Can intranasal saline be used to help children with sleep‑disordered breathing?

Intranasal Saline for Sleep-Disordered Breathing in Children

Intranasal saline is an effective first-line treatment for children with sleep-disordered breathing, resolving symptoms in approximately 30-50% of cases without requiring intranasal steroids or surgical intervention. 1

Primary Evidence from Recent High-Quality Research

The most recent and highest quality evidence comes from the 2026 MIST+ randomized clinical trial, which demonstrated that:

• 6 weeks of intranasal saline alone resolved sleep-disordered breathing symptoms in 29.5% of children (ages 3-12 years) before any additional intervention 1
• An additional 6 weeks of treatment (either continuing saline or switching to intranasal steroids) resolved symptoms in another third of children, bringing total resolution to approximately 50% 1
• Critically, there was no added benefit from intranasal steroids compared to continued saline (35.6% vs 36.4% resolution; risk difference -0.9%; P=0.93) 1

This finding was corroborated by the 2023 MIST trial, which found no difference between intranasal mometasone and saline for symptom resolution (44% vs 41%; P=0.51) 2

Clinical Algorithm for Implementation

Step 1: Initial Assessment

• Children aged 3-12 years with snoring, difficulty breathing during sleep, or behavioral symptoms suggestive of sleep-disordered breathing 1
• Exclude children with previous adenotonsillectomy, BMI >97th percentile, or severe sleep-disordered breathing requiring immediate intervention 2

Step 2: First-Line Treatment

• Prescribe intranasal saline (0.9% sodium chloride), 1 spray per nostril daily for 6 weeks 1
• This simple intervention resolves symptoms in nearly one-third of children without need for steroids or surgery 1

Step 3: Reassessment at 6 Weeks

• If symptoms resolve (SDB score <-1 or no longer requiring specialist referral per American Academy of Pediatrics guidelines), continue saline as needed 2, 1
• If symptoms persist, continue intranasal saline for an additional 6 weeks (total 12 weeks) rather than escalating to steroids 1

Step 4: Consider Specialist Referral After 12 Weeks

• Only after 3 months of saline therapy should polysomnography or surgical intervention be considered 1
• This approach reduces unnecessary specialist referrals by approximately 50% 2

Why Intranasal Steroids Are Not Superior to Saline

While older European Respiratory Society guidelines (2011) recommended intranasal steroids for childhood sleep-disordered breathing with co-existing rhinitis or adenotonsillar hypertrophy (Grade B recommendation) 3, the most recent high-quality randomized controlled trials directly contradict this recommendation by showing no benefit of steroids over saline 2, 1.

The 2023 and 2026 trials represent the highest quality evidence available:

• Double-blind, placebo-controlled design 2, 1
• Multicenter recruitment 2
• Intention-to-treat analysis 2
• Patient-centered outcomes (symptoms and quality of life, not just polysomnography parameters) 2

Safety Profile

Intranasal saline has a superior safety profile compared to intranasal steroids:

• Epistaxis occurred in 15% with saline vs 9.7% with mometasone 2
• Nasal irritation occurred in 18% with saline vs 9.7% with mometasone 2
• Both treatments showed similar mild adverse effects, but saline avoids potential concerns about systemic steroid absorption in children 2

Special Populations

Children with allergic rhinitis or adenotonsillar hypertrophy:

• Even in these subgroups, the 2026 MIST+ trial found no subgroup more or less likely to respond to medical treatment, suggesting saline is equally effective regardless of underlying pathology 1
• The American Academy of Otolaryngology-Head and Neck Surgery (2015) noted that treatment of allergic rhinitis can improve sleep-disordered breathing, but this does not require steroids when saline is equally effective 3

Common Pitfalls to Avoid

• Do not immediately prescribe intranasal steroids without first trying saline for 12 weeks 1
• Do not refer to specialists or order polysomnography before completing a 3-month trial of intranasal saline 1
• Do not assume that children with adenotonsillar hypertrophy require steroids—saline works equally well in this population 1
• Do not use the 2011 European guidelines as justification for steroids—they predate the definitive 2023 and 2026 trials showing no benefit 2, 1

Cost and Resource Implications

Intranasal saline represents a cost-effective first-line approach:

• Nearly 50% of children avoid specialist referral, polysomnography, and potential surgery 2, 1
• Saline is significantly less expensive than intranasal steroids 2
• Primary care providers can manage these patients without specialist involvement for the first 3 months 2