59 Randomized controlled trial comparing botulinum versus surgery for drooling in neurodisabilities 2 2-DL precludes subsequent SMDR. This is a significant disadvantage as SMDR is currently one of the most effective surgical treatment options for anterior drooling, and thus should be borne in mind when indicating 2-DL.30 We report a randomized controlled trial comparing 2-DL with BoNT-A injections. BoNT-A is an effective treatment for drooling in neurodevelopmentally disabled children with minor risk for adverse events and morbidity. 2-DL is a more effective treatment for drooling that is equally performed in day care, but includes a slightly greater risk for complications and morbidity compared to BoNT-A. 2-DL should therefore be considered in case of unsatisfactory results after BoNT-A, but onlywhen the child is over 8 years of age or when there is a low expectation of ‘outgrowing’ the drooling, and when SMDR is contraindicated or rejected by caregivers considering the irreversible contraindication for SMDR after 2-DL. Future research should focus on predictors for response to treatment, cost-effectiveness, quality of life, and the long-term effect of 2-DL to determine the exact position of 2-DL in treatment of drooling. Study funding This study and its analysis were subsidized by Johanna Kinderfonds, Arnhem, the Netherlands and Phelps Stichting voor spastici, Bussum, the Netherlands, and Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting, Rotterdam, the Netherlands. Acknowledgements The authors thank Peter Jongerius, who performed all the botulinum toxin injections, and Sandra de Groot and Marloes Lagarde, who contributed to data collection.
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