123 Surgery vs botulinum for the impact of drooling on daily life in children with neurodevelopmental disabilities: a randomized controlled trial 5 Future research should determine the exact long-term effect of 2-DL, droolingrelated well-being and quality of life in a larger patient population. CONCLUSION Previous literature illustrated that 2-DL procedure is a more effective treatment for drooling than BoNT-A, but carries a slightly greater risk of complications and morbidity.5 This RCT demonstrates a positive effect on the well-being of children, adolescents and their caregivers through a reduction in drooling severity, daily care, an improvement in social interaction and a higher self-esteem by both BoNT-A and 2-DL. Even though there is a greater risk of complications and morbidity after 2-DL, 2-DL is significantly more effective than BoNT-A with regard to reducing the amount of daily care, damage to electronics and floors and/or furniture, and positive changes in social interaction. Therefore, 2-DL could be considered when for various reasons BoNT-A is no longer preferred and when submandibular gland extirpation or submandibular duct relocation are rejected or contraindicated. In our clinic, systemic anticholinergics are currently only considered in case of an unsatisfactory effect from or contraindications to BoNT-A or surgery. Future research should focus on the costeffectiveness, long-term effect on drooling severity and its related impact of 2-DL in comparison with alternative surgery in order to exactly determine the position of 2-DL in the current drooling treatment strategy. Acknowledgements We acknowledge Peter Jongerius, rehabilitation specialist, who performed all the botulinum toxin injections, Laura Rodwell, for her statistical contribution and Corrie Erasmus for her contributions to the establishment and development of the trial. This study was subsidized by the Johanna Kinderfonds, Arnhem, the Netherlands, Phelps Stichting voor spastici, Bussum, the Netherlands and Stichting Rotterdams
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