Parents Struggle With Nasal Spray Technique Despite Good Attitudes, Study Finds

Intranasal corticosteroid sprays are among the most effective treatments available for children with allergic rhinitis, yet a new study suggests that the parents tasked with administering them may be undermining their benefits through imperfect technique and lingering misconceptions. The research, published in BMC Pediatrics by a team from West China Hospital of Sichuan University, examined the knowledge, attitudes, and practices of parents whose children rely on these sprays, and it uncovered a striking disconnect between what parents believe and what they actually do.

Allergic rhinitis is one of the most common chronic conditions of childhood, driven by an allergic inflammatory response in the nasal passages to triggers such as house dust mites, pollen, and animal dander. Symptoms including sneezing, nasal congestion, itching, and rhinorrhea can disrupt sleep, concentration, and quality of life. Intranasal corticosteroids, or INCS, are recommended as first-line therapy in major consensus documents because they deliver anti-inflammatory medication directly to the inflamed nasal mucosa while limiting systemic exposure. But their efficacy is unusually dependent on how they are used: the angle of the nozzle, the position of the head, and the coordination of breathing with the act of spraying all influence how much drug reaches the target tissue and how much simply drips out or irritates the throat.

To understand how well caregivers manage this technique-sensitive treatment, Hongting Zhang, Tianyi Guo, Xiaoqin Ji, Huiling Zhao, and colleagues conducted a cross-sectional online survey between May and September 2025. The study enrolled 273 parents of children with allergic rhinitis who were actively using intranasal corticosteroids. Participants completed a validated knowledge, attitudes, and practices questionnaire, a widely used survey framework that measures what respondents know, how they feel, and what they do regarding a specific health behavior. The researchers analyzed responses with descriptive statistics and used Spearman’s rank correlation analysis to probe the relationships among the three domains. The work received ethical approval from the Institutional Review Board of West China Hospital, Sichuan University, and all participants provided informed consent.

The headline finding is deceptively simple: nearly all parents had been taught how to use the sprays, but far fewer were doing it correctly. A full 90.84 percent of parents reported receiving prior guidance on INCS use, yet when asked whether they always performed the key administration steps, fewer than half answered affirmatively. Only 37.00 percent reported consistently coordinating their child’s breathing with the spray, and just 42.49 percent reported always directing the spray correctly. These are not minor stylistic preferences; breathing coordination and nozzle direction are precisely the steps that determine whether the medication deposits on the nasal turbinates, where it can act on inflamed tissue, or is wasted on the nasal septum or the back of the throat.

Knowledge gaps extended beyond technique into safety perceptions, which may shape adherence in subtle ways. Only 37.00 percent of parents knew that properly used intranasal corticosteroids carry minimal systemic risk, a misconception that matters because fear of corticosteroid side effects is a well-documented driver of undertreatment in pediatric allergy. Fewer than 40 percent knew the correct head position for administration, with 39.56 percent answering this item correctly, and only 41.03 percent identified the proper nozzle direction. In other words, even the fundamentals of positioning, the mechanical backbone of effective delivery, were unknown to a majority of respondents.

Not everything in the survey was discouraging. Parents reported generally positive attitudes toward the treatment, including its recommended duration and frequency, suggesting that the willingness to follow through is largely present. The problem, the authors argue, is not motivation but translation. Their statistical analysis found that all three KAP domains were positively correlated, but only weakly so, with correlation coefficients ranging from 0.15 to 0.27 and all reaching statistical significance at P values below 0.005. In practical terms, knowing more about the medication and feeling good about it barely predicted doing it right.

This pattern is what implementation researchers call a know-do gap, and the study suggests it may be substantial in this setting. The weak correlations carry a pointed message for clinicians: handing a parent a leaflet or delivering a one-time verbal explanation is unlikely to produce correct technique on its own. Knowledge and attitudes are necessary but not sufficient conditions for competent practice. What appears to be missing is a feedback loop, an opportunity for parents to demonstrate technique, receive correction, and confirm their skills before leaving the clinic.

The authors point to competency-focused educational approaches as a promising direction, with teach-back methods requiring particular attention in future research. Teach-back asks the learner to demonstrate or restate the instruction in their own words, allowing the educator to verify understanding and correct errors immediately. In the context of nasal sprays, this could mean having a parent administer a spray to a model or talk through each step, from shaking the device and priming it to positioning the head, aiming the nozzle away from the septum, coordinating inhalation, and avoiding sneezing or nose-blowing immediately afterward. Such methods have shown promise in other areas of chronic disease self-management, but the authors are careful to note that they require prospective evaluation with objective technique and outcome measures before firm recommendations can be made.

The study’s design and scope deserve consideration when weighing its implications. As a cross-sectional online survey, it captures a snapshot of self-reported behavior rather than directly observed technique, and self-reports of medical practices can diverge from reality in either direction. The sample of 273 parents, while adequate for correlation analysis, comes from a single healthcare system context, and the questionnaire-based approach cannot establish causality between knowledge, attitudes, and practices. The authors themselves frame their conclusions cautiously, describing a potential know-do gap rather than a proven one, and calling for future studies that pair educational interventions with objective assessments of spray technique and clinical outcomes such as symptom scores.

Even with those caveats, the findings resonate with a broader challenge in pediatric medicine: the quiet dependence of treatment success on caregiver skill. For a condition as prevalent as allergic rhinitis, affecting a large share of school-age children worldwide, small inefficiencies in drug delivery multiplied across millions of households could translate into substantial avoidable morbidity, unnecessary treatment escalations, and eroded confidence in an otherwise excellent therapy. The message for parents is not that nasal sprays are failing their children, but that the spray bottle is only as good as the hands holding it. The message for clinicians is arguably more important: instruction is not education, and a prescription handed over with a brief demonstration may need to be paired with structured, verified, and repeated technique training. As the study’s authors conclude, knowledge and good intentions alone do not ensure correct administration, and closing the gap between them will require methods that test what parents can actually do, not just what they have been told.

Subject of Research: Parental knowledge, attitudes, and practices regarding intranasal corticosteroid use in children with allergic rhinitis

Article Title: Knowledge, attitudes, and practices of parents regarding intranasal corticosteroid use in children with allergic rhinitis

Article References: Zhang, H., Guo, T., Ji, X., & Zhao, H. (2026). Knowledge, attitudes, and practices of parents regarding intranasal corticosteroid use in children with allergic rhinitis. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07879-z

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07879-z

Keywords: allergic rhinitis, intranasal corticosteroids, pediatrics, parents, KAP survey, treatment adherence, patient education, nasal spray technique, know-do gap, teach-back, cross-sectional study, BMC Pediatrics