Managing Excessive Saliva And Secretions
From Holoprosencephaly
Difficulty handling oral and respiratory secretions is a common problem in children with severe motor impairment and children with HPE. Potential sources of mucus are the nasal passages and sinuses, the lungs, and the gastrointestinal tract. Because of oral motor dysfunction, mucus from any of these sources can lead to frequent choking, gagging, and coughing.
It is important to try to determine where the mucus is coming from. Does the mucus being brought up appear to be coming from coughing or retching? This can help distinguish a respiratory from a gastrointestinal source of mucus. Does the mucus have any formula or stomach contents in it? Is his nose also very congested and productive of mucus? Could the mucus be from post-nasal drip?
Overnight gastrostomy tube feedings commonly cause increased mucus production. Feedings increase salivation which is normally suppressed while sleeping. The mucus and saliva collects while the child sleeps because of diminished cough and gag reflexes while sleeping. Then the child wakes and goes through fits of coughing, gagging, etc, trying to clear the mucus.
Gastroesophageal reflux also can contribute to increased mucus production while being tube fed at night. Sometimes refluxed stomach contents can be aspirated into the trachea and bronchi or can makes its way into the nasal passages and cause an inflammatory response, thus leading to increased mucus production.
Sometimes a tight Nissen can lead to pooling of secretions in the lower esophagus. When he wakes in the morning, he could actually be vomiting up plugs of mucus that have collected overnight in the esophagus. The can occur in some children with poor esophageal motility, even without previous surgery.
Several ways to handle mucus production during overnight tube feedings:
- Treat gastroesophageal reflux if present.
- Elevate the head of the bed. Decrease the rate and/or volume of tube feedings.
- Provide chest PT, suctioning or nebulizer treatments prior to bed and immediately in the morning.
- Treat sinus disease if present.
- If respiratory secretions are a problem, consider ipratropium (Atrovent) or albuterol (Proventil or Ventolin) nebulizer treatments.
- Ipratropium in some patients is particularly effective.
- Glycopyrrolate (Robinul) is sometimes effective for decreasing oral secretions, but is a systemic medication.
- Transderm Scopolomine patches may also be prescribed. Typically these patches are worn behind the ear to control motion sickness. Like the Robinul, this is a systemic medication.
- If nasal discharge is a major problem, consider using nasal steroids or nasal cromolyn sodium.
If your child is consistently junky in the morning after an overnight tube feeding, then this needs to be evaluated and adjustments made to the feeding or medical regimen.
Source: The Carter Center: http://www.stanford.edu/group/hpe/support/FAQ.html#Q5
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If you have any concerns, please don't hesitate to discuss your concerns with your child's doctor(s).
