Source: 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.Investigators from multiple institutions in Australia conducted a randomized clinical trial to compare the effectiveness of intranasal saline and intranasal steroid (INS) in improving symptoms of obstructive sleep-disordered breathing (OSDB) in children. Study participants were patients 3–12 years old with symptoms of OSDB who had been referred to a specialist for evaluation of OSDB and at baseline had a sleep disordered breathing (SDB) score of ≥-1. At enrollment, all study children received intranasal normal saline, 1 spray in each nostril daily, for 6 weeks. At the end of this run-in phase, those with persistent symptoms (SDB ≥-1) were randomized to continue intranasal saline or switch to INS (mometasone furoate 50 μg/spray) for an additional 6 weeks (treatment phase). Children with resolution of OSDB symptoms (SDB <-1) at the end of the run-in phase were not randomized. OSDB symptoms were assessed after 6 weeks of INS or intranasal saline in participants included in the treatment phase. OSDB symptoms also were assessed 12 weeks from the end of the treatment phase in randomized participants and 12 weeks from the end of the run-in phase for those not randomized. The primary study outcome was resolution of OSDB symptoms (SDB <-1) after the end of the run-in and treatment phases, and a main secondary outcome was resolution of OSDB symptoms 12 weeks after completing study treatment. Outcomes were compared in participants randomized to INS or intranasal saline.A total of 150 children, mean age 6.2 ±2.3 years, were enrolled in the run-in phase of the study. The mean SDB score at baseline in these participants was 1.2 ±1.5. Among those who completed the run-in phase, 41/139 (29.5%) had resolution of OSDB symptoms. Symptom resolution was sustained for 12 weeks in 24/37 (64.9%) children. For those with persistent OSDB symptoms, 93 participants, including 47 randomized to INS and 46 to intranasal saline, were enrolled in the treatment phase. At the end of 6 weeks, OSDB symptoms had resolved in 16/45 (35.6%) of children in the INS group and 16/44 (36.3%) of those randomized to intranasal saline (risk difference RD, -0.9%; 95% confidence interval CI, -20.8, 19.0). Twelve weeks following completion of the treatment phase, 9/45 (20.0%) children randomized to INS and 15/42 (35.7%) of those in the intranasal saline group had resolution of OSDB symptoms (RD, -17.6%; 95% CI, -35.7, 0.6).The authors conclude that there was no difference in resolution of OSDB symptoms in children treated with INS or intranasal saline for 6 weeks.Dr Dubik has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.In 1861, George Caitlin published The Breath of Life, in which he proposed that the root cause of sleep-related health issues is mouth breathing.1 In 2020, James Nestor published Breath: The New Science of a Lost Art, which included Nestor’s exploration of nasal breathing and his personal experiments with mouth taping at Stanford University.2 In 2014, Guilleminault and Sullivan argued that the ultimate treatment goal for pediatric SDB should be the restoration of continuous nasal breathing during wake and sleep.3The current rigorous, pragmatic study found that intranasal saline alone is an effective first-line therapy for obstructive sleep-disordered breathing (OSDB) symptoms and challenges the assumption that saline is merely a placebo.However, because the outcomes were entirely based on symptom-based questionnaires, the current researchers could not determine whether the interventions resulted in improved physiologic nasal obstruction or only symptom perception.Because all study participants received saline, there was no control group to assess the natural history or spontaneous resolution. The Childhood Adenotonsillectomy Trial (CHAT) demonstrated that nearly half of the children in the watchful waiting arm had normalization of polysomnographic findings over time, underscoring the importance of accounting for spontaneous resolution.4 Saline may, however, exert therapeutic effects through a combination of reduction of nasal resistance, improved mucociliary clearance, and enhanced airway humidification.The current authors conclude that treating OSDB symptoms with 6–12 weeks of intranasal saline before referral to a specialist is likely to reduce demand for polysomnography and surgery. However, this study does not definitively demonstrate equivalence to INS in treating pediatric SDB.A trial of intranasal saline for 3 months is reasonable in children with mild OSDB symptoms.
A Mon, study studied this question.