Botulinum Toxin A in the Management of Pediatric Sialorrhea: A Systematic Review

Abstract

Objective: Botulinum toxin A is known to be effective and safe in managing sialorrhea in pediatric patients; however, there is no consensus on a protocol for optimal injection sites and appropriate dosing for injection. Methods: This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. PubMed, EMBASE, and other databases were queried to identify articles that evaluated botulinum toxin type A for the treatment of sialorrhea in the pediatric population. A total of 405 studies were identified. After applying inclusion and exclusion criteria, 31 articles were included for review. Results: A total of 14 studies evaluated 2-gland injections, and 17 studies evaluated 4-gland injections. Of the 31 studies included, one study assessed incobotulinumtoxinA (Xeomin®) the remaining all used onabotulinumtoxinA (Botox®). For 2-gland injection studies, a combined total of 899 participants were reviewed, where 602 participants received 50 units into their submandibular glands, while 262 participants received 30 to 50 units. Among 4-gland injection studies, there was a combined total of 388 participants, with the most prevalent dosage utilized being 60 to 100 units in 230 participants, followed by 100 units total in 77 participants. The most common adverse event was dysphagia which resolved in nearly all cases. Three studies aimed to examine 2-gland versus 4-gland injections, with 2 of the studies concluding 4-gland injection was superior. Conclusions: The strength of evidence suggests that the dosing of 50 units total of onabotulinumtoxinA to the submandibular glands is safe and effective in the pediatric population. For 4-gland injections, bilateral submandibular and parotid gland injections of 60 to 100 units total is the safe and effective dosage. There is no substantial evidence comparing 4-gland injections to 2-gland injections, but research thus far suggests 4-gland injections to be superior. Future study is needed to evaluate incobotulinumtoxinA and abobotulinumtoxinA dosages in the pediatric population.

The effectiveness of ultrasound‐guided injection of BTX‐A in the management of sialorrhea in neurogenic dysphagia patients

“… 43 Diffusion of toxin into adjacent musculature can cause chewing difficulties and transient weakness of mouth closure; however, this is less common with ultrasound guidance for injection. 44 Due to the severe sialorrhea status of our patients, reasonable dose, and our accurate way to locate salivary glands, we have not found the side effects.…”

“…The side effect profiles of neurotoxin injections are generally fewer and more tolerable than anticholinergic medication, including dry mouth, saliva thickening, and salivary gland swelling 43 . Diffusion of toxin into adjacent musculature can cause chewing difficulties and transient weakness of mouth closure; however, this is less common with ultrasound guidance for injection 44 . Due to the severe sialorrhea status of our patients, reasonable dose, and our accurate way to locate salivary glands, we have not found the side effects.…”

Transient Worsening of Dysphagia and Dysarthria after Treatment with Botulinum Toxin in Patients with Acquired Brain Injury

“…These uncommon systemic effects, however, are only observed in people with underlying medical problems or at extremely high dosages. In a recent systematic review, Heikel et al [33] evaluated the impact of BoNT treatment in the management of pediatric sialorrhea. Adverse occurrences included speech problems, dysphagia, and dysarthria ranging from mild to moderate.…”

Recent Developments in Engineering Non-Paralytic Botulinum Molecules for Therapeutic Applications

“…While adverse events related to BoNT injections are rare, it is noteworthy that severe dysphagia can occur in children, leading to compromised food and fluid intake, as well as weight loss. Additionally, xerostomia, dysarthria, speech difficulties, coughing, and feeding difficulties have been reported, along with instances of saliva thickening and weakening of the oral musculature [ 28 ]. In the study by Yu et al, among adults, adverse events were reported in 7 out of 12 trials.…”