Treating childhood sleep apnoea without surgery

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About one in 10 children snore regularly, breathe noisily during sleep, or have short episodes where they stop breathing altogether. It understandably frightens parents, and often leads to trials of nasal steroid sprays, referral for sleep studies, or a visit to an ENT surgeon to discuss removing the adenoids and tonsils.

That last option is more common than many people realise. Tonsillectomy is the most common elective surgical procedure in Australian children, with more than 40,000 performed each year. Many hospitals carry long waiting lists for the procedure, and while it's generally effective, it's costly, involves a recovery period, and carries the risks that come with any surgery in a young child.

Saline spray was as effective as steroids for childhood sleep apnoea, and the need for sleep studies and surgery dropped by 60%

An Australian randomised trial, the MIST+ study, led by Monash University, Monash Children's Hospital and the Murdoch Children's Research Institute, set out to test whether something much simpler might work first. The trial involved 150 children aged three to 12 who had been referred to specialists for sleep-related breathing difficulties, all with reasonably severe obstructive sleep disordered breathing. All children were given a daily saline nasal spray for six weeks, after which those still symptomatic were randomised to either continue with saline or switch to a steroid spray for another six weeks.

Here's what's interesting: before the randomisation even happened, nearly one in three children had no remaining symptoms. That could have been the saline doing its job, or natural resolution. It's hard to separate the two. But in the second six weeks, saline and steroids performed equally well. The saline actually had a more sustained effect than the steroids, with no differences in side effects such as minor nosebleeds or nasal irritation.

Across the 12 weeks, half of the children had recovered without needing specialist care or surgery. The need for sleep studies and referral to ENT dropped by around 60%.

The practical takeaway for general practice: in children with obstructive sleep disordered breathing, a 12-week course of once-daily saline spray is a low-cost, low-risk first step that could spare a significant number from the surgical pathway altogether, and meaningfully reduce pressure on already stretched specialist waitlists.