Navigating the Treatment of Pediatric Sialorrhea: A Scoping Review of Management Algorithms

This scoping review aims to map the extent and nature of existing evidence regarding algorithmic approaches, clinical pathways, and decision trees for the management of sialorrhea in pediatric patients (ages 0-18). By systematically reviewing the literature, this project will identify and synthesize the structured decision-making tools currently available to guide clinical practice. Sialorrhea is a common issue in pediatric patients with neurological disabilities. Its management is complex and frequently requires a multimodal approach. While various individual treatments are well-documented, there is a distinct need to evaluate how these treatments are organized into comprehensive, stepwise clinical algorithms. The primary purpose of this review is to answer the following: What management algorithms, clinical pathways, or decision trees currently exist in the literature for pediatric sialorrhea? What are the common first-, second-, and third-line interventions across these algorithms? What specific clinical criteria are utilized to trigger a "step-up" or escalation in therapy? Who are the intended users of these pathways (e.g., pediatricians, respirologists, multidisciplinary clinics), and what patient outcome measures are used to define success? We hypothesize that while there may be general similarities in management approaches across institutions, there is likely limited high-quality evidence underpinning these algorithms specifically in the pediatric population. We anticipate mapping a standard progression of care where non-pharmacologic interventions (e.g., speech therapy, physiotherapy, occupational therapy) serve as first-line treatments, followed by pharmacologic options as second-line, and botulinum toxin injections or surgical interventions reserved as third-line therapies. Furthermore, we expect to highlight significant inconsistencies in how the literature defines "treatment failure" and the outcome measurement tools used to evaluate it. Ultimately, we will use a narrative synthesis approach to categorize the available algorithms by clinical setting and underlying disease population. The final outcome of this project will be a visual representation—such as a synthesized flowchart—that maps the consensus elements of these therapeutic stages to assist clinicians in navigating the treatment of pediatric sialorrhea.