A simple intranasal saline solution has been shown to resolve symptoms of obstructive sleep-disordered breathing in children over 12 weeks, with no additional benefit from intranasal steroids.

Obstructive sleep-disordered breathing is common in childhood, affecting up to 12% of children, and is associated with behavioural disturbance, impaired quality of life and cardiometabolic consequences.

Although adenotonsillectomy remains the first-line treatment, this surgical intervention carries cost and risk, and long waiting times can prolong symptom burden. Medical therapies, including intranasal steroids, are increasingly used to manage symptoms and potentially reduce the need for surgery.

Against this background, the MIST+ randomised clinical trial examined whether intranasal steroids provided additional benefit over saline in children with persistent obstructive sleep-disordered breathing symptoms.

The study was conducted at two tertiary paediatric centres in Melbourne, Australia, and recruited via specialist clinic waiting lists and community advertising.

MIST+ enrolled 150 children aged three to 12 years (mean age 6.2 years; 62% male) with clinically significant symptoms. All participants received once-daily intranasal saline for an initial six-week run-in period.

Children with previous adenotonsillectomy, obesity above the 97th centile, craniofacial or neuromuscular conditions, or recent corticosteroid use were excluded.

Of the 139 children who completed the run-in phase, symptoms resolved in 41 (29.5%), and these children did not proceed to randomisation. The remaining 93 children were randomised to receive either intranasal mometasone furoate 50 μg daily (n=47) or continued saline (n=46) for a further six weeks.

Obstructive sleep-disordered breathing symptom resolution

Among those randomised with persistent symptoms, resolution occurred in 35.6% of the intranasal steroid group and 36.4% of the saline group after the additional six-week treatment phase.

There was no clinically or statistically significant difference between groups (risk difference −0.9%; 95% CI −20.7%–19.0%; P=0.93). Overall, approximately 50% of the total cohort of children with obstructive sleep-disordered breathing experienced symptom resolution within 12 weeks.

Secondary outcomes such as sleep-related quality of life, behavioural measures, parental satisfaction and parental perception of the need for surgery did not differ between treatment groups.

Subgroup analyses by age, tonsillar hypertrophy, allergic rhinitis, weight status or baseline symptom severity did not identify any subgroup more likely to benefit from intranasal steroids.

Treatment adherence was high, with more than 90% of children using at least 80% of prescribed doses. Adverse events were generally mild, with nasal irritation and epistaxis occurring infrequently and at similar rates in both groups.

The authors highlighted the absence of an observation-only control group, which meant spontaneous symptom resolution could not be entirely excluded. In addition, the relatively short follow-up period further limited conclusions regarding longer-term effectiveness beyond three months.

The trial results support saline as an effective, short-term first-line therapy for childhood obstructive sleep-disordered breathing, potentially easing pressure on specialist services.

Use of intranasal saline for up to three months should be considered before polysomnography, specialist referral or surgical intervention, the authors said, but they cautioned that further investigations are needed to assess the durability of symptom improvement beyond the study period and to refine care pathways for children with obstructive sleep-disordered breathing.

Reference
Nixon GM et al. Intranasal Treatments for Children with Sleep-Disordered Breathing. The MIST+ Randomized Clinical Trial. JAMA Pediatr 2026;Jan 20:e255717.