Comparison between the use of saline and seawater for nasal obstruction in children under 2 years of age with acute upper respiratory infection

Abstract

Background/aim:
The effectiveness of isotonic and hypertonic saline solutions used to open the nasal passage and improve clinical symptoms was compared in children under 2 years of age admitted with the common cold.

Materials and methods:
The study was performed as a randomized, prospective, and double-blind study. The study included 109 children. The children using saline (0.9%) and seawater (2.3%) as nasal drops (the patient group) and the control group (in which nasal drops were not administered) were compared. Seventy-four patients received nasal drops from package A (seawater) in single days and from package B (physiological saline) in double days.

Results:
The mean age of the patients was 9.0 ± 3.9 months and the numbers of boys and girls were 65 (59.6%) and 44 (40.4%), respectively. There was no significant difference between Groups A and B in terms of nasal congestion (P > 0.05). However, a significant difference was found between the control group and Groups A and B (P < 0.05).

Conclusion:
Relief was seen in nasal congestion, weakness, sleep quality, and nutrition with the use of both saline and seawater in children with the common cold. Seawater or saline drops may be added to standard treatment protocols.

Full text

1004
http://journals.tubitak.gov.tr/medical/
Turkish Journal of Medical Sciences
Turk J Med Sci
(2016) 46: 1004-1013
© TÜBİTAK
doi:10.3906/sag-1507-18
Comparison between the use of saline and seawater for nasal obstruction in children
under 2 years of age with acute upper respiratory infection
Tülin KÖKSAL1,*, Mehmet Nevzat ÇİZMECİ2, Davut BOZKAYA2, Mehmet Kenan KANBUROĞLU2,
Şanlıay ŞAHİN1, Tuğba TAŞ2, Çiğdem Nükhet YÜKSEL2, Mustafa Mansur TATLI2
1Department of Pediatrics, Ankara Pediatric and Pediatric Hematology Oncology Training and Research Hospital, Ankara, Turkey
2Department of Pediatrics, Faculty of Medicine, Turgut Özal University, Ankara, Turkey
* Correspondence: tulinkoksal6623@gmail.com
1. Introduction
e common cold is an acute and self-limiting viral
infection of the upper respiratory tract. Varying degrees
of sneezing, nasal congestion, rhinorrhea, sore throat,
cough, mild fever, headache, and weakness are seen (1–3).
e treatment of the common cold is supportive. Plenty of
uid intake and opening of the nasal passage with saline or
hypertonic solution are recommended (2).
Paranasal sinus mucosa is a continuation of the
mucosa of the nasal cavity. erefore, the infection of this
region is usually seen as rhinosinusitis. e mucociliary
activity decreases in rhinosinusitis. It has long been argued
that nasal irrigation had a place in the treatment. Nasal
irrigation is used in rhinosinusitis and allergic rhinitis (4).
Mucociliary plaque in the respiratory tract is protective
against infection entering by inhaled air. Reduction in
mucociliary activity causes various respiratory diseases.
According to the accepted hypothesis, it is said that nasal
irrigation increases the mucociliary clearance and reduces
nasal edema and inammatory mediators (5). At the same
time, it is known that irrigation cleans dust and secretions
and makes the mucus more uid; irrigation is performed
with isotonic or hypertonic saline (4).
It is reported that nasal irrigation with saline
solution performs mechanical cleaning by increasing
the mucociliary clearance; in addition to increasing the
mucociliary activity, hypertonic serum reduces edema and
suppresses inammation (6–8).
Besides the benets of hypertonic solutions used for
nasal washes, studies have also reported side eects of
these solutions. It has been stated that hypertonic solutions
cause nasal congestion, rhinorrhea, and pain by increasing
histamine and substance P release. It was reported that the
side eects increased with increasing the concentration of
the nasal wash solution (9,10). In contrast, another study
reported that there was no adverse eect in children with
allergic rhinitis using hypertonic saline (3%) (11).
e studies conducted so far investigated the
eectiveness and the side eects of nasal irrigation in
children with allergic rhinitis or rhinosinusitis. ere
are very few studies in the literature related to the use of
physiological serum in upper respiratory tract infections
Background/aim: e eectiveness of isotonic and hypertonic saline solutions used to open the nasal passage and improve clinical
symptoms was compared in children under 2 years of age admitted with the common cold.
Materials and methods: e study was performed as a randomized, prospective, and double-blind study. e study included 109
children. e children using saline (0.9%) and seawater (2.3%) as nasal drops (the patient group) and the control group (in which nasal
drops were not administered) were compared. Seventy-four patients received nasal drops from package A (seawater) in single days and
from package B (physiological saline) in double days.
Results: e mean age of the patients was 9.0 ± 3.9 months and the numbers of boys and girls were 65 (59.6%) and 44 (40.4%),
respectively. ere was no signicant dierence between Groups A and B in terms of nasal congestion (P > 0.05). However, a signicant
dierence was found between the control group and Groups A and B (P < 0.05).
Conclusion: Relief was seen in nasal congestion, weakness, sleep quality, and nutrition with the use of both saline and seawater in
children with the common cold. Seawater or saline drops may be added to standard treatment protocols.
Key words: Child, common cold, nasal saline, nasal drop, seawater
Received: 03.07.2015 Accepted/Published Online: 13.09.2015 Final Version: 23.06.2016
Research Article

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KÖKSAL et al. / Turk J Med Sci
and inuenza (12,13). It is not known whether the use of
physiological serum or seawater is more eective in viral
upper respiratory tract infection. In the present study, we
aimed to investigate whether there is a dierence between
the use of seawater and saline in terms of the relief of nasal
congestion-associated symptoms in children with acute
upper respiratory tract infections.
2. Materials and methods
In this study 109 children under the age of 2 who were
admitted to Turgut Özal University School of Medicine
general pediatric outpatient clinic between 17 September
2012 and 16 November 2012 and diagnosed with acute
upper respiratory tract infection were evaluated. e
patient group consisted of children using saline (0.9%
isotonic saline) and seawater (2.3% hypertonic saline) as
nasal drops; the control group included children who were
not given nasal drops. e results of both groups were
compared.
e study was planned as a randomized, prospective,
and double-blind study. It was approved by the ethics
committee of Turgut Özal University (B 30 2 FTH 0 20 00
00/1093/2012). e families of the patients participating
in the study were informed and written consent was
obtained. Children with chronic diseases and other serious
infections were excluded from the study.
In this study, 38 of 74 patients admitted to the clinic
received nasal drops from package A (Group A: seawater)
in single days; the other 36 patients received nasal drops
from package B (Group B: physiological saline) in double
days. Cleaning with nasal aspirator or nasal pumps aer
instillation of drops in the nose was suggested for Groups
A and B. No drops or devices were recommended for the
control group (n = 35). While the study was being planned,
the A and B boxes were prepared equally, including 45 vials
in each of them. However, 7 patients from Group A and 9
patients from Group B could not be reached by telephone,
and these patients did not come for check-ups. ese
16 patients, who could not be reached for these reasons,
were excluded from the study, as shown in the study ow
diagram in Table 1.
ree boxes of nasal drops, including 5 vials in each
box, were given to the patients in their rst admission and
3 vials were recommended to be used each day. Enough
drops were given for 5 days. Group A and Group B were
treated exactly the same, and we did not provide any
treatment to the control group. All the groups (A, B, and
control) were examined on days 1 and 7 and rung on days
3 and 5. We planned to recall and examine the patients in
the presence of circumstances necessitating intervention
other than the standard ndings asked in the questionairre.
However, we did not observe a dierent cause other than
the patients’ complaints.
On days 3 and 5 aer the initiation of treatment, the
families were contacted by phone. As it was planned, the
contributions of “TK, MNÇ, DB, MKK, and TT” were in
the conception and design of the study, or the acquisition
of data, or analysis and interpretation of data (call the
patients’ families and/or answer the families’ call). e
telephone numbers of the doctors above were given to the
Assessed for eligibility (n = 125)
Excluded (n = 0)
Not meeting inclusion criteria (n = 0)
Declined to participate (n = 0)
Other reasons (n = 0)
Randomized (n = 125)
Group C (Control)
Allocated to intervention (n = 35)
Received allocated intervention (n = 35)
Did not receive allocated intervention
(Give reasons) (n = 0)

Group B
Allocated to intervention (n = 45)
Received allocated intervention (n = 45)
Did not receive allocated intervention
(Give reasons) (n = 0)
Group A
Allocated to intervention (n = 45)
Received allocated intervention (n = 45)
Did not receive allocated intervention
(Give reasons) (n = 0)
Lost to follow-up (give reasons) (n = 7)
Patients could not be reached by telephone
Discontinued intervention (give reasons) (n = o)
Lost to follow-up (give reasons) (n = 9)
Patients could not be reached by telephone
Discontinued intervention (give reasons) (n = 0)
Lost to follow-up (give reasons) (n = 0)
Discontinued intervention
(Give reasons) (n = o)
Analysed (n = 35)
Excluded from analysis
(Give reasons) (n = 0)
Analysed (n = 36)
Excluded from analysis
(Give reasons) (n = 0)
Analysed (n = 38)
Excluded from analysis
(Give reasons) (n = 0)
Table 1. Study ow diagram.

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families. If there was no problem, the doctors phoned the
families on days 3 and 5. However, if there was a problem
on days other than these days (3 and 5), the families
called the doctors. e calls by the families only included
questions about the parents’ concerns about their children
and so these calls did not aect the conclusion of the study.
e participants were called in for a check-up on day 7.
If we did not reach the participants by phone the rst
time, we tried again three times at dierent times of the
day. When we were not able to reach them the third time,
we excluded these participants from the study.
As mentioned above, the authors who made the calls
were experienced medical doctors. ey did not know to
which group the patient had been allocated and neither
did the families (double-blind study).
We always asked the same questions in the rst
application, the check-up (day 7), and over the phone
(days 3 and 5), and we have added in the “study form” the
exact wording of the questions.
In the rst application, on the phone (days 3 and 5),
and the check-up (day 7), the families were asked about
several parameters including nasal congestion, rhinorrhea,
nasal bleeding, weakness, sleep patterns, cough, whether
nutrition was aected, and whether there was a history of
usage of nasal pump or aspirator. e answers given were
evaluated as no symptoms: 0, mild symptoms: 1, moderate
symptoms: 2, and severe symptoms: 3.
2.1. Statistical analysis
Descriptive statistics were summarized as counts and
percentages for categorical variables, and as medians,
minimums, and maximums for continuous variables.
Repeated measures were determined by repeated
measures ANOVA, followed by Bonferroni’s post-hoc
test. Chi-square test was applied to compare the data
between the groups. All the data were analyzed using
SPSS for Windows 20 (SPSS Inc, Chicago, IL, USA). P <
0.05 was considered signicant. Sample size estimates
were calculated using G*Power. (Considering an eect
size d of 0.5 andalpha error probability of 0.05, the power
calculated byG*Power (Universität Düsseldorf ) was 78%).
3. Results
e mean age of the patients was 9.0 ± 3.9 months (with a
range of 2–17 months), and the numbers of boys and girls
were 65 (59.6%) and 44 (40.4%), respectively. In Group A
there were 22 boys (57.9%) and 16 girls (42.1%). In Group
B there were 25 boys (69.4%) and 11 girls (30.6%). In the
control group there were 18 boys (51.4%) and 17 girls
(48.6%).
ere was no signicant dierence between Groups A
and B in terms of nasal congestion (P > 0.05). However,
a signicant dierence was found between the control
group and Groups A and B (P < 0.001). As the days passed,
the nasal congestion in Groups A and B lessened, and a
signicant dierence was found when compared with the
control group (Figure 1).
Similarly, there was no signicant dierence between
Groups A and B in terms of weakness, but signicant
dierences were also found between the control group and
Groups A and B (P < 0.05) (Figure 2).
ere was no signicant dierence between Groups A
and B in terms of rhinorrhea, but signicant dierences
were found between the control group and Groups A and
B (P < 0.05) (Figure 3). ere was no signicant dierence
between the control group and Groups A and B in terms of
nasal bleeding (P > 0.05, for each) (Figure 4).
ere was no signicant dierence between Groups
A and B in terms of sleep quality (P > 0.05). However, a
signicant dierence for this variable was found between
the control group and Groups A and B (P < 0.001). Every
day sleep quality was found to be slightly increased in
Groups A and B (Figure 5).
ere was no signicant dierence between Groups A
and B in terms of diet (P > 0.05). A signicant dierence
for this variable was found between the control group and
Groups A and B (P < 0.001). However, changes were not
seen from day 5 (Figure 6).
ere was no signicant dierence between box A and
box B in the usage of nasal pump and nasal aspirator to
clean the nose. However, a signicant dierence for this
variable was found between the control group and Groups
A and B (P < 0.001) (Figure 7).
ere was no signicant dierence between the groups
in terms of cough (P > 0.05) (Figure 8).
Distributions of the parameters in Groups A and B and
the control group at 0, 3, 5, and 7 days are shown in Tables
2, 3, and 4, respectively.
Comparison between the study groups for all variables
(nasal congestion, weakness, etc.) is provided in Table 5.
4. Discussion
Children are mostly aected by nasal congestion in
upper respiratory tract infections. Treatment of acute
upper respiratory tract infections is supportive, including
the intake of food and plenty of uids and opening of
the nasal passage. In upper respiratory tract infections,
nasal secretions become more dense and mucopurulent;
therefore, this situation secondarily aects the mucociliary
transport. When mucus debris is aspirated or rehydrated
with a few drops of saline, it is seen that transport starts
again (14). It has been emphasized in many studies that
nasal irrigation is useful in seasonal allergic rhinitis, acute
sinusitis, and chronic sinusitis (11,15–17). In another
study it was shown that using nasal saline and nasal
corticosteroid together was more eective and economical
than using nasal saline alone or nasal steroid alone (18).

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Figure 1. Nasal congestion in Group A, Group B, and the control group 63 × 45 mm
(300 × 300 DPI).
Figure 2. Weakness in Group A, Group B, and the control group 54 × 47 mm (300
× 300 DPI).

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Figure 3. Rhinorrhea in Group A, Group B, and the control group 54 × 42 mm (300
× 300 DPI).
Figure 4. Nasal bleeding in Group A, Group B, and the control group 54 × 42 mm
(300 × 300 DPI).

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Figure 5. Sleep quality in Group A, Group B, and the control group 54 × 42 mm (300
× 300 DPI).
Figure 6. Diet in Group A, Group B, and the control group 54 × 42 mm (300 × 300
DPI).

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Figure 7. Use of nasal aspirator and nasal pump in Group A, Group B, and the
control group 54 × 42 mm (300 × 300 DPI).
Figure 8. Cough in Group A, Group B, and the control group 54 × 42 mm (300 × 300 DPI).

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Our results were in parallel with these studies and it was
observed that physiological saline and seawater had equal
eciency to relieve nasal congestion; moreover, nasal
congestion was relieved earlier in the treated groups than
in the control (untreated) group. e thickened mucus
was removed from the ambient and the nasal mucosa was
moistened with nasal drops. In addition, more eective
cleaning of the nose with a pump or aspirator and the
reduction of symptoms were signicant.
Šlapak et al. (13) showed that washing the noses of
children between 6 and 10 years of age with acute upper
respiratory tract infection with saline cured the nasal
symptoms and reduced the recurrence of common cold.
In that study, a group of patients were given standard
therapy (antipyretics, nasal decongestants, mucolytics,
and/or systemic antibiotics) and nasal saline wash was not
recommended. In one group, nasal wash with saline was
added to this standard treatment. ose who were enrolled
in the study were followed up for 12 weeks. At the end of
this process, earlier remission of symptoms and recurrence
prevention were found in the group treated with nasal
saline (13). In our study, patients aged 0 to 2 years did
not receive any treatment except isotonic and hypertonic
nasal drops. No nasal drops were recommended for the
control group. Patients were followed for 7 days and the
comparison was made among three groups. e symptoms
of the groups that used nasal drops were lighter and were
relieved sooner. Some researchers have argued that nasal
wash was not eective on the common cold (19).
e uses of buered hypertonic saline and buered
normal saline were compared in children with allergic
rhinitis previously. It was found that buered hypertonic
saline was more advantageous in reducing complaints
compared with normal saline, as it was well tolerated, safe,
Table 2. Distributions of the parameters of Group A (n = 38) at 0, 3, 5, and 7 days.
Days 0357
Parameters n (%) n (%) n (%) n (%)
Nasal congestion 38 (100) 26 (68) 14 (37) 8 (21)
Weak n e s s 28 (74) 21 (55) 14 (37) 9 (24)
Rhinorrhea 30 (79) 26 (68) 20 (53) 15 (39)
Nasal bleeding 1 (3) 0 0 0
Sleep quality* 30 (79) 27 (71) 19 (50) 13 (34)
Diet** 21 (55) 16 (42) 13 (34) 11 (29)
Cough 33 (87) 30 (79) 18 (47) 8 (21)
Nasal pump and aspirator*** 5 (13) 19 (50) 19 (50) 19 (50)
*Deterioration in sleep quality; **Deterioration in appetite;
***Use of nasal pump and aspirator.
Table 3. Distributions of the parameters of Group B (n = 36) at 0, 3, 5, and 7 days.
Days 0357
Parameters n (%) n (%) n (%) n (%)
Nasal congestion 36 (100) 24 (67) 12 (33) 6 (17)
Weak n e s s 29 (81) 24 (67) 15 (42) 8 (22)
Rhinorrhea 25 (69) 20 (56) 15 (42) 13 (36)
Nasal bleeding 2 (6) 1 (3) 0 0
Sleep quality* 31 (86) 30 (89) 18 (50) 6 (17)
Diet** 31 (86) 29 (81) 10 (28) 7 (19)
Cough 25 (69) 26 (72) 21 (58) 14 (39)
Nasal pump and aspirator*** 6 (17) 7 (19) 7 (19) 7 (19)
*Deterioration in sleep quality; **Deterioration in appetite;
***Use of nasal pump and aspirator.

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and cheap (20). Signicant dierence in the reduction of
complaints in our study was not observed between seawater
and physiological saline. e most important dierence
between this study and the previously mentioned one is
the content of the patient groups. Patients with allergic
rhinitis were included in that study and patients with
acute upper respiratory tract infection were included
in our study. Hypertonic solutions may become more
eective by reducing edema due to the predominance
of mucosal edema in allergic rhinitis. e dierence in
the washing eect of the two solutions may not be seen
due to the predominance of increase in secretion in the
pathophysiology of acute upper respiratory tract infection.
Washing with hypertonic saline, particularly in allergic
rhinitis, indicated an increase in the level of leukotriene
C4 (21). Garavello et al. (11) also supported this study
by saying that nasal wash with hypertonic saline relieved
seasonal allergic rhinitis. Ural et al. (4) emphasized in their
study that nasal irrigation was simple, cheap, and eective
in the treatment of sinonasal pathology and reduced the
use of antibiotics. ey reported that hypertonic saline
increased mucociliary clearance in patients with chronic
sinusitis only, but hypertonic irrigation was not superior
to saline irrigation in patients with allergic rhinitis (4). It
was seen in our study that the eects of using seawater and
physiological saline were similar in acute upper respiratory
tract infections.
Changes in cell structure and mucus secretion were
analyzed in nasal epithelial cells caused by pure water,
hypertonic (0.3%), isotonic (0.9%), and hypertonic (3%)
solutions in another in vitro study. As a result, it was
reported that pure water, hypotonic, and hypertonic
solutions increased mucus secretions and damaged the
cells, but isotonic solutions did not cause any change in
the mucous secretion and cell structure (22). In another
study, it was emphasized that hypertonic saline, given as
inhaler, increased mucus secretion (23). It has also been
reported in a review published in 2007 that nasal irrigation
reduced the use of antibiotics and had very few side eects.
ese side eects are nasal itching and nausea. Serious side
Table 4. Distributions of the parameters of Group C (n = 35) at 0, 3, 5, and 7 days.
Days 0357
Parameters n (%) n (%) n (%) n (%)
Nasal congestion 35 (100) 34 (97) 30 (86) 26 (74)
Weak n e s s 34 (97) 31 (89) 27 (77) 26 (74)
Rhinorrhea 35 (100) 35 (100) 35 (100) 33 (94)
Nasal bleeding 1 (3) 0 0 0
Sleep quality* 33 (94) 34 (97) 34 (97) 31 (89)
Diet** 35 (100) 35 (100) 32 (91) 31 (89)
Cough 35 (100) 35 (100) 35 (100) 35 (100)
Nasal pump and aspirator*** 10 (29) 10 (29) 10 (29) 10 (29)
*Deterioration in sleep quality; **Deterioration in appetite; ***Use of nasal pump and aspirator.
Table 5. Comparison between study groups for all variables (nasal congestion, weakness, etc.).
95% Condence interval for dierence
Group Mean dierence ± std. error p Lower bound Upper bound
A* B –0.024 ± 0.114 >0.05 –0.301 0.252
C –0.413 ± 0.115 0.001 –0.692 –0.134
B** A 0.024 ± 0.114 >0.05 –0.252 0.301
C –0.388 ± 0.116 0.003 –0.671 –0.106
C*** A 0.413 ± 0.115 0.001 0.134 0.692
B 0.388 ± 0.116 0.003 0.106 0.671
*Group A (seawater); **Group B (physiological saline); ***Control group. Values in bold are signicant.

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eects have not been reported (24). It has also been shown
in a study conducted by Jee et al. (25) that nasal irrigation
with saline was cheap and had minimal side eects.
In conclusion, we found relief with the use of both
physiological saline and seawater in the following
parameters: nasal congestion, weakness, nutrition, and
sleep quality. Opening the nasal passage with the aid of a
simple device was highly eective in relieving symptoms
regardless of which solution was used. e signicant
dierences found between the control group and Groups A
and B have shown that washing the nose with physiological
saline or seawater in order to clear the nose in acute upper
respiratory tract infections has utility in the improvement
of symptoms. Seawater or saline drops may be added to
standard treatment protocols.
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