Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children

For nasal patency (breathing score) at the second visit, the mean difference between saline wash and control groups was -0.33 (95% CI -0.47 to -0.19).

“The difference for the saline wash group compared with the control group at the second visit was MD ‐0.33 (95% CI ‐0.47 to ‐0.19).”

Slapak 2008 reported a significant reduction in nasal secretion score at visit two (up to three weeks) for all nasal saline groups compared to control, with a mean difference of -0.31 (95% CI -0.48 to -0.14) on a four-point scale.

“Slapak 2008 reported a significant reduction nasal secretion score at visit two (up to three weeks after enrolment) for all nasal saline groups compared to control as a mean difference (MD) of ‐0.31 (95% confidence interval (CI) ‐0.48 to ‐0.14) on a four‐point scale.”

Slapak 2008 adequately discussed drop-outs and losses to follow-up, which numbered only 11 out of the initial 401 participants enrolled (low risk of bias).

“Slapak 2008 adequately discussed drop‐outs and losses to follow‐up, which numbered only 11 out of the initial 401 participants enrolled in the trial (low risk of bias).”

In Slapak 2008, patient blinding was largely impossible, and outcome assessors were blinded only to the type of saline spray delivery, not to whether participants were using saline treatment (unclear risk of bias).

“In particular, the design of Slapak 2008 made patient blinding largely impossible as each participant either used the saline spray or did not. The outcome assessors were blinded only to the type of saline spray delivery used and not blinded as to whether or not participants were using the saline treatment (unclear risk of bias).”

Slapak 2008 reported statistically significant reductions in nasal decongestant and mucolytic medication used for symptomatic relief in the saline groups (P < 0.5) (Table 4).

“Slapak 2008 did report statistically significant reductions in nasal decongestant and mucolytic medication used for symptomatic relief in the saline groups (P value < 0.5) (Table 4).”

In Slapak 2008, the mean health status score at follow-up for the control group was 2.6 (SD 1.02) for cold and 2.00 (SD 0.91) for flu, compared with 1.87 (SD 0.84) for cold and 1.59 (SD 0.74) for flu in the saline wash group, with P < 0.05 for both.

“The mean health status score at the follow‐up examination for the subgroups 'entry during cold' and 'entry during flu' respectively was 2.6 (standard deviation (SD) 1.02) and 2.00 (SD 0.91) for the control group, compared with 1.87 (SD 0.84) and 1.59 (SD 0.74) for the saline wash group, with a P value of < 0.05 reported for both groups.”

King 2012 and Slapak 2008 found a trend to reduced antibiotic use in the nasal saline group, though this did not reach statistical significance (Analysis 2.1).

“King 2012 and Slapak 2008 compared the use of antibiotics in saline groups versus controls and found a trend to reduced antibiotic use in the nasal saline group, though this did not reach statistical significance (Analysis 2.1).”

Slapak 2008 found an overall rate of adverse events of 8.7%, most of which were reported by participants in the medium jet group and associated with the higher flow rate.

“The third study, using children, found an overall rate of adverse events of 8.7%, most of which were reported by participants in the medium jet group and associated with the higher flow rate (Slapak 2008).”

For nasal secretion type at the second visit, the mean difference between saline wash and control groups was -0.34 (95% CI -0.50 to -0.18) on a four-point scale, indicating a small improvement with nasal saline irrigation.

“For this comparison of the saline wash and control groups at the second visit on a four‐point scale the MD was ‐0.34 (95% CI ‐0.50 to ‐0.18), indicating a small improvement with nasal saline irrigation.”

The largest trial (Slapak 2008), which had a high risk of bias, reported statistically significant outcomes for the nasal saline group at follow-up, including reduction of sore throat, nasal secretion and secretion type, nasal breathing score, and improvement in health status score.

“The largest trial, which also had a high risk of bias, reported a number of statistically significant outcomes for the nasal saline group at follow‐up, including reduction of sore throat, nasal secretion and secretion type and nasal breathing score (Slapak 2008). It also reported a significant improvement in the health status score.”

There was a trend towards reduced antibiotic use in one study with saline nasal irrigation, and this study also demonstrated a statistically significant reduction in the use of adjunct nasal decongestant treatment with nasal saline irrigation compared to control (Slapak 2008).

“There was a trend towards reduced antibiotic use in one study with saline nasal irrigation and this study also demonstrated a statistically significant reduction in the use of adjunct nasal decongestant treatment with nasal saline irrigation compared to control (Slapak 2008).”

Only one of the included papers (Slapak 2008) examined the effect of saline irrigation on other symptoms, such as anosmia and cough associated with acute URTIs.

“Only one of the included papers examined the effect of saline irrigation on other symptoms, such as anosmia (loss of the sense of smell) and cough associated with acute URTIs (Slapak 2008).”

Discomfort in one study was associated with higher application pressures rather than the nasal saline solution itself (Slapak 2008).

“Discomfort in one study was associated with higher application pressures rather than the nasal saline solution itself (Slapak 2008).”

No serious adverse effects occurred in the included trials, although three children in one study experienced nosebleeds (Slapak 2008).

“No serious adverse effects occurred in the included trials, although three children in one study experienced nosebleeds (Slapak 2008).”

Slapak 2008 used a commercial isotonic seawater product containing zinc and other elements that may be a factor in the effects of the product.

“In particular, Slapak 2008 used a commercial isotonic seawater product containing zinc and other elements that may be a factor in the effects of the product.”

In Slapak 2008, drop-out and losses to follow-up were small and adequately discussed, with 390 of 401 completing the study, judged low risk of attrition bias.

“Drop‐out and losses to follow‐up small and adequately discussed. 390 of 401 completed the study (11 lost to follow‐up)”

In Slapak 2008, no patient blinding was possible due to study design, and outcome assessors were blinded to saline delivery method but not to intervention versus control, judged unclear risk of performance and detection bias.

“No patient blinding possible due to study design; outcome assessors blinded to saline delivery method but not to intervention versus control”

In Slapak 2008, intention-to-treat analysis was not performed and the original study protocol was not available, judged unclear risk of reporting bias.

“Intention‐to‐treat analysis not performed; original study protocol not available”

Slapak 2008 used sequence of clinic arrival for allocation, judged high risk of selection bias.

“Sequence of clinic arrival used for allocation”

No other potential sources of bias were identified in Slapak 2008, judged low risk of other bias.

“No other potential sources of bias identified”

The review omitted the outcome 'time off work or school' from Slapak 2008 because it was based on follow-up periods outside the specifications for acute URTIs as specified in the protocol.

“Also, we noted the inclusion of the outcome 'time off work or school' from Slapak 2008 in the original review to be based on follow‐up periods outside of the specifications for acute URTIs as specified in the protocol, so we omitted this from inclusion in this 2014 update.”

Slapak 2008 did not mention allocation concealment, judged unclear risk of selection bias.

“Not mentioned in paper”