Use of saline nebulizers (nebs) for infant cough?

From the Guidelines

Saline nebulizers should not be used as a first-line treatment for relieving cough in infants, as there is no evidence to support their effectiveness in thinning mucus or providing symptomatic relief 1. When considering the use of saline nebulizers for infant cough, it's essential to prioritize the most recent and highest-quality evidence. The 2020 Chest guideline and expert panel report 1 emphasizes that cough in children should be treated based on etiology, and there is no evidence for using medications or saline nebulizers for symptomatic relief of cough.

Some key points to consider:

• The British Thoracic Society nebulizer project group 1 suggests that nebulizers may be necessary for some infants who cannot tolerate face masks and spacers, but this does not directly address the effectiveness of saline nebulizers for cough relief.
• The American Thoracic Society 1 notes that the routine use of normal saline instillation may be associated with undesirable outcomes, such as a decrease in oxygen saturation and contamination of the lower airways with unsterile saline.
• The most recent guideline 1 recommends a thorough clinical review to identify underlying respiratory and/or systemic illness in children with chronic cough, rather than relying on symptomatic treatments like saline nebulizers.

In terms of administration, if a saline nebulizer is deemed necessary, the following steps can be followed:

1. Fill the nebulizer cup with sterile saline solution.
2. Place the mask over the infant's nose and mouth.
3. Run the nebulizer for about 5-10 minutes or until the solution is gone.
4. Gently pat the infant's back to help loosen mucus. However, it's crucial to consult a pediatrician immediately if symptoms persist or worsen, or if the infant shows signs of respiratory distress, as saline nebs should not replace medical evaluation for persistent or severe cough in infants.

From the Research

Use of Saline Nebulizers for Infant Cough

• The use of saline nebulizers for infant cough has been studied in various research papers 2, 3, 4, 5, 6.
• A study published in 1997 found that nebulized saline solution can be effective in treating croup, a common cause of upper airway obstruction in children between the ages of 6 months and 6 years 2.
• Another study published in 2023 found that nebulised hypertonic saline solution may reduce the length of hospital stay and improve clinical severity scores in infants with acute bronchiolitis 3.
• A study published in 2021 compared the outcome of 3% saline and 0.9% normal saline nebulization in children with bronchiolitis and found that 3% saline was more effective in reducing the duration of cough, wheezing, and hospital stay 4.
• However, a study published in 2014 found no advantage of hypertonic saline over normal saline nebulization in the management of bronchiolitis 5.
• A study published in 2010 compared the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in infants and found that nebulization with 5% hypertonic saline may be superior to current treatment for early outpatient treatment of bronchiolitis 6.

Key Findings

• Nebulised hypertonic saline solution may reduce the length of hospital stay and improve clinical severity scores in infants with acute bronchiolitis 3.
• 3% saline may be more effective than 0.9% saline in reducing the duration of cough, wheezing, and hospital stay in children with bronchiolitis 4.
• Nebulization with 5% hypertonic saline may be safe and effective for early outpatient treatment of bronchiolitis 6.

Saline Concentration

• The concentration of saline used in nebulizers can vary, with studies using 0.9%, 3%, and 5% saline solutions 3, 4, 5, 6.
• The use of hypertonic saline (3% or 5%) may be more effective than normal saline (0.9%) in treating acute bronchiolitis 3, 4, 6.