Honey for acute cough in children

Review question
We wanted to know if honey can reduce cough symptoms caused by bacteria and viruses in children.

Background
Cough is a cause for concern for parents and a major cause of outpatient visits in most clinics for both children and adults. Cough can affect quality of life, cause anxiety and affect sleep for parents and children. An immediate remedy is usually sought by the caregiver and patient. Cochrane reviews have reported on the effect of over-the-counter (OTC) cough medicines, but none have studied honey as a cough relief.

Honey is a sweet mixture of different types of carbohydrates, amino acids, flavonoids, vitamins and trace elements. Honey is believed to prevent the growth of bacteria, viruses and yeast, and reduce inflammation.

Study characteristics
We included three small randomised controlled trials involving 568 children, aged one to 18 years. The evidence is current to November 2014.

Key results
These small trials showed that honey may be better than 'no treatment' and placebo (a liquid that looks like and taste like honey, but is not honey) for cough relief. The evidence also showed that honey may be better than placebo in reducing worrying as a result of cough. However, it was no different to 'no treatment'. Honey allowed children and parents to sleep moderately better at night than 'no treatment'.

The effects of honey and dextromethorphan on all cough symptoms were not different. Honey may be better than diphenhydramine for relieving and reducing the effect of cough on children. Honey may also allow parents and children to sleep better than diphenhydramine.

Diphenhydramine and dextromethorphan are both common ingredients in cough syrups. Parents of seven children given honey and two given dextromethorphan reported side effects that were not too serious, such as not falling asleep easily, or being very restless and over excited. Parents of three children in the diphenhydramine group reported that their children were often sleepy.

Quality of the evidence
As with other medicines, the benefit of honey should be considered alongside the harms. The limitation of this updated review is that only three studies were included. Two were small studies with a high chance that some of their results may not be very accurate.

It is also important to state that the use of honey in infants under the age of one is not advised because of their poor immunity against Clostridium botulinum (C. botulinum), a bacteria that causes infant botulism that may be present in honey.

Authors' conclusions: 

Honey may be better than 'no treatment', diphenhydramine and placebo for the symptomatic relief of cough, but it is not better than dextromethorphan. None of the included studies assessed the effect of honey on 'cough duration' because intervention and follow-up were for one night only. There is no strong evidence for or against the use of honey.

Read the full abstract...
Background: 

Cough causes concern for parents and is a major cause of outpatient visits. It can impact on quality of life, cause anxiety and affect sleep in parents and children. Several remedies, including honey, have been used to alleviate cough symptoms.

Objectives: 

To evaluate the effectiveness of honey for acute cough in children in ambulatory settings.

Search strategy: 

We searched CENTRAL (2014, Issue 10), MEDLINE (1950 to October week 4, 2014), EMBASE (1990 to November 2014), CINAHL (1981 to November 2014), Web of Science (2000 to November 2014), AMED (1985 to November 2014), LILACS (1982 to November 2014) and CAB abstracts (2009 to January 2014).

Selection criteria: 

Randomised controlled trials (RCTs) comparing honey given alone, or in combination with antibiotics, versus nothing, placebo or other over-the-counter (OTC) cough medications to participants aged from one to 18 years for acute cough in ambulatory settings.

Data collection and analysis: 

Two review authors independently screened search results for eligible studies and extracted data on reported outcomes.

Main results: 

We included three RCTs, two at high risk of bias and one at low risk of bias, involving 568 children. The studies compared honey with dextromethorphan, diphenhydramine, 'no treatment' and placebo for the effect on symptomatic relief of cough using a seven-point Likert scale. The lower the score, the better the cough symptom being assessed.

Moderate quality evidence showed that honey may be better than 'no treatment' in reducing the frequency of cough (mean difference (MD) -1.05; 95% confidence interval (CI) -1.48 to -0.62; I2 statistic 23%; two studies, 154 participants). High quality evidence also suggests that honey may be better than placebo for reduction of cough frequency (MD -1.85; 95% Cl -3.36 to -0.33; one study, 300 participants). Moderate quality evidence suggests that honey does not differ significantly from dextromethorphan in reducing cough frequency (MD -0.07; 95% CI -1.07 to 0.94; two studies, 149 participants). Low quality evidence suggests that honey may be slightly better than diphenhydramine in reducing cough frequency (MD -0.57; 95% CI -0.90 to -0.24; one study, 80 participants).

Adverse events included mild reactions (nervousness, insomnia and hyperactivity) experienced by seven children (9.3%) from the honey group and two (2.7%) from the dextromethorphan group; the difference was not significant (risk ratio (RR) 2.94; 95% Cl 0.74 to 11.71; two studies, 149 participants). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14; 95% Cl 0.01 to 2.68; one study, 80 participants). When honey was compared with placebo, four children (1.8%) in the honey group and one (1.3%) from the placebo group complained of gastrointestinal symptoms (RR 1.33; 95% Cl 0.15 to 11.74). However, there was no significant difference between honey versus dextromethorphan, honey versus diphenhydramine or honey versus placebo. No adverse event was reported in the 'no treatment' group.