European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113

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Technical note

Paediatric nasal irrigation: The “fencing” method

L. de Gabory a,b,∗ , M. Kérimian a,b , T. Sagardoy a,b , A. Verdaguer c , H. Gauchez d
a
Service d’ORL et de chirurgie cervico-faciale, Centre F.-X. Michelet, Hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux cedex,
France
b
Université Bordeaux, 33000 Bordeaux, France
c
Pôle de Santé de la Grâce de Dieu, 14000 Caen, France
d
Centre de kinésithérapie respiratoire et fonctionnelle du Nord (CKRF), 59700 Marcq-en-Baroeul, France

a r t i c l e i n f o a b s t r a c t

Keywords: Nasal irrigation is a grade A recommendation treatment, which is essential in many pathological con-
Nasal irrigation ditions. Very heterogeneous practices are observed in paediatrics as a result of poor instruction in this
Nasal lavage technique. We propose to describe the nasal irrigation technique developed by a team of respiratory phys-
Nasal spray
iotherapists in Lille for the management of cystic fibrosis and bronchiolitis. This technique is intended
Nasal obstruction
for children over the age of 6 months, as it requires an oral breathing reflex and cough reflex that are not
Infection
systematically acquired before this age. Nasal irrigation is performed on a 30◦ upward inclined plane on
a calm and cooperative child, away from meals. The child is maintained gently, without pressure, in the
fencing position with the head turned away from the practitioner. Using a continuous flow spray, the
practitioner grasps the top of the upper nostril and irrigates the nostril for an average of 3 s (6 mL per
nostril). These steps are then repeated until satisfactory patency is achieved in both nostrils. This tech-
nique constitutes a practical tool to help healthcare professionals and parents perform nasal irrigation in
young children over the age of 6 months.
© 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction 2. Technique

Nasal irrigation is essential in the management of nasal obstruc- 2.1. Requirements/precautions

tion in young children with respiratory tract infections, including
bronchiolitis [1,2]. It is recommended (grade A) for chronic rhi-
nosinusitis with the same level of scientific evidence as nasal
corticosteroids [3]. While the majority of practitioners consider
this procedure to be essential, a review of the literature failed to
identify a standardized method, optimized for infants and young
children, to explain and demonstrate a simple, effective, transmis-
sible method of nasal irrigation that can be included in a therapeutic
patient education approach [4].
A team of respiratory physiotherapists from the Lille region has
developed a nasal irrigation technique that satisfies the efficacy and
reproducibility requirements for the management of cystic fibrosis
and bronchiolitis. The aim of this article is to describe this nasal
irrigation technique performed in health centres and to provide a
practical teaching tool for healthcare professionals and parents.
The first irrigation must be performed by a healthcare pro-
fessional trained in the technique. This technique is intended for
children over the age of 6 months because it requires the oral
breathing reflex, which has not been systematically acquired before
this age. In addition, the cough reflex, which can be triggered
after irrigation, may be less effective in infants under the age of 6
months, who are more likely to produce a less powerful expiratory
reflex to protect the lower airways [5,6]. The appointment with
the healthcare professional must be selected carefully to ensure
optimal tolerance of the procedure by the child. The modalities
of nasal irrigation and the precautions required are described in
Table 1.
2.2. Initial assessment of the child

∗ Corresponding author at: Service d’ORL et de chirurgie cervico-faciale, Centre
F.-X. Michelet, Hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076
Bordeaux cedex, France.
E-mail address: ludovic.de-gabory@chu-bordeaux.fr (L. de Gabory).
The healthcare professional assesses the child and asks the par-
ents about the child’s general state of health, last visit to the doctor
and any recent or ongoing treatment. The healthcare professional
identifies any potential risks, such as breath-holding spells or gas-
troesophageal reflux disease that require increased caution when

https://doi.org/10.1016/j.anorl.2020.08.004
1879-7296/© 2020 Elsevier Masson SAS. All rights reserved.
108 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Table 1
Description of the various steps of paediatric nasal irrigation.
Steps
Preparing the When?
procedure
Equipment
Technique
Performing the Irrigation characteristics
procedure
Detection and management of
side effects
Evaluation of efficacy
performing nasal irrigation. Although no contraindications have
been reported in the literature, nasal irrigation is not recommended
in children with swallowing disorders, epistaxis or suspected for-
eign body in the upper airways.
Before performing nasal irrigation, the healthcare professional
must evaluate upper airway patency by means of the Rosenthal test,
adapted to infants and used in clinical practice by physiotherapists
[7]. This test of upper airway patency should be performed before
and after nasal irrigation.
In practice, the Rosenthal test, also known as the oral occlusion
test, consists of placing a hand underneath the child’s chin to gently
close the mouth and counting the number of nasal inspirations. A
child with totally patent nostrils should be able to breathe through
the nose 10 times without trying to open the mouth, with no signs
of distress and no increase in heart rate.
2.3. Preparation
The child must be calm and the parents must be informed about
the procedure, which should be performed in a suitable environ-
ment. The nasal irrigation device and the solution should also be
tested before the procedure. Several in vitro and in vivo studies
have shown that mineral-rich solutions, such as undiluted seawa-
ter, are the most effective irrigation solutions [8–10]. The irrigation
technique is carried out with a sterile, reusable, continuous spray at
room temperature or placed in lukewarm water for several minutes
Key elements and necessary precautions
Calm and awake child
Avoid late afternoons, immediately before or after a meal/bottle
Choose a device that delivers a volume adapted to the size of the infant’s or child’s nasal
cavities (continuous spray)
The temperature of the solution must be close to body temperature (approximately 30 ◦ C)
When a spray is used, the bottle can be warmed under a stream of lukewarm water before
the procedure
Spray a small amount of solution onto the child’s hand to:
Make sure the device is working correctly,
Check that the temperature is suitable,
Spray a small amount of solution onto the child’s hand to reassure the child and to ensure
that it is well tolerated
Preferably use mineral-rich solutions
Table tilted upwards to 30◦
Positioning of the child:
Child in the supine position
Head to one side (resting and security position)
The adult’s arm is in contact with the child’s cheek to ensure the “fencer’s” position
Attitude to be adopted:
This technique must be performed gently without applying any force or pressure on the
child
Stop the procedure to let the child recover
Change the child’s position to improve tolerance, if necessary
Spray introduced into the upper nostril. The device delivers a regular volume at low
pressure (to avoid the Karcher effect)
Duration: 3 s per nostril (for a continuous spray delivering 1–2 mL/s)
Volume: 6 mL/nostril (equivalent to 3 times the volume of a one nasal cavity in a 1- to
2-year-old child)
Constant, gentle flow: continue spraying for at least 3 s until the solution flows out
through the lower nostril
Signs of pain or discomfort:
Grimacing, frowning
Agitation, kicking
Moaning
Crying
FLACC score must be < 5 [12,13]
Nose blowing
Assessment of upper airway patency: Rosenthal test (oral occlusion test)
before irrigation and delivered with an atraumatic nasal tip adapted
to the child’s age. To avoid irritative rhinitis in children with chronic
conditions, it is preferable to use an isotonic or slightly hypertonic
neutral pH solution [8,9]. When the material is ready, the parent
hands the child over to the practitioner, who will then perform the
procedure.
The successive steps of nasal irrigation are described in Figs. 1–4
and Video S 1 [see the additional material accompanying the online
version of this article].
Certain techniques are adapted to the child’s age (infant or
young child).
2.4. Positioning of the child and the practitioner
The child is positioned in the supine position on an examina-
tion table with a 30 degree upward tilt (Figs. 1a and 3a). The child
remains in a resting position (supine with the head to one side)
throughout the procedure to avoid any risk of aspiration in the
event of regurgitation, reflux, or swallowing of part of the irrigation
solution.
For irrigation of the left nasal cavity, the child’s head is turned
towards the right and the practitioner stands to the child’s left. After
checking the child’s temperature, the practitioner sprays the child’s
hand to show the gentle pressure and comfortable temperature of
the spray, to reassure the child and ensure that he or she remains
calm and cooperative.
 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Fig. 1. Successive steps of nasal irrigation in young children (2.5 years) from positioning of the child to instillation of the solution: (a) position; (b and c) immobilization in
the “fencer’s” position; (d) position of the spray; (e and f) instillation of the solution.
2.5. Immobilization of the child in the “fencer’s” position
The practitioner’s right hand grasps and extends the child’s right
forearm to simulate the “fencer’s” position (Figs. 1b,c–3b). This
position is natural in infants and corresponds to the archaic asym-
metric tonic neck reflex [11]. The purpose of this position is to
immobilize the child’s shoulder girdle. The practitioner gently tilts
the child’s head towards the right so that he or she is looking away
from the practitioner. The practitioner then slides paper tissues
underneath the child’s cheek to prevent the solution from leak-
ing onto the table during irrigation and examines the appearance
of the secretions.
The practitioner then immobilizes the child’s right forearm by
applying gentle pressure. The practitioner’s right forearm is placed
in contact with the child’s left cheek (without pressure), preventing
the child from turning his/her head to the left.
2.6. Nasal irrigation
The practitioner’s left hand grasps the spray and places it on his
right forearm to ensure stability during irrigation (Figs. 1d–3c). The
109
spray is applied to the superior and lateral margins of the child’s
upper nostril. This contact with the nostril is painless and avoids
any trauma to the nasal septum, even when the child moves. The
nasal tip of the spray should be directed at an angle of 45◦ with
respect to the plane of the palate, towards the contralateral inner
canthus and vice versa on the other side. The practitioner actuates
the spray and maintains the instillation for an average of 3 s, while
monitoring the infant’s tolerance (Fig. 1e,f – Video S1). The treat-
ment should be stopped and resumed later in the presence of any
change in behaviour suggestive of discomfort.
The solution enters via the upper nostril to emerge through
the lower nostril. The irrigation fluid is collected on tissues placed
underneath the child’s cheek. The same procedure is repeated on
the other side by reversing the movements and positions described
above (Fig. 2a–c and Fig. 4b–d).
2.7. Nose blowing
The infant remains in the supine position: the practitioner’s
right hand releases the child’s extended right arm and places
his hand on the left cheek with the thumb underneath the chin
110 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Fig. 2. Successive steps of nasal irrigation in young children (2.5 years) from repetition of irrigation to evaluation of efficacy: (a–c) contralateral irrigation; (d) bilateral nose
blowing; (e and f) verification of upper airway patency.
(Fig. 3d). During expiration, the practitioner’s thumb prevents the
child from opening the mouth and encourages nose blowing. The
practitioner’s left hand collects the secretions with a tissue (Fig. 3e).
This procedure can be repeated unilaterally by alternately obstruct-
ing the right nostril and then the left nostril with the index finger
(Fig. 3f and Fig. 4a).
The young child is seated (Fig. 2d), the practitioner slides his left
hand underneath the child’s chin to maintain the mouth closed after
inspiration in order to generate nasal expiration. The practitioner
collects the secretions with his right hand. This procedure can be
reproduced unilaterally by alternately blocking the right nostril and
then the left nostril with the index finger.
2.8. Verification of bilateral upper airway patency
With the child lying down or sitting, depending on the child’s
age, the practitioner places his left hand underneath the chin and
prevents mouth opening in order to generate a gentle nasal inspira-
tion (Fig. 2e–f and Fig. 4e,f). The practitioner’s index finger lifts the
tip of the chin to ensure closure of the mouth (Fig. 2e and Fig. 4e).
With his right index finger (while keeping the palm of the hand
on the top of the infant’s head), the practitioner blocks the right
nostril, forcing the child to breathe through the left nostril (Fig. 2f
and Fig. 4f) and vice versa for the other side.
2.9. Evaluation of pain/discomfort
The tolerance of nasal irrigation is assessed using the FLACC
(Face, Legs, Activity, Cry and Consolability) scale, a validated and
reproducible scale in young children unable to verbalize pain
[12,13]. Each of the 5 items on the scale is scored between 0 and 2,
resulting in a total score ranging from 0 to 10 (0: relaxed and com-
fortable child, 1–3: mild discomfort, 4–6: moderate pain and/or
discomfort, 7–10: severe pain or major discomfort). The FLACC
score should remain less than 5 for the duration of nasal irrigation.
Nasal irrigation is repeated until satisfactory patency is obtained
in both nostrils. The frequency of nasal irrigation should be
adapted to the child’s age, health status and neurological devel-
opment. Nasal patency should allow normal feeding. The parents
can perform nasal irrigation at home after therapeutic education
 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113 111

Fig. 3. Successive steps of nasal irrigation in infants (7 months) from infant positioning to instillation of the solution: (a) position; (b) immobilization in the “fencer’s”
position; (c) instillation of the solution; (d–f) nose blowing.

and after ensuring that they comply with the practitioner’s recom-
mendations.
3. Discussion
The technique described was developed in accordance with the
neurological development and physiology of the upper airways in
children. This method constitutes a practical tool to help health-
care professionals and parents perform nasal irrigation with the
necessary precautions adapted to the child’s age.
By proposing a precise and standardized procedure, we want
to encourage practitioners and parents to perform nasal irrigation
according to a reproducible and reliable method, as part of a safety,
optimization and quality control process. In an Italian survey,
55% of the 860 paediatricians surveyed considered that parental
refusal to perform nasal irrigation was mainly due to the technical
difficulties of this procedure [14]. Generalization of this procedure
is also hampered by the parents’ perception that their child would
not tolerate the procedure, despite clinical experience showing that
this procedure is well tolerated [7,15].
Few studies have been conducted on nasal irrigation in young
children, and most of them present major methodological biases
[4]. The modalities of irrigation (device, volume, duration) are not
clearly defined; infants and young children cannot use adult devices
[4]. The volume of solution must always be adapted to the total
volume of the nasal cavities: from 1.76 to 2.10 cm3 for a 2- to 4-
day-old newborn [16,17], 2.44 to 4.08 cm3 for a 1- to 2-year-old
infant [18,19] and 3.5 to 4.14 cm3 for a 3- to 4-year-old child [19]. It
has been estimated that the volume required to effectively irrigate
a nasal cavity must be equal to at least three times the volume of
this cavity, i.e. a total of about 6 to 12 mL of solution depending on
the child’s age.
112 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Fig. 4. Successive steps of nasal irrigation in infants (7 months) from repetition of irrigation to evaluation of efficacy: (a) unilateral nose blowing (left nostril); (b–d)
contralateral irrigation; (e) verification of bilateral upper airway patency; (f) verification of unilateral upper airway patency.
4. Conclusion
This is the first reported technique to describe the standardized
steps of nasal irrigation in infants and young children. It responds to
the need for therapeutic education of healthcare professionals and
parents concerning a procedure for which no specific instructions
are currently available, resulting, over time, in very heterogeneous
practices.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgements
We thank the Centre de kinésithérapie respiratoire et fonc-
tionnelle du Nord physiotherapy team for sharing their expertise.
Hughes Gauchez developed this nasal irrigation method.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.anorl.2020.08.004.
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