out to assess the success of ultrasound-guided botulinum toxin injections in either the submandibular or combined with parotid salivary glands for children with cerebral palsy suffering from sialorrhea, while also identifying factors that predict a positive treatment outcome. Method: This cross-sectional study included 30 children with cerebral palsy who have Sialorrhea. Ultrasound-guided botulinum toxin injections of submandibular salivary glands alone or combined with parotid glands were done. Drooling was evaluated using Drooling Rating Scale, Drooling Impact Scale, and 5-minute Drooling Quotient. Children were followed up weekly for 12 weeks after botulinum toxin injections. Result: All children showed a significant decline in drooling and sufficient caregivers’ satisfaction for the first 8 weeks after botulinum toxin injections, with gradual worsening of drooling later in 60% of children. Assessment scores were significantly lower in those who received combined parotid and submandibular injections than those who received submandibular gland injections alone. Changes in drooling scores have a significant negative correlation with the severity of motor disabilities. Conclusion: Submandibular salivary gland injection alone has a satisfactory response in decreasing drooling in children with cerebral palsy. However, a combined injection of both parotid and submandibular salivary glands gives a better response for at least 8 weeks without complications. This study not only addresses the clinical effectiveness of botulinum toxin injections in managing sialorrhea in children with cerebral palsy but also opens avenues for improved dietary strategies. Keywords: botulinum toxin; salivary gland; sialorrhea; cerebral palsy

Comparing botulinum toxin and 4-duct ligation for Sialorrhea in children — A systematic review

IntroductionSialorrhea or drooling can result in physical and psychosocial complications, such as aspiration and social isolation. Treatment options include botulinum toxin into the salivary glands and 4-duct ligation (i.e., simultaneous ligation of the bilateral parotid and submandibular ducts). This systematic review aimed to compare the efficacy and complication rates of botulinum toxin and 4-duct ligation for the treatment of drooling in children. MethodsFollowing PRISMA guidelines, PubMed, Embase, Web of Science, and Cochrane Library were searched from inception through June 17, 2021 for studies examining the efficacy of botulinum toxin or 4-duct ligation for drooling in children. Data were summarized by pooled counts, percentages, and means. Complication rates were compared by a chi-squared test. ResultsA total of 22 studies (n = 606) examining botulinum toxin and 5 studies (n = 124) examining 4-duct ligation were included. From 12 botulinum toxin studies (n = 211), mean drooling frequency and severity scores was 7.5 at baseline. Mean difference from baseline was −2.6 (n = 92) at 4 weeks follow-up, −2.1 at 8 weeks (n = 41), −2.1 at 12 weeks (n = 56), and − 2.1 at 16 weeks (n = 58). From 4 4-duct ligation studies (n = 103), mean baseline drooling frequency and severity score was 8.4. Mean difference was −3.7 at mean follow-up of 35.6 months (n = 103). Eighteen botulinum studies (n = 343) recorded 53 (15.5 %) complications, including thickened saliva (n = 9), dysphagia (n = 4), and cheek abscesses (n = 4). Four 4-duct ligation studies (n = 108) recorded 25 (23.1 %) complications, including parotid gland swelling (n = 4), aspiration pneumonia (n = 3), and oxygen desaturation (n = 3). There was no statistically significant difference in complication rates between botulinum toxin and four-duct ligation (p = 0.065). ConclusionBotulinum toxin injection and 4-duct ligation are both effective in improving sialorrhea in children and have comparable complication rates.

Examining the Role of Sublingual Atropine for the Treatment of Sialorrhea in Patients with Neurodevelopmental Disabilities: A Retrospective Review.

Sialorrhea is common in children with neurodevelopmental disabilities (NDD) and is reported in >40% of children with cerebral palsy (CP). It causes a range of complications, including significant respiratory morbidity. This single-center retrospective chart review aims to document sublingual atropine (SLA) utilization to guide further study in establishing its role in secretion management for children with NDD. A chart review was completed for patients with NDD ≤ 22 years of age treated with SLA at a free-standing children's hospital between 1 January 2016 and 1 June 2021. Descriptive statistics were generated to summarize findings. In total, 190 patients were identified, of which 178 met inclusion criteria. The average starting dose for SLA was 1.5 mg/day, or 0.09 mg/kg/day when adjusted for patient weight. Eighty-nine (50%) patients were prescribed SLA first line for secretion management while 85 (48%) patients tried glycopyrrolate prior to SLA. SLA was used after salivary Botox, ablation, and/or surgery in 16 (9%) patients. This study investigates SLA as a potential pharmacologic agent to treat sialorrhea in children with NDD. We identify a range of prescribing patterns regarding dosing, schedule, and place in therapy, highlighting the need for further evidence to support and guide its safe and efficacious use.

Long-term efficacy of glycopyrrolate on sialorrhea in Goldenhar syndrome: a case report

BackgroundGoldenhar syndrome (GS) is a rare congenital disease characterized by impaired development of different facial structures and deformations of the teeth structures. Sialorrhea, which can cause difficulties in breathing and language impairment, is very common in GS and often difficult to treat. This case report highlights the short- and long-term importance of the therapeutic choice – glycopyrronium in oral solution - for the treatment of sialorrhea in children with poly-malformative syndrome, complicated by outcomes of post-hemorrhagic hydrocephalus.Case presentationWe report the case of a 6-year-old child with GS, carrying a percutaneous endoscopic gastrostomy after tracheostomy. The child also presented developmental dysfunction of oral motor skills of feeding, complicated by severe sialorrhea, related to the maxillo-facial dysmorphism. Sialorrhea caused several respiratory tract infections and led to an increase in the care burden. Both the inoculations of botulinum toxin and the treatment with scopolamine transdermal patch have shown mild and transient efficacy. The therapeutic choice of glycopyrronium in oral solution was the most suitable for this patient, leading to long-term sialorrhea control.ConclusionsThis clinical experience represents the first long-term efficacy and tolerability evaluation in using glycopyrrolate oral solution in treating drooling in children with GS. The reduction of drooling over time and the lack of clinically relevant adverse events have contributed to the decrease of respiratory tract infections, the development of oral motor skills, and determining a positive psycho-social impact on the patient's quality of life and her family.

Current Aspects of Treatment Options of Chronic Sialorrhea in Children.

Current Aspects of Treatment Options of Chronic Sialorrhea in Children.

A critical review of incobotulinumtoxinA in the treatment of chronic sialorrhea in pediatric patients

Introduction Sialorrhea, also known as hypersalivation, ptyalis or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients. Areas covered This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed. Expert opinion IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea.

Treatment of sialorrhea with botulinum toxin A injection in children.

We aimed to evaluate the effectivity and safety of botulinum toxin A (BT-A) to reduce sialorrhea in children with hypersalivation due to neurological diseases. Patients who had a complaint of severe sialorrhea were included in the study. Drooling severity of the patients was evaluated using the classification of Thomas-Stonell and Greenberg. The frequency of aspiration before and after the procedure was recorded. The 24-hour saliva amount and mean duration of two consecutive aspirations were recorded. BT-A was injected into the bilateral parotid and submandibular glands by a otorhinolaryngologist under the guidance of ultrasound guidance (USG). When patients' mean drooling severity scores, drooling frequency scores, mean duration of two consecutive aspirations, and amount of saliva collected before and after procedure were compared, a statistical significance was observed. One-year hospital records before after and injection were examined and it was observed that after BT-A injection, hospital visits were statistically significantly low (P = 0.017). BT-A injection into salivary glands is well tolerated, is minimally invasive, has low complication rates and should be performed into both parotid and submandibular glands under USG. Although there is still no consensus on the ideal dose and frequency of injections, it is thought that a dose of 1U/kg/gland can be used with safety in pediatric age groups and the dimensions of the salivary glands and quantitative measurements of the amount of saliva should be utilized. Larger studies involving more patients are required in order to constitute a standard injection protocol.

Anticholinergic treatment for sialorrhea in children: A systematic review.

Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious. To examine the effectiveness of anticholinergic medications for sialorrhea in children. A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized. The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis. Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.

Management of sialorrhea in children

Management of sialorrhea in children

Treatment of sialorrhoea with repeated ultrasound-guided injections of botulinum toxin A into the parotid and submandibular glands

Botulinum toxin injections are useful in patients with refractory sialorrhoea although the optimum treatment protocol and its efficacy over a long period of follow up are controversial. The aim of our prospective study was to examine the efficacy and complications of a protocol of repeated ultrasound-guided botulinum toxin injections of fixed doses at a tertiary children’s hospital. A total of 79 procedures were done in 34 patients who were followed up for two years. The overall complication rate was 3%. The outcome measures considered included the Drooling Frequency Severity Scale (DFSS), visual analogue scale (VAS), and carers’ assessments of the reduction in drooling. Our study highlighted two types on non-responders (primary and secondary) of which 3/34 required definitive surgical management. In summary, this study shows that a protocol of repeated injections of fixed doses of botulinum toxin A, while not beneficial in all cases, is a potentially valuable option for the safe and effective treatment of sialorrhoea in children.

Botulinum toxin treatment of sialorrhea in children

Botulinum toxin treatment of sialorrhea in children

Botulinum toxin type A in the treatment of sialorrhea - Our experience

Sialorrhea consists of an involuntary loss of saliva, and is considered pathological after 4YO. The aim of this study is to describe our methodology and evaluate the efficacy and safety of Botulinum Toxin Type A (BTX-A) in sialorrhea in children and adults with cerebral palsy (CP) or cognitive deficit, referenced to PMR consultation between 2002–2017. Longitudinal descriptive study with clinical records analysis and consultation of drooling rate scale (DRS) and teacher drool scale (TDS) prior to BTX-A injections and 1-month after. Injection of BTX-A performed with ultrasound and sedation. Total of 104 patients, 86 patients selected, 32 female (37.21%), 54 male (62.79%), current ages 7–29YO (mean 18), age of the 1st application 3–22YO (mean 9.76), age of last application 4–23YO (mean 11.83). Fifty patients (58.14%) diagnosed with CP. Two hundred and three total applications (average 2.36), maximum 10 applications. Parotids (55.56%), submandibular (9.09%) or both (35.35%), mean periodicity of 11.81 months. Sedation: 49.38% midazolam, 41.36% nitrogen protoxide, 0.62% Chloral-Hydrate and 8.64% without. Surveys: mean pre-application-DRS of 33.98 (minimum 19, maximum 58), mean post-application-DRS of 28.46 (min 15, max 54), with P = 6.48–5, average difference 4.28 points in DRS (min −27, max 22). Mean pre-application-TDS of 4.04 (min 2, max 5), mean post-applicantion-TDS of 3.38 (min 1, max 4), with P = 2.80–5, average difference of 0.69 points in TDS (min −1, max 3). Difference in DRS and TDS of 0.76 and 0.24 respectively in the parotids, 6.33 and 0.83 in the submandibular and 8.52 and 1.43 in both. Improvements were statistically significant. Surgery: 6 (6.98%). Side effects: 5 children (5.81%) insomnia/vomiting. No complications related to the administration technique. The application of BTX-A in the treatment of sialorrhea is a safe, easy-to-apply technique, with statistically significant improvement in QoL and severity. Benefit in the application of BTX-A in both glands treatment is shown.

Botulinum toxin type A in the treatment of sialorrhea - Our experience

Sialorrhea consists of an involuntary loss of saliva, and is considered pathological after 4YO. The aim of this study is to describe our methodology and evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in sialorrhea in children and adults with cerebral palsy (CP) or cognitive deficit, referenced to PMR consultation between 2002–2017. Longitudinal descriptive study with clinical records analysis and consultation of Drooling Rate Scale (DRS) and Teacher Drool Scale (TDS) prior to BTX-A injections and 1-month after. Injection of BTX-A performed with ultrasound and sedation. Total of 104 patients, 86 patients selected, 32 female (37.21%), 54 male (62.79%), current ages 7–29YO (mean 18), age of the 1st application 3–22YO (mean 9.76), age of last application 4–23YO (mean 11.83). Fifty patients (58.14%) diagnosed with CP. Two hundred and three total applications (average 2.36), maximum 10 applications. Parotids (55.56%), submandibular (9.09%) or both (35.35%), mean periodicity of 11.81 months. Sedation: 49.38% midazolam, 41.36% nitrogen protoxide, 0.62% chloral-hydrate and 8.64% without. Surveys: mean pre-application-DRS of 33.98 (minimum 19, maximum 58), mean post-application-DRS of 28.46 (min 15, max 54), with P = 6.48–5, average difference 4.28 points in DRS (min −27, max 22). Mean pre-application-TDS of 4.04 (min 2, max 5), mean post-applicantion-TDS of 3.38 (min 1, max 4), with P = 2.80–5, an average difference of 0.69 points in TDS (min −1, max 3). Difference in DRS and TDS of 0.76 and 0.24 respectively in the parotids, 6.33 and 0.83 in the submandibular and 8.52 and 1.43 in both. Improvements were statistically significant. Surgery: 6 (6.98%). Side effects: 5 children (5.81%) insomnia/vomiting. No complications related to the administration technique. The application of BTX-A in the treatment of sialorrhea is a safe, easy-to-apply technique, with statistically significant improvement in QoL and severity. Benefit in the application of BTX-A in both glands treatment is shown.

Sialorrhea in children with cerebral palsy

ObjectiveTo review the literature on sialorrhea in children with cerebral palsy. Source of dataNon‐systematic review using the keywords “sialorrhea” and “child” carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed. Data synthesisThe prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment. ConclusionsThe most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.

Botulinum toxin injections for chronic sialorrhoea in children are effective regardless of the degree of neurological dysfunction: A single tertiary institution experience

ObjectiveTo determine the effectiveness of submandibular salivary gland Botulinum Toxin Type-A (BTX-A) injection in the treatment of drooling in children with varying degrees of neurological dysfunction. MethodsA retrospective review of pre- and post-procedure drooling frequency and severity scores of patients receiving BTX-A between January 2008 and January 2013. Stratification to different subgroups of neurological impairment was performed according to Gross Motor Function Classification System (GMFCS) score. Drooling severity was assessed using Thomas-Stonell and Greenberg symptom questionnaires administered at time of initial consultation and 3 months after treatment. Results48 sets of BTX-A injections in 26 patients with an average age of 9.45 years (range 7 months–18 years) were included in the study. Marked improvement in drooling was seen in 60.4% of patients, a marginal or brief improvement was seen in 20.8% and there was no improvement in 18.8%. No adverse events were reported following any of the BTX-A injections. BTX-A was safe and effective in the eight patients with pre-existing swallowing dysfunction. Subsequent drooling surgery was performed in 15 (57.7%) of the cohort, all 15 patients responded to BTX-A injections.In patients with Cerebral Palsy, there was no correlation between the severity of the neurological dysfunction as measured by the Gross Motor Function Classification System (GMFCS) score and the response to BTX-A treatment. ConclusionsInjection of BTX-A to the submandibular glands of children with neurological disorders is a safe procedure and results in a reduction in drooling in the majority of patients. Children with severe neurological dysfunction respond to BTX-A injections as effectively as their less impaired peers and the degree of response does not appear to be associated with the severity of neurological disability. BTX-A injection is a good initial procedure when drooling surgery is being considered.

Sialorrhea in children with cerebral palsy

ObjectiveTo review the literature on sialorrhea in children with cerebral palsy. Source of dataNon-systematic review using the keywords “sialorrhea” and “child” carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed. Data synthesisThe prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment. ConclusionsThe most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.

Four-Duct Ligation for the Treatment of Sialorrhea in Children.

The 4-duct ligation procedure has appeal for its surgical simplicity and limited invasiveness in the management of pediatric sialorrhea. However, more information is required to understand the benefits, risks, success rates, and long-term effects of this intervention. To report the clinical outcomes of the 4-duct ligation procedure in pediatric patients diagnosed as having sialorrhea and the associated complication rates and to characterize patient and caregiver satisfaction in a consecutive series. This investigation was a retrospective cohort study at an academic tertiary pediatric center and pediatric rehabilitation hospital. Patients included 38 children with neurological impairment who underwent a 4-duct salivary gland ligation (parotid and submandibular glands) between January 1, 2004, and July 31, 2012. The dates of the analysis were August 2013 through February 2015. Posttreatment assessments included duration of effect, severity and frequency of drooling before and after the procedure, patient complications, caregiver satisfaction, caregiver recommendation of the procedure, and caregiver overall assessment of the child's quality of life. Clinical and outcome measures were collected before the procedure, 1 month after the procedure, 1 year after the procedure, and at the most recent follow-up (range, 3-8 years). The study cohort comprised 38 participants. Their median age was 11 years (age range, 5-17 years), and 37% (14 of 38) were female. The mean (SD) duration of effect was 52.6 (20.4) months. Patients with previous sialorrhea management were more likely to demonstrate an improvement in their drooling frequency score at 1 year. Thirteen complications were documented in 12 patients. The most common complications were persistent facial swelling and aspiration pneumonia. Eighty percent (28 of 35) of caregivers reported an improvement in their child's drooling at 1 month, while 69% (25 of 36) and 71% (24 of 34) stated that there was an improvement at the 1-year follow-up and the most recent follow-up, respectively. The 4-duct ligation procedure offers a simple, effective, and minimally invasive approach to the management of sialorrhea in children.

Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital

BackgroundSialorrhea is problematic for neurologically impaired children, and botulinum toxin A salivary gland injection has been reported as effective in reducing sialorrhea. This article assesses the success and safety of ultrasound-guided weight-based botulinum toxin A injection for the management of sialorrhea in children. MethodsA total of 111 patients (63 males; 48 females; average age 7 years) with refractory sialorrhea were treated with ultrasound-guided botulinum toxin type A salivary gland injections (144 procedures) from July 1, 2004, to July 1, 2014, using a single weight-based protocol. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data were compared with reported effectiveness and complications using odds ratios. ResultsA total of 144 procedures were performed in 111 patients with refractory sialorrhea. Cerebral palsy was the most common underlying etiology for sialorrhea (29%), whereas others included encephalopathy (5%), anoxic brain injury (4%), and a variety of chromosomal anomalies (5%). There was a 100% technical success rate. Overall treatment effectiveness was 68%. Repeat injections were not associated with increased clinical success. No procedure-related deaths or major complications were identified; the minor complication rate was less than 2%. ConclusionsThe protocol used for ultrasound-guided injection of botulinum toxin A proved to be safe and effective in children suffering from sialorrhea. Image guidance technique may lead to a reduction in rates of adverse events reported in other series. Subsequent procedures do not improve upon initial efficacy.