Question & Answer - Oral Sensory-Motor, Myofunctional, Vocal Tract, & Airway Information
What can I do for a 7-year-old child with cri-du-chat syndrome whose biggest problem is drooling?Angela Rivera, MS, CCC-SLP, TSSLD from New York City
Question from Angela Rivera, MS, CCC-SLP, TSSLD, firstname.lastname@example.org. Permission granted to publish name and email.
What can I do for a 7-year-old child with cri-du-chat syndrome whose biggest problem is drooling? He can process simple commands and speak using at least 3-word sentences.
Answer by Diane Bahr, MS, CCC-SLP, CIMI
Angela, this is a great question! When I teach my courses on feeding, motor speech, and mouth development/function, most participants raise their hands when I ask, “Who works with children who drool?” Many children with whom we work seem to have this problem. Therefore, I am going to talk about how to treat drooling overall, as well as specifically with a child who has cri-du-chat syndrome.
Drooling and Development
Let’s begin by discussing drooling with regard to development. Profuse drooling is never normal or typical. When children learn motor skills and teethe before the age of two-years (Bahr, 2010, pp. 115-119), parents usually see a mild amount of drooling (which I like to call “dribbling”). Once the child has all of his or her primary teeth (around the age of 2-years), drooling or “dribbling” should stop.
If a child’s shirt is constantly or frequently wet, I would consider this profuse or atypical drooling. Atypical drooling is often seen in children with developmental disabilities (e.g., those with cri-du-chat syndrome, Down syndrome, cerebral palsy, etc.). It is best to begin oral sensory-motor work during the birth to 2-year period with children who drool profusely if possible.
When working with a child (of any age) who has atypical drooling, parents and therapists need to consider four aspects of mouth function that may contribute to it (Bahr, 2010, pp. 120-121). Each aspect is discussed in the following sections.
Nasal, Sinus, and Other Upper Airway Problems
Nasal, sinus, or other upper airway concerns need to be addressed in a proactive, ongoing manner in someone who drools. Anyone who can’t breathe consistently through the nose will breathe through the mouth. Mouth-breathing (which is unhealthy for many reasons, Bahr, 2010, pp. 54-56) frequently leads to excessive saliva pooling within the mouth which in turn can lead to drooling.
Children who cannot nose-breathe may have structural problems and/or allergies. For example a high, narrow, hard palate (i.e., roof of the mouth) can impinge upon the nasal and sinus areas making them small and difficult to clear. The upper airway can also become blocked by enlarged tonsils or adenoids. Allergies or sensitivities may cause swelling within the upper airway making it difficult to nose-breathe.
Therefore, it is crucial for a child who cannot breathe through the nose to work with appropriate professionals in an ongoing manner as needed. A pediatric otolaryngologist can address overall nasal and sinus concerns. An orthodontist or functional jaw orthopedist can address palatal expansion. A speech-language pathologist or occupational therapist can help a child establish the habit of nose breathing once airway issues are resolved.
In addition to the possible nasal, sinus, and upper airway concerns we just discussed, children with cri-du-chat syndrome often have underdeveloped lower jaws. An underdeveloped lower jaw may also impinge on the airway because the jaw has not grown appropriately forward (Page, 2003). Therefore, the child may open the mouth to breathe.
Open Mouth Posture
Once nasal, sinus, and other upper airway concerns have been resolved, a child’s open mouth posture requires treatment if he or she has this problem. Ultimately, we want a child to develop the habit of keeping the mouth closed at rest while breathing through the nose. I use systematic jaw work for this aspect of treatment.
In addition to underdeveloped lower jaws, children with cri-du-chat syndrome tend to have low muscle tone in their bodies (US National Library of Medicine, 2014). Children with low muscle tone also tend to have muscle weakness. The lower jaw bone is heavy and requires muscle strength to raise it against the constant force of gravity. Systematic jaw work can assist a child in developing the strength and new habits needed to close the mouth at rest.
I use Chewy Tubes, Grabbers, Y-chews, chewy foods in cheesecloth, etc. along with the concepts of exercise physiology for jaw strengthening (Bahr, 2010, pp. 136-147). I teach parents to facilitate 12-15 solids, graded chews at each of the child’s back molar areas, alternating sides for 3 sets (at least once per day) to help the child appropriately strengthen the jaw. I also have the child practice keeping the jaw closed at rest once the jaw is strong enough to remain closed against the force of gravity. Cues, prompts, and physical support can assist with this process. Jaw work can be done while a parent and child are relaxing and looking at books together, and I encourage parents to do the work along with the child.
Systematic oral massage may be another step (in the process of drooling treatment) if the child does not seem to have the oral awareness needed to sense saliva pooling in the mouth (Bahr, 2010, pp. 125-136; Bahr 2001, pp. 117-119). The sensation of pooling saliva usually helps us initiate a swallow. Like other forms of massage, oral massage can bring blood supply and awareness to the inside of the mouth. This can be particularly useful for children who have low muscle tone and tend to have low oral awareness called hyporesponsivity. Children with cri-du-chat syndrome tend to have low muscle tone and, therefore, likely have low oral awareness. Oral massage can be easily incorporated into a child’s toothbrushing routine (3 times daily).
Swallowing Every 30 Seconds
We typically swallow about every 30 seconds when awake (approximately 2000 times per day). Therefore, we can time a child’s swallows and help him practice swallowing every 30 seconds using a straw or open cup. Parents and others can do this practice with a child for several short periods throughout the day to help establish this swallowing habit. Since your client understands simple commands, you can also use verbal cues to help with this process.
It is also important to evaluate the maturity of a child’s swallow. Any form of a “tongue thrust swallow” is less efficient than a typical oral phase swallow (which begins to be seen around 1-year of age in typically developing children). A straw program such as the one from TalkTools may be incorporated into swallowing practice to begin remediation of a “tongue thrust swallow” and practice the habit of 30-second swallows.
Additionally, children who do not swallow every 30 seconds have an increased risk of gastroesophageal reflux. Frequent swallows reportedly keep reflux from occuring. Reflux has also been linked to upper respiratory issues (e.g., sinus concerns and middle ear problems) due to the reflux traveling into nasal, nasopharynx, and sinus spaces. Therefore, reflux may be a component of a drooling problem. Pediatricians and pediatric gastroenterologists can guide parents in the care of a child's reflux.
While the treatment of drooling is therapeutic in nature, I encourage parents to fit activities into daily family life whenever possible (e.g., jaw work during book reading, oral massage during toothbrushing, straw-drinking during snacks and meals, etc.). I hope this answer will help you and many others who work with children who drool. Thank you again for submitting your question and for networking with us.
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Needham Heights, MA: Allyn & Bacon.
Bahr, D. (2010). Nobody ever told me (or my mother) that! Everything from bottles and breathing to healthy speech development. Arlington, TX: Sensory World.
Page, D. C. (2003). Your jaws – Your life. Baltimore, MD: SmilePage Publications.
US National Library of Medicine. (2014, Feb.). Cri-du-chat syndrome. Retrieved from http://ghr.nlm.nih.gov/condition/cri-du-chat-syndrome.