Intranasal saline improved symptoms in children with obstructive sleep-disordered breathing (OSDB) and may represent an effective first-line intervention before consideration of polysomnography or surgical intervention, according to a randomized clinical trial published in JAMA Pediatrics.1
OSDB, characterized by snoring and upper airway obstruction during sleep, affects up to 12% of children and is a leading indication for adenotonsillectomy. However, long wait times for specialist evaluation and surgery can prolong disrupted sleep and its downstream behavioral and health consequences.
The study’s lead author, Gillian Nixon, MD, said the results suggest that treatment with intranasal saline before referral to specialist services may reduce demand for these services.
“Early recognition of symptoms of obstructive sleep-disordered breathing by parents and primary care physicians and a trial of treatment with saline nasal spray has the potential to address these issues early,” she said.
The Intranasal Steroid as Medical Therapy For Sleep-Disordered Breathing in Children (MIST+) trial enrolled children aged 3 to 12 years old who had been referred to specialist clinics for symptoms of OSDB and were awaiting evaluation, reflecting a population commonly encountered in clinical referral pathways.2 All participants received once-daily intranasal saline for an initial six-week period. Children whose symptoms persisted were then randomized to receive either intranasal mometasone furoate or continued saline for an additional six weeks.
The MIST+ study relied on parent-reported symptoms rather than requiring polysomnography, making the findings more directly applicable to primary care settings. Symptom resolution was defined using a validated parent-reported sleep-disordered breathing symptom score.
“Previous studies have relied on sleep studies to define both eligibility and treatment response,” Dr. Nixon said. “We planned this study based on symptom reports from parents to make sure it was directly translatable into primary care, without the need for specialist investigations.”
Of 139 children who completed the run-in phase, saline treatment alone resulted in symptom resolution in nearly 30% of participants. Among the 93 children who remained symptomatic and were randomized, symptom resolution occurred at similar rates in both groups—35.6% with intranasal corticosteroids and 36.4% with continued saline—indicating no meaningful additional benefit from corticosteroid therapy.
“The results of both our randomized controlled trials are consistent in the conclusion that saline is as effective as corticosteroid in managing symptoms of OSDB,” Dr. Nixon said. “We think this should make intranasal saline the first-line treatment for these symptoms. The wait time for specialist clinics and for surgery is months to years in many settings.”1,3
She said symptom improvement before referral could result in fewer parents seeking surgical treatment, potentially reducing surgical exposure while improving access to specialist care for children with persistent or more severe disease.
However, the relatively short duration of follow-up in the study is an important limitation. Additionally, the study does not address whether nasal saline is effective in managing OSDB in children younger than 3 years old.
“We don’t yet know whether the improvement in symptoms with saline treatment persists beyond 18 weeks or whether further courses of treatment are needed over time,” Dr. Nixon said.
Additional research is needed to determine whether symptom improvement is sustained and whether initial saline treatment in primary care settings could reduce long-term specialist referrals.
References
1. Nixon GM, Anderson D, Baker A, et al. Intranasal treatments for children with sleep-disordered breathing: the MIST+ randomized clinical trial. JAMA Pediatr. 2026;180(3):240-249. doi:10.1001/jamapediatrics.2025.5717
2. Intranasal Steroid as Medical Therapy For Sleep-Disordered Breathing in Children (MIST+). ClinicalTrials.gov. NCT05382494
3. Baker A, Grobler A, Davies K, et al. Effectiveness of intranasal mometasone furoate vs saline for sleep-disordered breathing in children: a randomized clinical trial. JAMA Pediatr. 2023;177(3):240-247. doi:10.1001/jamapediatrics.2022.5258
