A daily spray of saline in each nostril significantly improved symptoms of obstructive sleep-disordered breathing (OSDB) in children, researchers in Australia found.

The nasal spray was as effective as a steroid spray in helping children breathe and sleep better, potentially avoiding the need for surgery and specialist care, said Gillian M. Nixon, MD, adjunct clinical professor at Monash Children’s Hospital in Clayton, Australia, who led the research.

Although adenotonsillectomy is often the first-line treatment for obstructive sleep apnea (OSA), the demand for ear, nose, and throat specialists outweighs their availability, Nixon said.

“The current study was specifically designed to use saline as a first-line treatment and to test whether those that did not respond to saline would respond to steroid spray, but we again found that saline worked as well as steroid [spray],” Nixon said.

Older studies, such as a randomized controlled trial from 2001, showed treating OSA with intranasal steroids improved symptom severity. A 2023 Australian study showed equivalent improvement among children with OSDB treated with intranasal steroids and those treated with intranasal saline for 6 weeks.

Simple Saline Worth Trying

In the new study, published in JAMA Pediatrics, Nixon and her team analyzed the data of 139 children aged 3-12 years with OSDB who were on the waitlists at otolaryngology, sleep, or respiratory medicine clinics. All participants received once-daily intranasal saline for a 6-week run-in period, with 29.5% showing resolution of their symptoms.

The remaining 93 children (mean age, 6.2 years; 62% boys; 54.1% White) with persistent symptoms were randomly assigned to continue once-daily intranasal saline or switched to a once-daily intranasal steroid (50 µg mometasone furoate) for another 6 weeks.

After this second period, approximately one third of the children in both the steroid and saline groups saw their symptoms resolved (35.6%; 95% CI, 22.9%-50.6% and 36.4%; 95% CI, 23.5%-51.6%, respectively), with no significant difference between the groups.

Secondary outcomes included behavior, quality of life, and parental perception of need for surgery, and no significant differences appeared between the groups. In a subgroup analysis, neither treatment arm stood out as more or less likely to respond to either method.

Approximately half of the children in each treatment group reported at least one adverse event, including nasal itches, nosebleeds, and specks of blood from the nose.

Arianne K. Baldomero, MD, MS, assistant professor of medicine and specialist in pulmonary, allergy, critical care, and sleep medicine at the University of Minnesota in Minneapolis, said she was surprised by the effectiveness of the saline treatment.

“It is striking that such a large proportion of children with OSDB could be managed conservatively with a simple, low-cost intervention rather than proceeding directly to surgery,” she said.

The main barrier to routine use of saline would be tolerability of the spray, but most children in the current study adhered to the treatment: 92% of children took 80% or more of the prescribed doses. Nixon said she and her colleagues are following up the children for 1 year to determine whether the benefit of nasal spray is sustained.

The main takeaway for clinicians is to consider a trial of conservative management with intranasal saline, with or without intranasal steroid, early in the care for children with OSDB, Baldomero said.

“For a substantial subset of patients, this approach may provide sufficient symptom relief and allow families to avoid or defer adenotonsillectomy, reserving surgery for those with more severe or persistent disease,” she said.

The study was supported by the Garnett Passe and Rodney Williams Memorial Foundation. Nixon and Baldomero disclosed having no financial conflicts of interest. 

Heidi Splete is a freelance writer.