Saline spray clears obstructive sleep-disordered breathing symptoms for some kids

Two 6-week courses of intranasal saline help resolve symptoms of obstructive sleep-disordered breathing (OSDB) for about half of the children in the MIST+ trial, with efficacy similar to that of intranasal steroid.

In a cohort of 3–12-year-olds with persistent OSDB symptoms, a 6-week run-in phase of intranasal treatment resulted in symptom resolution for 29.5 percent. Most of these children remained symptom-free at the 6- and 12-week follow-up visits (76.3 percent and 64.9 percent, respectively). [JAMA Pediatr 2026;doi:10.1001/jamapediatrics.2025.5717]

At the end of the run-in phase, the number of parents who reported that their child needed surgery dropped from 64.5 percent at baseline to 56.3 percent, while the number of parents who expressed willingness to proceed with surgery if recommended decreased from 91.1 percent to 87.6 percent. Requirement for a specialist appointment also declined (from 92.9 to 89.4 percent).

Overall, “parents perceived a very small benefit of the spray,” with a mean Glasgow Children’s Benefit Inventory score of 9.4 at the end of the run-in phase, reported first author Dr Gillian Nixon from Monash Children's Hospital in Melbourne, Victoria, Australia, and colleagues.

Nevertheless, most parents were partly or completely satisfied with the treatment (56.7 percent), Nixon and colleagues added.

Randomized treatment phase

Meanwhile, the children who continued to exhibit symptoms at the end of the run-in phase were randomly assigned to receive 6 weeks of treatment with either intranasal saline or intranasal steroid.

Symptom resolution occurred in 35.6 percent of children in the steroid group vs 36.4 percent of those in the saline group, with the difference not reaching significance (risk difference, −0.9 percent, 95 percent confidence interval [CI], −20.7 to 19; p=0.93).

Treatment effect was more likely to be sustained in the saline group, with the number of children who remained symptom-free at 12 weeks from the start of the randomized treatment phase being 20 percent with intranasal steroid vs 35.7 percent with intranasal saline (risk difference, −17.6 percent, 95 percent CI, −35.7 to 0.6).

“Subgroup analysis by age and risk factors at baseline, including tonsillar hypertrophy, allergic rhinitis, overweight/obesity, and severity of OSDB symptoms, did not affect the outcome, suggesting that saline has the potential to benefit all children with OSDB symptoms,” according to Nixon and colleagues.

Mean treatment compliance, as recorded in diaries, was 87.6 percent in the steroid group and 93.5 percent in the saline group.

There were no significant between-group differences in the number of parents who answered positively to the questions about the need for surgery or a specialist appointment at the 12-week visit. Most parents in both the steroid and saline groups were partly or completely satisfied with the treatment (65.3 percent and 55.8 percent, respectively) groups.

Saline as first-line option

“We confirmed that saline alone is effective as a first-line treatment, and even after not responding after 6 weeks of treatment, another one-third of children responded to a further 6 weeks of intranasal saline, similar numbers to intranasal steroid,” Nixon and colleagues said.

As for safety, adverse events (AEs) occurred in 69.3 percent of children during the run-in phase and in 55 percent of those in the steroid group and 54 percent in the saline group during the randomized treatment phase. These AEs were generally mild, and most were deemed unrelated to the study medications.

AEs potentially related to the study medication included nasal itch or irritation and epistaxis, occurring in 16.1 percent and 5.1 percent of children, respectively, in the run-in phase. The frequencies of nasal itch or irritation and epistaxis were similar between the steroid and saline groups during the randomized treatment phase.

In light of the findings, Nixon and colleagues recommended that intranasal saline be given for 3 months in children with OSDB before assessing the need for specialist referral.

Often, children referred to a sleep medicine specialist are likely to be referred for polysomnography, whereas children referred to an otolaryngologist are likely to be offered surgery without polysomnography. [Laryngoscope 2013;123:1055-1058] 

Waiting time for specialist clinics and for surgery ranges from months to years in many settings, “resulting in prolonged exposure to the consequences of obstructed breathing during sleep,” the authors noted.

Nixon and colleagues emphasized that using intranasal saline to treat children with OSDB in the first-line setting ensures that symptoms are “managed as quickly as possible.”

Furthermore, “resolution of symptoms before specialist referral will likely result in fewer parents seeking surgical treatment, with the dual impact of avoiding surgical treatment for some children and alleviating the pressure on specialist services, thereby improving access to specialist care for those who most need it,” they said.

MIST+ population

MIST+ included 150 children (mean age 6.2 years, 62 percent male) with persistent OSDB symptoms, including frequent snoring and at least occasional other symptoms of obstructive sleep apnoea. All of them received one spray of 0.9% sodium chloride (normal saline) per nostril per day for 6 weeks during the run-in treatment phase. A total of 139 children completed this phase.

During the randomized treatment phase, a total of 93 children underwent randomization, with 47 allocated to the steroid group and 46 to the saline group. Those in the steroid group received one spray per nostril of mometasone furoate 50 µg once daily, while those in the saline group continued intranasal saline for 6 weeks.