Management of pediatric sialorrhea: A systematic review with a stepwise evidence-based clinical algorithm

Pediatric sialorrhea, or pathological drooling beyond early childhood, is commonly associated with neurological and motor impairments, particularly cerebral palsy. It can cause significant physical, psychosocial, and caregiver burden. Despite multiple treatment modalities, management remains inconsistent, with no universally accepted guideline for assessment or treatment sequencing.

To evaluate current interventions and develop a practical, evidence-based, stepwise clinical management algorithm.

A PRISMA-guided systematic review was conducted. Medline, PubMed, Scopus, OVID, CENTRAL, and other databases were searched for studies reporting management strategies for pediatric sialorrhea. Randomized controlled trials were included for non-surgical interventions, while all study designs were considered for surgical management. Outcomes included drooling severity, frequency, adverse events, and treatment durability. Risk of bias was assessed using Cochrane RoB 2 and MINORS, while the GRADE framework evaluated evidence certainty.

Twenty-two studies encompassing 1028 pediatric participants were included. Interventions were categorized as behavioral/rehabilitative, pharmacologic, botulinum toxin, and surgical therapies. Behavioral therapies, particularly oral motor therapy, produced modest short-term improvements in drooling severity and frequency (low-to-moderate certainty). Pharmacologic agents, primarily anticholinergics, demonstrated medium-term efficacy but were limited by systemic side effects (moderate certainty). Botulinum toxin injections offered reversible, short-to medium-term reductions (low certainty), while surgical interventions provided the most durable benefit in severe or refractory cases (moderate certainty). A stepwise, severity-informed algorithm was developed, integrating initial risk stratification, escalation principles, and multidisciplinary collaboration.

Pediatric sialorrhea requires a structured, individualized approach. The proposed algorithm provides a stepwise management framework, emphasizes early conservative measures, and reserves invasive interventions for severe or refractory cases. Prospective validation is needed.