Effectiveness of Saline Nasal Sprays and Rinses in Pediatrics
Saline nasal irrigation is effective for relieving nasal congestion in pediatric patients with acute upper respiratory infections, with one large pediatric trial demonstrating significant symptom improvement, though the evidence base remains limited and mixed. 1
Evidence Quality and Recommendations
The 2013 American Academy of Pediatrics guideline on acute bacterial sinusitis in children acknowledges that one pediatric study showed greater improvement in nasal airflow, quality of life, and total symptom scores when saline irrigation was used as adjuvant therapy compared to placebo in children treated with antibiotics and decongestants. 1 However, the guideline notes that very few randomized controlled trials exist using saline nasal irrigation in acute sinusitis, with mixed results overall. 1
The 2020 European Position Paper on Rhinosinusitis provides more nuanced guidance: in acute rhinosinusitis (ARS), the majority of studies did not find a difference between saline nasal treatment versus control, but one larger trial in children suggests that nasal saline irrigation has benefits for relieving ARS symptoms. 1 For chronic rhinosinusitis (CRS), the evidence is stronger—nasal saline irrigation is considered an important aspect of treatment by improving nasal mucosa function and should be recommended. 1
Mechanism and Practical Application
Nasal irrigation works by thinning and removing mucus, clearing inflammatory proteins, and flushing out irritants and bacteria from the nose and sinus cavities. 1 The physiological rationale is particularly important in infants, who are obligate nasal breathers until at least 2 months of age, making even minor nasal obstruction potentially serious. 2
Isotonic vs. Hypertonic Solutions
In general, studies do not show that rinsing with hypertonic saline is more effective than isotonic saline. 1 Specifically:
- Three studies (325 patients) found better results with isotonic than hypertonic saline 1
- Two studies (248 patients) found no difference 1
- One study (60 patients) showed hypertonic nasal spray had significantly better results on congestion and cough than isotonic saline 1
A 2016 pediatric study comparing isotonic saline (0.9%) and hypertonic seawater (2.3%) found no significant difference between the two solutions, though both were superior to no treatment for nasal congestion, weakness, sleep quality, and nutrition. 3
Volume and Delivery Method
Although nasal douches have been shown to be more effective in distributing irrigation solution to the sinuses, there are no studies that show nasal douches are also more effective in reducing symptoms and signs of chronic rhinosinusitis compared to nasal sprays. 1 One study in 86 CRS patients found no differences in symptom scores between squeeze bottle irrigation and nasal spray. 1
Age-Specific Considerations and Safety
Infants Under 1 Year
Saline nasal lavage followed by gentle aspiration represents an effective method for prevention and control of nasal congestion in term or preterm neonates and infants, particularly given the lack of safe alternative medications in this age group. 2 This is critical because:
- Nasal passages contribute 50% of total airway resistance in newborns, meaning any obstruction creates near-total blockage and potential respiratory failure 4
- OTC cough and cold medications should be avoided in all children below 6 years of age due to documented fatalities 5
- Topical decongestants should be used with extreme caution below age 1 year due to increased risk for cardiovascular and CNS side effects 5
Between 1969-2006, there were 54 fatalities associated with decongestants in children under 6 years, with 43 deaths in infants under 1 year. 5
Children 1-12 Years
A 2020 systematic review and meta-analysis found that saline nasal irrigation showed benefit for rhinological symptoms (standard mean difference = -0.29) but no significant improvement in respiratory symptoms or overall health status. 6 However, its use appeared to limit the prescription of other treatments, particularly antibiotics, and long-term use decreased the incidence of acute rhinosinusitis and its complications. 6
A 2024 systematic review concluded that nasal irrigation with saline solution may reduce symptom severity in children with upper respiratory tract infections, with a level of evidence of 2 and recommendation strength of B. 7
Clinical Algorithm for Use
For acute upper respiratory infections in children:
- Age <1 year: Use isotonic saline drops or spray followed by gentle aspiration (avoid high-volume irrigation in very young infants) 2
- Age 1-2 years: Isotonic saline irrigation or spray 2-4 times daily; avoid OTC decongestants and antihistamines 5, 3
- Age >2 years: Isotonic saline irrigation (large volume if tolerated) 2-4 times daily as adjunct to other appropriate therapies 1, 6
For chronic rhinosinusitis: Large-volume, low-pressure, twice-daily intranasal hypertonic or isotonic irrigation for at least 6 weeks is safe and effective and should be used as baseline treatment before considering surgical interventions. 8
Important Caveats
Adverse effects of saline irrigations are rare but include local irritation, ear pain, nosebleeds, headache, nasal burning, and nasal drainage. 1
Xylitol-containing solutions are not recommended as first-line treatment for pediatric chronic rhinosinusitis due to low tolerance, compliance issues, and side effects. 8
Temperature of the solution does not appear to influence outcomes—one study found no differences between room temperature and 40°C saline on mucociliary transit time and nasal obstruction. 1