Is nebulising with 3 percent saline effective for treating cough in infants?

Nebulizing with 3% Saline for Infants with Cough

Nebulizing with 3% hypertonic saline is not recommended for treating cough in infants unless the cough is specifically related to bronchiolitis with a hospital stay expected to exceed 3 days. 1

Effectiveness in Different Clinical Scenarios

For Bronchiolitis

• 3% hypertonic saline may improve symptoms of mild to moderate bronchiolitis after 24 hours of use and may reduce hospital length of stay, but only in settings where the average stay exceeds 3 days 1
• The benefit is primarily seen in clinical severity scores on days 1-3 of treatment (day 1: -0.64, day 2: -1.07, day 3: -0.89) 2
• For outpatients and emergency department patients with bronchiolitis, hypertonic saline may reduce hospitalization risk by approximately 13% 2

For Chronic Cough After Bronchiolitis

• For children with chronic cough (>4 weeks) after acute viral bronchiolitis, inhaled osmotic agents including hypertonic saline are not recommended 1
• Instead, these children should be managed according to standard pediatric chronic cough guidelines, which may include antibiotics targeted to common respiratory bacteria if wet/productive cough is present 1

For General Cough in Infants

• There is no evidence supporting the use of hypertonic saline for general cough in infants outside the context of bronchiolitis 1
• Normal saline (0.9% sodium chloride) may be tried to loosen tenacious secretions, but there is no supporting scientific evidence for this practice 1

Safety Considerations

• When used for bronchiolitis, hypertonic saline appears to be generally safe with only minor adverse events that resolve spontaneously 2
• Safety is improved when hypertonic saline is co-administered with bronchodilators 2
• Reported adverse effects include worsening cough, agitation, bronchospasm, bradycardia, desaturation, and gastrointestinal symptoms 2
• Some studies show significantly more cough (46% vs. 20%) and rhinorrhea (58% vs. 31%) in patients receiving hypertonic saline compared to normal saline 3

Administration Guidelines

• If using hypertonic saline for bronchiolitis:
  • The standard concentration is 3%, though some studies have used 5-7% 2
  • Monitoring of oxygen saturation is recommended as unpredictable arterial oxygen desaturation may occur 1
  • Pre-treatment with a bronchodilator is recommended to reduce the risk of bronchospasm 1

Common Pitfalls and Caveats

• The benefits of hypertonic saline in bronchiolitis may not be generalizable to healthcare settings where the average length of stay is less than 3 days 1
• There is significant inconsistency in study results, with more recent trials showing less benefit than earlier studies 1, 2
• The evidence quality for all outcomes related to hypertonic saline use is low to very low, mainly due to inconsistency and risk of bias 2
• Hypertonic saline should not be used as a substitute for other appropriate treatments when specific causes of cough are identified 1

Alternative Approaches for Infant Cough

• For infants with cough due to bronchiolitis, supportive care remains the mainstay of treatment 1
• For chronic cough after bronchiolitis, evaluation for cough pointers and consideration of a 2-week course of antibiotics for wet/productive cough may be appropriate 1
• Asthma medications should not be used for post-bronchiolitis cough unless other evidence of asthma is present 1