When Does the Rash of Roseola Occur?

Patient Presentation
A 12-month-old male came to clinic for a rash. Six days prior he had his health supervision visit where he had received MMR-V, Prevnar and Influenza vaccines. Three days prior he developed a fever to 102° F and was fussy. One day prior he became quite fussy and had decreased oral intake, but his fever stopped. The morning of the clinic visit he woke up with a rash that began on his head and progressed down to his body. He had no history of vaccine reactions, food allergies, or atopia. There were normal bowel movements, with slight decrease in urination, no cough, upper respiratory tract symptoms or localized pharyngitis. He had no difficulty walking. The past medical history was positive for upper respiratory infections and one ear infection. The family history was non-contributory. The social history showed he attended daycare and roseola was circulating in the community.

The pertinent physical exam showed a tired appearing male who was afebrile with normal vital signs and growth parameters in the 75-90%. HEENT revealed moist mucous membranes. There was no conjunctival or pharyngeal injection. Nose and ears were normal. He had shoddy anterior cervical lymph nodes and groin nodes with all < 1.0 cm. Skin showed anerythematous macular-papular rough rash on the body, groin and axilla. It was blanching and non-pruritic. He had no mucositis or joint swelling or pain. The rest of his examination was normal. At this time, the pediatrician's working differential diagnosis included Group A beta-hemolytic streptococcal infection, viral exantham especially roseola, vaccine reaction, Kawasaki Disease (unlikely) and unrecognized food allergy/sensitivity (unlikely). The work-up included a normal rapid strep test and later throat culture for streptococcus. A complete blood count showed a white blood cell count of 5.0 x 1000/mm2 with slight neutropenia. The diagnosis of a viral exantham most likely roseola was made. The patient’s clinical course showed that he had resolution of the rash and other symptoms over the next 1.5 days. Long-term he had no similar reactions with subsequent vaccines.

Discussion
Rashes, particularly ones caused by viruses, are common presenting problems. In his first edition of Pediatrics, Dr. Rotch spent 72 pages describing infectious exanthemata. The cause of the exanthemata was unknown at the time, and thankfully many of those that he wrote of have been eradicated (smallpox), have effective vaccines to prevent (measles, rubella, varicella) or effective antibiotics for treatment (streptococcus).

Dr. Rotch ends his extensive treatise with a table describing “the chief points of differential diagnosis in the exanthemata.” This is what was state-of-the-art in 1896 with his spellings:

  • Variola (Smallpox)
    • Incubation: 12 days
    • Prodromata: 3 days
    • Efflorescence: macules, papules, vesicles, pustules
    • Desquamation: large crusts
    • Complication and sequelae: larynx, lungs
  • Varicella
    • Incubation: 17 days
    • Prodromata: a few hours
    • Efflorescence: vesicles
    • Desquamation: small crusts
    • Complication and sequelae: …..
  • Scarlet Fever
    • Incubation: 4 days
    • Prodromata: 2 days
    • Efflorescence: erythema
    • Desquamation: lamellar
    • Complication and sequelae: kidney, ear heart
  • Measles
    • Incubation: 10 days
    • Prodromata: 3 days
    • Efflorescence: papules
    • Desquamation: furfuraceous
    • Complication and sequelae: eye, lung, tuberculosis
  • Rubella
    • Incubation: 21 days
    • Prodromata: a few hours
    • Efflorescence: papules
    • Desquamation: …..
    • Complication and sequelae: …..

    Learning Point
    Not long after Dr. Rotch’s description, around the turn of the last century, several viral exanthamas were given numbers and therefore some still carry these distinctions (i.e. Fifth’s disease). Below is a comparison of these exanthamas with two additional other common viral exanthamas described today for comparison.

    Common viral exanthamas:

    • 1. Measles (First disease)
      • Etiology: Measles virus (paramyxoviridae family)
      • Description: Erythematous macules and papules that first appears on the lateral and posterior neck, that progresses to involve the face, trunk and extremities (spreading distally). The rash fades in the same direction. Cough, coryza, Koplik spots and fever also occur.
      • Time course: Incubation is 8-12 days. Patients are contagious from 1-2 days before the rash until 4 days after the rash.
    • 2. Scarlet Fever (Second disease)
      • Etiology: Group A, beta-hemolytic streptococcus
      • Description: Erythematous papules that are fine giving a rough, sandpaper feel to the face, trunk and extremities. Begins often in flexural areas and linear petechiae may be seen in the fold. Fever, sore throat, and emesis may also occur.
      • Time course: Incubation 1/2-10 days depending on presentation, but pharyngitis is 1-2 days. Patients are contagious until at least 24 hours after antibiotics are begun.
    • 3. Rubella (Third disease)
      • Etiology: Rubella virus (togaviradae family)
      • Description: Erythematous macules that occur first on the face and then spread to extremities and trunk (spreading distally). The rash fades in the same direction. Fever, posterior cervical lymphadenopathy or arthritis may also occur.
      • Time Course: Post-natally acquired infection incubation is 14-23 days, patients are contagious from 7 days before the rash until 14 days after the rash. Rash generally last 3 days.
    • 4. Duke’s disease (4th disease)
      • No longer a recognized entity
    • 5. Erythema infectiosum (Fifth’s disease)
      • Etiology: Parvovirus B19
      • Description: Lacy, reticulated pink colored rash of trunk or extremities, fades in 3-5 days but can recur with sun exposure, overheating or exercise
      • Time Course: Incubation is 4-21 days, patients are contagious before the onset of the rash.
    • 6. Roseola (Exanthem Subitum, 6th disease)
      • Etiology: Human herpesvirus 6 or echovirus 16
      • Description: Erythematous pink macules on trunk and extremities. The patient has a high fever for 2-3 days, then the fever resolves and the rash begins. Rash fades in 1-2 days.
      • Time Course: Incubation is 9-10 days.
    • Hand Foot and Mouth
      • Etiology: Coxsackievirus A16, other coxsackievirus, echovirus or enterovirus
      • Description: Erythematous papules or intact vesicles on the palms, soles and also buttocks. Small ulcers on the palate, uvula, tonsils and tongue are also seen. Rash resolves in 1 week.
      • Time Course: Incubation is 3-6 days, patients can be contagious for weeks because of fecal shedding.
    • Varicella
      • Etiology: Varicella-zoster virus (herpes virus)
      • Description: Erythematous macular-papular, pruritic lesions that develop a vesicle (“dew drop on a rose petal”). The vesicles rupture and form crust. Lesions occur on the trunk, extremities and head. The lesions appear in new crops over 3-4 days
      • Time Course: Incubation is 10-21 days, patients are contagious until all lesions are crusted over.

    Questions for Further Discussion
    1. What other viral exanthamas can you list?
    2. When can patients return to group settings like school or childcare for the viral exanthamas listed above?
    3. What are the indications for consultation with infectious disease or dermatology for a viral exantham?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rotch TC. Pediatrics. Lippincott and Company, Philadelphia, PA. 1896:517-89.

    Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:425-26.

    American Academy of Pediatrics. Measles, Rubella, Parvovirus B19, Human Herpes Virus 6 and &, Enterovirus (nonpoliovirus) Infections, Group A Streptococcal Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;287, 378, 445, 491-92, 579-80, 618-19.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Pros and Cons to Different Wound Closure Devices?

    Patient Presentation
    An 8-year-old male came to clinic after riding his bike into a pole. It was witnessed by his friend and both agreed he did not lose consciousness. His bike helmet had a dent in the front but was not broken. His friend brought him home and he was brought to the clinic because of a facial laceration. He and his mother reported that he had been acting normally, no sleepiness or emesis. His immunizations were current. The past medical history revealed a hernia repair as an infant.

    The pertinent physical exam showed an alert male who was oriented x 4. His vital signs were normal. Head revealed a small bruise just above the right eyebrow. There was a laceration around the right alae nasa that extended along the right edge of the filtrum that ended approximately 7 mm from the vermilion border. The skin between the nose and lips had a moderate amount of abrasion. His nose also had some minor abrasions. His teeth and oral structures were intact, but his lips were slightly swollen without bruising. He had some minor abrasions on the palms of his hands and knees. His neurological examination was normal. The diagnosis of facial laceration and head trauma was made. Several general pediatricians looked at the wound and then discussed the best option for closing the wound. The patient was sent to plastic surgery for wound closure. The surgeon chose to use small sutures because of the relative tension so close to the mouth, and because there was an open abrasion, and that since adhesive was likely to become wet he did not want to use tissue adhesives. The surgeon also told the pediatrician that he felt this was a very appropriate referral because of the various lines of tension in the skin in this area, and that it was located in such a prominent area of the face The patient was also discharged with head injury instructions and told to replace his helmet. At two months follow-up the scar is healing well.

    Discussion
    About 7 million traumatic wound lacerations are repaired each year in emergency departments. Many more are repaired in practitioner’s offices. The ideal wound closure device and technique would be easy to perform consistently, quick to perform, be able to be performed in all clinical circumstances, painless, without the need to remove the device, have excellent cosmetic results and be cost effective. All of the current options for wound closure (i.e. sutures, staples, surgical tapes and tissue adhesives) do not meet all these criteria and therefore choosing among the options is necessary.

    Sutures have been available for millennia. Staples and surgical tapes have been around for less time. The Federal Drug Administration has only sanctioned general use of tissue adhesives in about the last 20 years, although the first successful wound closure using a tissue adhesive was in 1959. The first randomized controlled clinical trial for pediatric facial lacerations using tissue adhesives was completed in 1993.

    Learning Point
    A wound closure comparison

    • Tissue adhesives
      • Examples: Dermabond®
      • Indications: low tension lacerations, generally linear lacerations, use under casts and splits, fragile skin
      • Contraindications: high tension laceration, inadequate hemostasis, proximity to wet areas, heavily infected or contaminated wound
      • Pros: fast to learn and perform procedure, no need to remove device, no risk of needle stick, provides microbial barrier, may have less pain to perform, comfortable for patient to have on skin
      • Cons: less tensile strength, some increased dehiscence risk, poor moisture resistance, may cause skin reactions
    • Surgical Tapes
      • Examples: Steri-stripsTM
      • Indications: low tension lacerations, generally linear lacerations, use under casts and splits, fragile skin, also as secondary sound support for suture and staple removal
      • Contraindications: high tension laceration, proximity to wet areas, uncooperative patients, circumferential use around digits, heavily infected or contaminated wound
      • Pros: fast to learn and perform procedure, no risk of needle stick, may have less pain to perform, comfortable for patient to have on skin, inexpensive, generally does not cause skin reactions
      • Cons: less tensile strength, increased risk of dehiscence, possible need to remove device, may fall off before wound heals, no moisture resistance, could cause skin reactions
    • Staples
      • Indications: long lacerations or incisions, linear lacerations, scalp wounds
      • Contraindications: complex wounds, inadequate hemostasis, risk of foreign body ingestion in an impaired patient (e.g. psychiatric patient, several mental disability), heavily infected or contaminated wound
      • Pros: very fast to learn and perform procedure, lower risk of needle stick, low risk of skin reactions
      • Cons: painful, requires removal, less meticulous skin approximation, may have worse cosmetic results
    • Sutures
      • Indications: most lacerations and incisions, come in various sizes and types for most circumstances
      • Contraindications: heavily infected or contaminated wound
      • Pros: good tensile strength, low dehiscence risk, had been used for many years, most meticulous approximation
      • Cons: longer to perform procedure, longer to learn to do procedure, requires removal, risk of needle stick, can cause skin reactions, may leave suture marks

    Questions for Further Discussion
    1. What are the indications for consulting a plastic surgeon for laceration repair?
    2. If a plastic surgeon was not available, what other specialties could be consulted for laceration repair?
    3. What are the pros/cons of using different type of sutures?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Wounds

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N. Tissue adhesives for traumatic lacerations in children and adults.
    Cochrane Database Syst Rev. 2002;(3):CD003326.

    Zempsky WT, Parrotti D, Grem C, Nichols J. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive.
    Pediatr Emerg Care. 2004 Aug;20(8):519-24.

    Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am J Emerg Med. 2008 May;26(4):490-6.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Some Common Presentations for Inborn Errors of Metabolism?

    Patient Presentation
    A 14-year-old male was admitted for increasing seizures and a febrile illness. He had recently moved to a new care facility but had lived in one for several years because of ornithine transcarbamalyse deficiency (OTC deficiency), severe mental retardation and seizures, and he needed 24 hour nursing care and supervision. He had a temperature of 102° F off and on for 2 days. He was non-verbal but appeared to be having a sore throat to the staff. His seizures had increased from 2-3 tonic-clonic seizures/day to 6-7/day especially when anti-pyretics wore off. He also hadn’t been drinking as well. The staff at the new facility was very concerned and felt that they could not properly care for him, so he was transferred. The past medical history showed that he was diagnosed with OTC deficiency after multiple episodes of emesis. An allopurinol challenge test showed increased orotic acid. He also had a history of 2 episodes of cystitis but the evaluation of his genitourinary systems were negative. The review of systems showed minor cough, no rhinorrhea, rashes, or changes in bowel habits, but he did have some decreased urination.

    The pertinent physical exam showed a non-verbal male with a temperature of 101.5° F and his respiratory rate was 30. His weight was 50%. HEENT revealed thick secretions in his mouth and purulent material on the tonsils. He became somewhat agitated when examining his mouth. Bilateral tympanic membranes were thickened and had decreased movement but had no erythema. There were shoddy anterior cervical nodes. Heart was normal but his lungs had coarse breath sounds and slightly diminished sounds on the right. Abdomen was normal. Neurologically he would look at the examiner, and would help with movement in the bed. His capillary refill was about 2 seconds. The laboratory evaluation showed a complete blood count with a hemoglobin of 11.5 mg/dl, white blood cell count of 16.4 x 1000/mm2 with a 20% left shift. Urinalysis, glucose and electrolytes were normal. A rapid strep test was positive. His portable chest x-ray showed some consolidation at the right lung base. The diagnosis of group A, beta-hemolytic streptococcal pharyngitis and possible lobar pneumonia was made. Because he was somewhat dehydrated he was given intravenous fluids with glucose and one dose of ceftriaxone. Genetics was consulted to assist with his OTC treatment. His glucose and electrolytes were always normal and he then began to eat his normal diet after 24 hours. Neurology was also consulted and they did not want to change his medication as he had been well controlled previously. He became afebrile and was discharged to his care on day 2 on oral antibiotics to finish a 10 day course. He had had 3 seizures in the prior 24 hours, and slightly diminished breath sounds on the right at discharge.

    Discussion
    Each inborn errors of metabolism (IEM) by itself is often rare but taken as a whole, IEM are common. IEM often present in the newborn or infancy periods but can present at any time including adulthood. The genetic defect often causes a problem in the catabolism or synthesis of carbohydrates, fats, or proteins. The defect causes a blockage in the metabolic pathway with intermediate molecules accumulating (often toxic accumulations) before the blockage and metabolites after the blockage being scarce (inadequate energy production/utilization). Diet and stresses including surgery, trauma, and illness often can trigger intermittent decompensation.

    Common IEM include:

    • Carbohydrate metabolism – carbohydrate intolerance, geoneogenic and glycogenolytic disorders, glycogenic storage defects
    • Fat metabolism – fatty acid oxidation
    • Protein metabolism – amino acidopathy, organic acidopathy, urea cycle defects
    • Oxidation defects – mitochondrial disorders, peroxisomal disorders
    • Storage disorder – lysosomal storage disorders

    Learning Point
    Some presentations of IEM include:

    • Acute encephalopathy
      • Usually due to toxic accumulations in organic acidemia, urea cycle defects and some amino acidemia
      • Presentation may include lethargy, poor feeding, vomiting, abnormal muscle tone, tachypnea and decreased arousal progressing to coma
      • Acute encephalopathy caused by IEM often have:
        • Hyperammonemia
          • Usually due to urea cycle defects and organic acidemia, or transient hyperammonemia of the newborn
          • Ammonia is usually in the 1700 mcg/dL but can be lower. Ammonia > 100 mcg/dL in the neonate or >80 mcg/dL in an infant are considered elevated
        • Metabolic acidosis with an increased anion gap
          • Usually due to organic acidemias such as methylmalonic acidemia, propionic acidemia and isovaleric acidemia
          • A normal anion gap is usually due to diarrhea or renal tubular acidosis
          • Pyruvate and lactate are often abnormal
    • Hypoglycemia
      • Usually due to glycogen storage diseases and fatty acid oxidation
      • Presentation may include organomegaly (tongue, liver, heart), symptoms consistent with congestive heart failure, arrhythmia, tachypnea, hypotonia, mental status changes
      • Hyperammonemia, elevated liver enzymes, metabolic acidosis
    • Jaundice and Liver Dysfunction
      • Usually due to erythrocyte metabolism or liver dysfunction
      • Presentation may also include vomiting, diarrhea, poor weight gain
      • Hypoglycemia may also be a presenting feature
    • Abnormal Odor
      • Often due to isovaleric acidemia (sweaty feet smell), glutaric acidemia (sweaty feet smell) or maple syrup urine disease (maple syrup or burnt sugar smell)
    • Dysmorphic features
      • Associated with Zellweger syndrome, neonatal adrenal leukodystrophy, and other problems
      • Dysmorphic features may be isolated
    • Storage Diseases
      • Usually present in later infancy or childhood
      • Presentation may include organomegaly, coarse facial features, skeletal abnormalities

    Initial laboratory tests to investigate for possible IEM generally includes:

    • Complete blood count for neutropenia, thrombocytopenia and anemia, and possible sepsis
    • Blood gas, electrolytes, bicarbonate – for electrolyte imbalance and evaluation for metabolic acidosis
    • Blood urea nitrogen and creatinine – evaluate renal function
    • Bilirubin (direct and indirect) – direct hyperbilirubinemia is more likely to be associated with an IEM
    • Transaminases – evaluate hepatic function, hepatocyte destruction
    • Coagulation profile – evaluate hepatic synthetic function, and possible sepsis
    • Ammonia level, lactate and pyruvate – evaluate various IEMs
    • Glucose

    Questions for Further Discussion
    1. Where is the nearest center that can assist in managing a patient with an IEM?
    2. What protocols are in place at my local hospital for evaluating an infant who presents with sudden death?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Streptococcal Infections and Throat Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Burton, BK. Inborn Errors of Metabolism in Infancy: A Guide to Diagnosis. Pediatrics. 1998;102;e69.

    Weiner DL. Inborn Errors of Metabolism. eMedicine. Available from the Internet at http://emedicine.medscape.com/article/804757-overview (rev.3/30/09, cited 8/24/09).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are The Options for Treating Excessive Salivation?

    Patient Presentation
    A 6-year-old female came to clinic for her health supervision visit. She had cerebral palsy and mild mental retardation but was making good progress with appropriate interventions. She continued to have significant drooling that was interfering with her social relationships with peers. Although peers liked her and included her, they did not want to work in small groups or eat lunch next to her because of the drooling. Glycopyrrolate had been tried without success. She was otherwise doing well in school and was able to participate in modified gross motor games and gym activities. The past medical history was signficant for heel cord lengthening and general anesthesia for dental restorations. The pertinent physical exam showed her growth parameters to be in the 10-75%. She was conversant and used ankle-foot orthoses and a walker because of an unsteady gait. HEENT showed excessive salivation and some plaque on her teeth. She had spasticity of all 4 extremities with lower extremities more affected than upper. Her heel cords were tight, but she easily used her orthoses.

    The diagnosis of cerebral palsy, mild mental retardation, and excessive salivation causing social impairment was made. The pediatrician told the mother that he knew there were other options but wasn’t sure about all of them. He said that he would investigate and then follow-up. Over the next week, he contacted a developmental pediatrician, a neurologist and did an Internet PubMed search. He sent the parents a letter with the various options he had found. They chose to try cyproheptadine every evening. The patient’s clinical course at one month followup showed the cyproheptadine had improved the drooling significantly and was not causing any side effects.

    Discussion
    Drooling, excessive salivation, hypersalivation, or sialorrhea can be a big problem for children. It can cause wet clothing necessitating bibs or multiple changes of clothing. It can cause dermatitis of the face, neck and chest, with possible skin breakdown and/or possible secondary infection. Sialorrhea can also potentiate the spread of common infections to others though direct or indirect contact with the saliva. It can also cause impaired social interaction as noted above. Therefore it is a problem that should be taken seriously and treated as necessary.

    Sialorrhea is generally considered abnormal if it occurs during the day after the age of 3-4 years. Most people affected have some other neurological problem including cerebral palsy or in adult populations, patients with Parkinson’s disease. Sialorrhea varies minute to minute and day to day. Therefore it is hard to quantify the overall outcome, especially for research purposes.

    Learning Point
    There are several options for treatment:

    • Do nothing – If the drooling is relatively mild and can be effectively managed by the child and family easily, and the child is not distressed by the drooling and is not having social impairments, this can be a good option.
    • Behavioral modification, speech therapy, with or without intraoral appliances – effectively used to train the patient to improve the stability of the jaw and lip closure. Trained personnel are needed for this option.
    • Medication
      • Anticholinergic agents – these are the most common medication used. Different forms of the medications are available in different countries and therefore there are differences in their utilization. Side effects can include constipation, urinary retention, sleepiness, irritability, and flushing, and generally are expected and reversible.
        • Glycopyrrolate – often used as a first agent with variable results but improvement in 70-90% of patients is reported. However because of side effects, about 30% of patients will choose to discontinue because of side-effects.

        • Scopolamine – also a common agent. Often has more severe side effects than glycopyrrolate.
        • Benztropine – also a common agent.
        • Cyproheptadine – less often used than other anticholinergics for sialorrhea, but often used in children for migraines or appetite enhancement.
      • Anti-reflux agents – as reflux causes excessive salivation, if the reflux is treated then the salivation will decrease. May or not be effective.
      • Trihexyphenidyl – antispasmotic agent used with Parkinson’s patients that also may decrease salivation
    • Botulinum toxin injection – Has been used in children (but mainly with adults) with maximum effect 2-8 weeks after injection. It can have side effects and must be repeated at intervals.
    • Surgery – The specific surgeries vary but often include transection of some innervation to the salivary glands. It can be very effective. However it does require surgery and excessive salivation may still occur and there may be side effects such as facial nerve palsy. The surgeries are generally infrequently performed, so it may be difficult to find an experienced, willing surgeon to perform the operation.

    With successful treatment of sialorrhea, the decrease in saliva can pose an increase risk of dental disease. Patient need to have appropriate dental care and utilize fluoride toothpaste to maintain good oral health.

    Questions for Further Discussion
    1. What health care professionals are available locally to help you manage sialorrhea?
    2. What is the definition of cerebral palsy and what are common causes?
    3. What are common problems associated with cerebral palsy?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Mouth Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Nunn JH. Drooling: review of the literature and proposals for management. J Oral Rehabil. 2000 Sep;27(9):735-43.

    Blasco PA. Management of drooling: 10 years after the Consortium on Drooling, 1990. Dev Med Child Neurol. 2002 Nov;44(11):778-81.

    Tscheng DZ. Sialorrhea – therapeutic drug options. Ann Pharmacother. 2002 Nov;36(11):1785-90.

    Jongerius PH, van Tiel P, van Limbeek J, Gabreels FJ, Rotteveel JJ. A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling. Arch Dis Child. 2003 Oct;88(10):911-4.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital