Impact and management of drooling in children with neurological disorders: an Italian Delphi consensus
Authors: Riva Antonella , Amadori Elisabetta , Vari Maria Stella , Spalice Alberto , Belcastro Vincenzo , Viri Maurizio , Capodiferro Donatella , Romeo Antonino , Verrotti Alberto ,   the Delphi panel experts’ group, Aiello Maria Francesca , Bagnasco Irene , Battistella Pier Antonio , Bergamoni Stefania , Boldrini Benedetta , Bratta Pasquale , Brusaferro Andrea , Brusco Mario , Burchiani Beatrice , Burdino Elisa , Cardinali Beatrice , Cassani Morena , Cavalli Elena , Cavallini Anna , Duccio Maria Cordelli , D’agata Gaetano , Di Corcia Giovanna , D’onofrio Gianluca , Fagiolari Giulia , Fattorusso Antonella , Felicioni Matteo , Gaiotti Federica , Galati Cristina , Gasola Luisa , Giaquinto Giuseppina , Gizzi Chiara , Grasso Domenico Leonardo , Isidori Chiara , Marcucci Maria Teresa , Mazzoni Valentina , Mencaroni Elisabetta , Monacelli Gianluca , Nicita Francesco , Orsini Alessandro , Pellegrino Annamaria , Peruzzi Cinzia , Piccolo Gianluca , Pistola Ilaria , Prezioso Giovanni , Pulitano Patrizia , Raieli Vincenzo , Saladino Marina , Sapuppo Annamaria , Sica Rossella , Spagnoli Carlotta , Tagliente Maria , Tascini Giorgia , Terrone Gaetano , Tulli Eleonora , Vinti Valerio , Striano Pasquale 
Published: July 2022

Abstract
Background
The rate of chronic drooling in children older than 4 years is 0.5%, but it rises to 60% in those with neurological disorders. Physical and psychosocial consequences lead to a reduction in the quality of Life (QoL) of affected patients; however, the problem remains under-recognized and under-treated. We conducted an Italian consensus through a modified Delphi survey to discuss the current treatment paradigm of drooling in pediatric patients with neurological disorders.

Methods
After reviewing the literature, a board of 10 experts defined some statements to be administered to a multidisciplinary panel through an online encrypted platform. The answers to the questions were based on a 1–5 Likert scale (1 = strongly disagree; 5 = strongly agree). The scores were grouped into 1–2 (disagreement) and 4–5 (agreement), while 3 was discarded. The consensus was reached when the sum of the disagreement or agreement was ≥75%.

Results
Fifteen statements covered three main topics, namely clinical manifestations and QoL, quantification of drooling, and treatment strategies. All statements reached consensus (≥75% agreement). The 55 Italian experts agreed that drooling should be assessed in all children with complex needs, having a major impact on the QoL. Attention should be paid to investigating posterior hypersalivation, which is often neglected but may lead to important clinical consequences. Given that the severity of drooling fluctuates over time, its management should be guided by the patients’ current needs. Furthermore, the relative lack of validated and universal scales for drooling quantification limits the evaluation of the response to treatment. Finally, the shared therapeutic paradigm is progressive, with conservative treatments preceding the pharmacological ones and reserving surgery only for selected cases.

Conclusion
This study demonstrates the pivotal importance of a multidisciplinary approach to the management of drooling. National experts agree that progressive treatment can reduce the incidence of complications, improve the QoL of patients and caregivers, and save healthcare resources. Finally, this study highlights how the therapeutic strategy should be reconsidered over time according to the available drugs on the market, the progression of symptoms, and the patients’ needs.