Pharmacological Management of Drooling in Children

Persistent drooling beyond early childhood is a common and burdensome problem specifically in children with cerebral palsy and other neurodevelopmental disorders, adversely affecting physical health, social participation, and quality of life. Management is ideally multimodal and stepwise, with pharmacologic therapy introduced when conservative measures fail. This chapter reviews current evidence for pharmacologic management of pediatric drooling, focusing on anticholinergic medications and botulinum toxin therapy. Anticholinergics—including glycopyrrolate, scopolamine hydrobromide (hyoscine), atropine, and trihexyphenidyl—remain first-line noninvasive options. Glycopyrrolate is the best-studied agent and demonstrates consistent efficacy with a comparatively favorable safety profile, whereas scopolamine is widely used due to its transdermal formulation but is limited by higher rates of adverse effects. Sublingual atropine has emerged as a promising off-label alternative with rapid onset and minimal reported side effects, though evidence remains limited. Trihexyphenidyl may provide benefit through combined peripheral and central mechanisms but requires cautious use due to frequent adverse effects. Botulinum toxin type A is a well-established, minimally invasive treatment for moderate to severe drooling, offering reversible, sustained reductions in salivary flow with good safety when ultrasound-guided and appropriately dosed. Overall, individualized treatment selection, careful titration, and multidisciplinary monitoring are essential to optimize outcomes and minimize risk.