Open Access

Nasal saline irrigation in preschool children: a survey of attitudes and prescribing habits of primary care pediatricians working in northern Italy

  • Paola Marchisio1Email author,
  • Marina Picca2,
  • Sara Torretta3,
  • Elena Baggi1,
  • Angela Pasinato4,
  • Sonia Bianchini1,
  • Erica Nazzari1,
  • Susanna Esposito1 and
  • Nicola Principi1
Italian Journal of Pediatrics201440:47

DOI: 10.1186/1824-7288-40-47

Received: 10 March 2014

Accepted: 6 May 2014

Published: 15 May 2014

Abstract

Background

It has been shown that nasal saline irrigation (NSI) alone can be effective in children with infectious and/or allergic respiratory problems, but no study has assessed the awareness or clinical use of NSI among practising pediatricians. The main aim of this study was to evaluate the use of NSI in pre-school children by primary care pediatricians working in northern Italy.

Methods

Nine hundred randomly selected National Health Service primary care pediatricians with an e-mail address were sent an e-mail asking whether they were willing to respond to a questionnaire regarding the use of NSI. The 870 who answered positively were sent an anonymous questionnaire by post and e-mail that had 17 multiple-choice items.

Results

Completed questionnaires were received from 860 of the 870 primary care pediatricians (98.8%). NSI was used by almost all the respondents (99.3%), although with significant differences in frequency. It was considered both a prophylactic and a therapeutic measure by most of the respondents (60.3%), who prescribed it every day for healthy children and more frequently when they were ill. Most of the primary care pediatricians (87%) indicated an isotonic solution as the preferred solution, and the most frequently recommended administration devices were a nasal spray (67.7%) and bulb syringe (20.6%). Most of the pediatricians (75.6%) convinced parents to use NSI by explaining it could have various beneficial effects, and two-thirds (527/854; 61.7%) thought that most of the parents agreed about the importance of NSI. Analysis of possible associations between NSI prescribing behaviour and the demographic data revealed an associations with age and gender, with pediatricians aged <50 years prescribing NSI more frequently than their older counterparts (p < 0.01), and females prescribing NSI more frequently than males (p < 0.01).

Conclusions

In Northern Italy, most primary care pediatricians prescribe NSI for both the prophylaxis and therapy of upper respiratory tract problems in pre-school children. However, many aspects of the procedure are not clarified, and this reduces parental compliance. Given the medical and economic advantages of NSI, this situation should be changed as soon as possible.

Keywords

Isotonic saline solution Hypertonic saline solution Nasal saline irrigation Nasal spray Respiratory tract infection

Background

A number of recent studies have shown that nasal saline irrigation (NSI), a practice widely used to treat upper respiratory tract diseases in adults [1, 2], can also be effective in children with infectious and/or allergic respiratory problems not only as adjunctive treatment, but also alone [38]. NSI significantly reduces nasal secretions/post-nasal drip in children with chronic rhinosinusitis, and considerably improves radiographic signs of disease [3]; it also reduces the need for surgery even in patients resistant to medical treatment with antibiotics and nasal corticosteroids [4, 5]. Although it is not effective in reducing inflammation in nasal smears or modifying post-treatment radiography when prescribed to children with acute rhinosinusitis, it does improve mean quality life scores by reducing nasal symptoms and significantly increasing peak nasal expiratory flow [6]. Finally, Garavello et al. [7] and Marchisio et al. [8] have found that it reduces signs and symptoms of seasonal allergic rhinitis and limits the need for antihistamines. All of these studies showed that NSI is safe and well tolerated because there were no severe adverse events and only a minority of children had to discontinue the treatment because of poor tolerance [38]. It has also been shown that the procedure is quite inexpensive and reduces the use of prescription and over-the-counter medications, and therefore have a substantial impact not only on medical costs, but also on antibiotic pressure and the associated antibiotic resistance [9].

On the basis of these findings, a number of experts have identified NSI as an appropriate adjunctive treatment for many pediatric upper respiratory tract diseases, and some scientific societies have included it in their treatment guidelines for selected respiratory diseases [10, 11]. However, it is not clear how or how extensively NSI is used in everyday practice, particularly in the community and in younger children. The only available data, which were collected some years ago from family physicians in Wisconsin [12], indicate that NSI is frequently prescribed for a variety of upper respiratory conditions, but administered using various dosing schedules and types of solution, some of which are different from those suggested in the studies that have found the practice effective, safe and well tolerated. No study has assessed the awareness or clinical use of NSI among practising pediatricians, and so nothing is known about the extent of their awareness of the procedure, how they use it and for what conditions, its clinical successfulness or otherwise, or the physician characteristics that might influence their NSI-related practice patterns.

Main aim of this study was to evaluate the use of NSI in pre-school children by primary care pediatricians working in northern Italy.

Methods

Study design

This cross-sectional survey of the use of NSI by a representative sample of primary care pediatricians working in Northern Italy was carried out between 10 January 2012 and 31 March 2013. The study was approved by the Ethics Committee of the University of Milan, Italy, and informed consent was obtained from all of the participants before study entry.

Study population

A group of 900 National Health Service primary care pediatricians with an e-mail address were randomly selected by means of a computer-based randomisation list from among those working for the in the northern regions of Italy (Piedmont, Liguria, Lombardy, Veneto, Friuli-Venezia Giulia and Emilia-Romagna). In order to assure a fully representative sample, the same percentage of pediatricians was selected in each region. The physicians were sent an e-mail before the beginning of the survey in which they were asked whether they were willing to respond to a questionnaire regarding their use of NSI. The 870 pediatricians who answered positively were e-mailed an anonymous questionnaire that was also sent by post together with a stamped envelope addressed to the trained study researchers (PM, ST, EB and SB). Fifteen days later, any pediatrician who had not returned the completed questionnaire was telephoned and urged to do so.

Questionnaire design and administration

The questionnaire, which was anonymous but coded in order to be able to identify non-responders and ensure the elimination of multiple responses, was conceived by the first author (PM) in collaboration with the co-authors (MP,AP) and pilot tested on a sample of 20 pediatricians in Milan, Italy. It required about 10 minutes to complete and guided respondents through 17 multiple-choice items divided into two main sections: one for personal and demographic data, including gender, and the years of birth, graduation and specialisation; the other concerning attitudes towards the use of NSI in pre-school children (i.e. personal opinions about the efficacy and usefulness of NSI) and the prescribing behaviour adopted in routine clinical practice (i.e. indication, frequency of administration, the composition of the solutions, administration method).

Statistical analysis

The data were descriptively analysed to assess the prevalence and distribution of all the variables. The continuous variables were expressed as mean values and standard deviation (SD), and the categorical variables were expressed as absolute numbers and percentages. The categorical variables were analysed dichotomously and at multiple levels. The Kruskal-Wallis equality-of-populations rank test and Fisher’s exact test were used to determine whether the attitudes toward NSI and prescribing behaviours were related to the demographic data. Simple and multiple logistic regression models were used after adjusting for the main confounders; and odds ratios (ORs) and their standard error (SE) and 95% confidence intervals (95% CI) were computed to measure the strength of the associations. Statistical significance was set at p = 0.05. The data were analysed using STATA 10.0 software (StataCorp, College Station, TX).

Results

Questionnaires were completed by 860 (98.8%) of the 870 primary care pediatricians, most of whom were female (635; 73.8%), aged >50 years (557; 64.8%), and had been practising as primary care pediatricians for more than 20 years (509; 59.1%) (Table 1).
Table 1

Demographic characteristics of the primary care pediatricians who returned completed questionnaires concerning their use of nasal saline irrigation (NSI)

Demographic characteristics

No. of primary care pediatricians

Percentage

Total number

860

 

Females

635

73.8

Age, years

  

  >50

557

64.8

  35-50

273

31.7

  <35

13

1.5

  Non-responders

17

2.0

No. years since graduation

  

  >30

178

20.7

  20-30

495

57.5

  10-19

132

15.3

  <10

30

3.5

  Non-responders

25

2.9

No. of years since specialising in pediatrics

  

  >30

77

8.9

  20-30

432

50.2

  10-20

243

28.2

  <10

83

9.6

  Non-responders

25

2.9

Table 2 shows that almost all the pediatricians prescribed NSI for pre-school children (854/860; 99.3%), although with significant differences in frequency: it was prescribed at least once to >75% of their younger patients by 358 (41.9%), to 25-75% by 452 (52.9%), and to <25% by 44 (5.2%). About 45% of the respondents considered NSI important for patients of all pre-school ages, whereas 14.2% thought that it was more important for children aged 2–3 years, and 37.8% that it was more important for those aged <1 year. Most of the respondents (60.3%) considered NSI both prophylactic and therapeutic. Of the 515 pediatricians who also prescribed it for prophylaxis, 84.5% recommended its administration 3–4 times a week whereas, in the case of ill children, the frequency of administration was once daily (37.1%), 2–3 times a day (48.2%), or even more frequently (14.7%). Most of the primary care pediatricians (87%) indicated isotonic solution as the preferred solution, and only 7.8% recommended hypertonic solutions. The most frequently recommended methods of administration were nasal sprays (67.7%) followed by the use of a bulb syringe (20.6%). As regards the volume of solution, 28.2% suggested 5–20 mL per nostril regardless of age, 23.0% adjusted the volume on the basis of age, and 20.7% did not prescribe more than 2.5 mL per nostril.
Table 2

Primary care pediatricians’ use of nasal saline irrigation in pre-school children

Parameter

Possible answers

No. of primary care pediatricians

Percentage

Percentage of pre-school children for whom NSI is recommended

   
 

None

6/860

0.7

 

<25%

44/860

5.1

 

25-75%

452/860

52.5

 

>75%

358/860

41.6

Age of patients for whom NSI is considered important

   
 

All pre-school years

473/854

43.7

 

<1 year

323/854

37.8

 

1-2 year

37/854

4.3

 

2-3 years

121/854

14.2

Use of NSI for upper respiratory tract diseases

   
 

Treatment of acute phase

339/854

39.7

 

Prophylaxis in healthy children

515/854

60.3

Frequency of therapeutic administration of NSI

   
 

Once per day

317/854

37.1

 

2-3 times per day

412/854

48.2

 

>3 times per day

125/854

14.7

Frequency of prophylactic administration of NSI

   
 

Never

339/854

39.7

 

Daily

80/515

15.5

 

3-4 times per week

435/515

84.5

Type of solution

   
 

Isotonic saline solution

743/854

87.0

 

Hypertonic saline solution

67/854

7.8

 

Hypotonic saline solution

44/854

5.2

Method of administration

   
 

Spray

578/854

67.7

 

Bulb syringe

176/854

20.6

 

Gravity

100/854

11.7

Volume of solution recommended for NSI

   
 

Depending on patient age

196/854

23.0

 

5-20 mL per nostril

241/854

28.2

 

5 mL per nostril

157/854

18.4

 

2.5 mL per nostril

177/854

20.7

 

Other

83/854

9.7

Final evaluation of efficacy and safety of NSI

   
 

Effective and safe

845/860

98.3

 

Effective but poorly tolerated

9/860

1.0

 

Ineffective

2/860

0.2

 

No opinion

4/860

0.5

Table 3 shows how the primary care pediatricians instructed parents to administer NSI and the reasons for parental refusal to use it. Parental education was most frequently only verbal (54.5%), whereas 33.2% of the pediatricians gave a practical demonstration, and 10.4% written instructions; only 1.9% gave no instructions at all. Most of the pediatricians (75.6%) convinced parents to use NSI by explaining it that it had a number of beneficial effects, including improved nasal respiration, a reduction in the bacterial complications of viral respiratory infection, and a reduction in the duration of viral illnesses; a few pediatricians cited only one of these advantages, and three (0.3%) did not give any explanation. Concerning the direction in which to move the syringe or nozzle of the device used to administer NSI, 33.0% declared that they did not suggest any direction, whereas 29.4% and 23.6% respectively recommended “toward the ipsilateral ear” and “toward the contralateral ear”. Two-thirds of the prescribing pediatricians (527/854; 61.7%) thought that most of the parents of their patients agreed that NSI was important, but the main perceived reasons for parental refusal were the difficulty of administration (471; 55,1%) or the supposed invasiveness of the procedure (279; 32.7%).
Table 3

Parents’ NSI education by primary care pediatricians, and judgement of parents’ compliance

Parameter

Possible answer

No. of primary care pediatricians

Percentage

Method used to educate parents

   
 

Verbal instructions

465/854

54.5

 

Written instructions

89/854

10.4

 

Practical demonstration

284/854

33.2

 

No instructions

16/854

1.9

Reasons given to convince parents to use NSI

   
 

Improved nasal respiration

70/854

8.2

 

Reduced bacterial super-infection

90/854

10.5

 

Improved treatment of respiratory infection

29/854

3.4

 

All of these reasons

645/854

75.6

 

Other

17/854

2.0

 

No reason

3/854

0.3

Direction in which to move the administration device

   
 

Toward the ipsilateral ear

250/854

29.4

 

Toward the contralateral ear

202/854

23.6

 

Other

120/854

14.0

 

No suggestion

282/854

33.0

Recommended position for NSI

   
 

Infants: lying on one side; Older children: bending forward over a sink with the head tilted down and a little to one side

639/854

74.8

 

On the side at any age

146/854

17.1

 

Other

35/854

4.1

 

No suggestion

34/854

4.0

Reasons parents are not compliant with recommendation to use NSI

   
 

Not useful

194/854

12.2

 

Dangerous

279/854

32.7

 

Difficult to administer

471/854

55.1

Analysis of the possible associations between NSI prescribing behaviour and the demographic data revealed that the number of patients for which NSI was prescribed and judgements of its efficacy were apparently influenced by age and gender. Pediatricians aged <50 years prescribed NSI more frequently than their older counterparts (85.5% vs 78.5%; p = 0.01), and females prescribed NSI more frequently than males (85.0% vs 66.1%; p < 0.01) (Figure 1). Moreover, younger pediatricians considered NSI effective more frequently than the older pediatricians (38.3% vs 31.2%; p = 0.01), and females more frequently than males (35.7% vs. 26.2%; p = 0.02). However, multiple logistic regression analysis showed that only gender adjusted for age remained significantly associated with the prescription of NSI (OR = 2.76, SE = 0.53, 95% CI 1.89-4.04, p < 0.01) and a positive opinion concerning its usefulness (OR = 1.52, SE = 0.28, p = 0.03). Moreover, parents understood the importance of NSI significantly more frequently when their pediatricians considered NSI effective (63.0% vs 49.0%; p < 0.01). None of the other demographic variables was statistically associated with attitudes toward NSI or prescribing behaviour.
Figure 1

Proportions of pediatricians prescribing NSI and considering NSI effective by age and gender.

Discussion

This is the first study designed to evaluate primary care pediatricians’ knowledge and prescription of NSI in pre-school children. The randomised selection of potential participants and the fact that the number of those who refused to take part in the survey was very small makes it unlikely that the responders were only those aware of NSI. Consequently, it is reasonable to conceive that the study population was truly representative of the primary care pediatricians living in Northern Italy and working for the National Health Service.

The data indicate that, despite some age- and gender-related differences, the majority of the respondents knew NSI, prescribed it for their pre-school patients, and considered it effective and well tolerated. As NSI is a relatively new means of treating upper respiratory problems in younger children, it is not surprising that younger pediatricians were more likely to use it and consider it effective than those aged >50 years. The use of NSI in younger patients is not extensively examined in the scientific literature because most pediatric studies of NSI have mainly involved school-age children . However, Rabago et al. [12] found that family physicians in Wisconsin included children aged <7 years among the subjects eligible for NSI. The opinion of these physicians concerning the tolerability of NSI is similar to that of the primary care pediatricians enrolled in this study, and is supported by the data collected in other studies evaluating the effect of NSI on children [38]. The incidence of adverse events following NSI was usually very low, and most of the studies highlighted the fact that they were not severe enough to preclude continuing treatment.

A substantial proportion of the respondents prescribed NSI not only for the treatment of rhinitis and upper respiratory tract infections, but also for prophylactic purposes. The widespread therapeutic use of NSI was not surprising given the frequency of these diseases in younger children, their very high tendency to recur, the positive opinion of the pediatricians concerning the effectiveness of NSI, and the results of the published pediatric studies. On the contrary, its prophylactic use was quite unexpected because NSI has never been evaluated in randomised, double-blind and placebo-controlled studies.

The only published studies are two open studies. In the first, children aged 6–10 years with uncomplicated cold or influenza were treated with NSI and standard therapy or NSI alone for three months, and the cure of the first episode and any subsequent recurrences were recorded [13]. Nasal symptoms during acute illness resolved more rapidly in the children treated with NSI alone, who also experienced less frequent recurrences of rhinitis. The second was a Russian multi-centre, open-label, randomised study, which found that NSI reduced the morbidity due to acute respiratory infections in children attending secondary schools and day-care centres by 2.4-3.2 times throughout the epidemiological period, and simultaneously improved the clinical course of upper respiratory tract diseases and bronchial asthma [14].

However, some of the presumed mechanisms of action of NSI may explain why our primary care pediatricians think it effective as preventive measure. In addition to cleaning the nasal cavities and removing antigens and local inflammatory mediators such as histamine and prostaglandins, it is thought that NSI may improve mucus clearance by enhancing ciliary beat frequency, thus reducing the risk of bacterial super-infections and enhancing mucosal healing [15]. This may be more beneficial during the winter (when respiratory infections are more frequent) because of the co-existence of conditions related to impaired respiratory epithelial ciliary activity, such as low temperatures, air pollution, inspired air humidity and dehydration [16].

The most favoured way of administering NSI was by means of a nasal spray, whereas only about 20% of the respondents recommended a bulb syringe. The most appropriate method of administration is still subject to debate. A review published in 2010 found that high-volume, positive-pressure devices led to better fluid distribution throughout the sinuses than low-volume applications such as nebulisers or sprays, or low-pressure devices such as the Neti pot [17]. However, it only considered adult studies, and there are no published data comparing bulb syringes and sprays in children, particularly very young subjects. There is therefore a need for pediatric studies but, in meantime, it can be suggested that NSI should be started using a bulb syringe because of the larger amount of solution it delivers, and that its use may be continued if the child tolerates it without any problem.

Most of the respondents use isotonic saline for a NSI, and only about 8% use hypertonic saline. This does not seem to be in line with the literature because a number of in vitro[18] and clinical studies [1, 3, 8], including pediatric studies [3, 8], have found that hypertonic saline is more effective than isotonic in reducing the signs and symptoms of upper respiratory diseases. However, the effect of hypertonic saline has only been tested in ill patients, and the better results may be explained by its greater activity in improving mucociliary clearance [18]. Furthermore, it has not been demonstrated that hypertonic saline is better in the case of prophylaxis, and it is worth remembering that it may be a little less tolerated because it can cause uncomfortable burning or stinging sensations, even if rarely [1]. Both solutions are able to clear germs, allergens and other pollutants from the nasopharynx and can protect children against respiratory diseases. Once again, further studies are needed, but it can be suggested that normal saline should be used for prophylaxis and hypertonic saline for therapy.

About 75% of the respondents chose the correct position for NSI: i.e. infants should be lying down on their side, whereas older children bend forward over a sink with their head tilted down and a little to a side in the older ones. This is not surprising because the correct position has been described on websites [1922] and in newpapers and magazines [23]. This is also true for Italy, where the most important newspaper has repeatedly published the best way to use administer NSI to children in its health section [24].

On the contrary, the answers to the questions regarding the volume of liquid to use were disappointing because only about 25% of the pediatricians declared that it depended on the child’s age, and about 20% prescribed only 2.5 mL per nostril for all children. This highlights the poor knowledge of Italian primary care pediatricians and is probably due to the lack of precise data in information sources [1924]. The same can be said about the responses concerning the direction of administration because only about 30% of the responders told parents to move the syringe or nozzle toward the ipsilateral ear; once again, there is a lack of adequate published information.

Most of the respondents declared that parents have generally understood the importance of NSI, and that was particularly evident when the pediatricians themselves were convinced of its efficacy. However, about 40% expressed doubts about parental compliance mainly because of a certain difficulty in administration or the supposed invasiveness of the procedure. These doubts seem to due to the lack of adequate information concerning the correct amount of solution and the best way of administering. The findings of this study seem to indicate, that if NSI is to be completely accepted by parents, it is essential that pediatricians clarify these points and communicate their conclusions to parents. Studies involving younger children and health authority educational programmes are urgently needed.

Conclusions

Primary care pediatricians in northern Italy largely use NSI for prophylaxis and to treat upper respiratory tract problems in pre-school children. However, many aspects of the procedure have not been clarified and this reduces parental compliance. Given the medical and economic advantages of NSI, it is essential to change this situation as soon as possible.

Abbreviations

95% CI: 

95% confidence intervals

NSI: 

Nasal saline irrigation

ORs: 

Odds ratios

SD: 

Standard deviation

SE: 

Standard error.

Declarations

Acknowledgements

The study was supported by an Italian Ministry of Health grant Ricerca Corrente 2013 to Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.

Authors’ Affiliations

(1)
Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico
(2)
Primary care pediatrician
(3)
Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico
(4)
Primary care pediatrician, Torri di Quartesolo

References

  1. Dunn JD, Dion GR, McMains KC: Efficacy of nasal irrigations and nebulizations for nasal symptom relief. Curr Opin Otolaryngol Head Neck Surg. 2013, 21: 248-251. 10.1097/MOO.0b013e32835f80bb.View ArticlePubMedGoogle Scholar
  2. Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R: Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. Am J Rhinol Allergy. 2012, 26: e119-e125. 10.2500/ajra.2012.26.3787.PubMed CentralView ArticlePubMedGoogle Scholar
  3. Shoseyov D, Bibi H, Shai P: Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol. 1998, 101: 602-605. 10.1016/S0091-6749(98)70166-6.View ArticlePubMedGoogle Scholar
  4. Pham V, Sykes K, Wei J: Long-term outcome of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. Laryngoscope. 2014, 124: 1000-1007. 10.1002/lary.24224.PubMed CentralView ArticlePubMedGoogle Scholar
  5. Hong SD, Kim JH, Kim HY, Jang MS, Dhong HJ, Chung SK: Compliance and efficacy of saline irrigation in pediatric chronic rhinosinusitis. Auris Nasus Larynx. 2014, 41: 46-49. 10.1016/j.anl.2013.07.008.View ArticlePubMedGoogle Scholar
  6. Wang YH, Yang CP, Ku MS, Sun HL, Lue KH: Efficacy of nasal irrigation in the treatment of acute sinusitis in children. Int J Pediatr Otorhinolaryngol. 2009, 73: 1696-1701. 10.1016/j.ijporl.2009.09.001.View ArticlePubMedGoogle Scholar
  7. Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A: Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol. 2003, 14: 140-143. 10.1034/j.1399-3038.2003.00021.x.View ArticlePubMedGoogle Scholar
  8. Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, Capaccio P, Gasparini C, Patria F, Esposito S, Principi N: Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int J Immunopathol Pharmacol. 2012, 25: 721-730.PubMedGoogle Scholar
  9. Jeffe JS, Bhushan B, Schroeder JW: Nasal saline irrigation in children: a study of compliance and tolerance. Int J Pediatr Otorhinolaryngol. 2012, 76: 409-413. 10.1016/j.ijporl.2011.12.022.View ArticlePubMedGoogle Scholar
  10. Wald ER, Applegate KE, Bordley C, Darrow DH, Glode MP, Marcy SM, Nelson CE, Rosenfeld RM, Shaikh N, Smith MJ, Williams PV, Weinberg ST, American Academy of Pediatrics: Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013, 132: e262-e280. 10.1542/peds.2013-1071.View ArticlePubMedGoogle Scholar
  11. Esposito S, Principi N, Italian Society of Pediatrics, Italian Society of Pediatric Infectivology, Italian Society of Pediatric Allergology and Immunology, Italian Society of Pediatric Respiratory Diseases, Italian Society of Preventive and Social Pediatrics; Italian Society of Otorhinolaryngology, Italian Society of Chemotherapy; Italian Society of Microbiology: Guidelines for the diagnosis and treatment of acute and subacute rhinosinusitis in children. J Chemother. 2008, 20: 147-157. 10.1179/joc.2008.20.2.147.View ArticlePubMedGoogle Scholar
  12. Rabago D, Zgierska A, Peppard P, Bamber A: The prescribing patterns of Wisconsin family physicians surrounding saline nasal irrigation for upper respiratory conditions. WMJ. 2009, 108: 145-150.PubMed CentralPubMedGoogle Scholar
  13. Slapak I, Skoupá J, Strnad P, Horník P: Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children. Arch Otolaryngol Head Neck Surg. 2008, 134: 67-74. 10.1001/archoto.2007.19.View ArticlePubMedGoogle Scholar
  14. No authors listed: Prophylaxis of acute respiratory infections in children’s collectives: results of treatment with nasal and nasopharyngeal irrigation. Vestn Otorinolaringol. 2012, 1: 44-46.Google Scholar
  15. Khianey R, Oppenheimer J: Is nasal saline irrigation all it is cracked up to be?. Ann Allergy Asthma Immunol. 2012, 109: 20-28. 10.1016/j.anai.2012.04.019.View ArticlePubMedGoogle Scholar
  16. Cohen NA: Sinonasal mucociliary clearance in health and disease. Ann Otol Rhinol Laryngol. 2006, 196 (Suppl): 20-26.Google Scholar
  17. Harvey RJ, Psaltis A, Schlosser RJ, Witterick IJ: Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2010, 39: 217-231.PubMedGoogle Scholar
  18. Talbot AR, Herr TM, Parsons DS: Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope. 1997, 107: 500-503. 10.1097/00005537-199704000-00013.View ArticlePubMedGoogle Scholar
  19. Dr Hana’s Nasopure: Nasal Irrigation for Children – Improved Children’s Nasal Spray & Neti Pot. Available at: http://www.nasopure.com/how_to_treat_asthma_with_nasal_washing_s/1844.htm. Accessed on 4 February 2014
  20. ENT Surgical Consultants: Nasal saline irrigation. Available at: http://www.entsurgicalillinois.com/webdocuments/pdf. Accessed on 4 February 2014
  21. Children’ Hospital of Michigan: Nasal wash instructions. Available at: http://www.childrensdmc.org/?Id=183&sid=1. Accessed on 4 February 2014
  22. National Jewish Health: Nasal wash treatment. Available at: http://www.nationaljewish.org/healthinfo/medications/lung-diseases/alternative/nasal-wash-treatment.aspx. Accessed on 4 February 2014
  23. USA Today News Health & Behavior: Sinus sufferers applaud nasal washing. Available at: http://usatoday30.usatoday.com/news/health/2007-05-29-nasal-washing_n.htm. Accessed on 4 February 2014
  24. Corriere della Sera: Laviamo i nasini tappati. Corriere Salute, Available at: http://archiviostorico.corriere.it/2004/dicembre/05/laviamo_nasini_tappati_cs_0_041205026.shtml. Accessed on 4 February 2014

Copyright

© Marchisio et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement