PRACTICE CHANGER
When a parent brings in a child (ages 1 to 5 years) with cough, runny nose, and other symptoms of a viral upper respiratory infection (URI), recommend that honey be given at bedtime.1
STRENGTH OF RECOMMENDATION
A: Based on a well-designed, randomized controlled trial.1
ILLUSTRATIVE CASE
A mother brings in her 18-month-old son because he’s had a runny nose and low-grade fever for the past four days—and a cough that kept them both up last night. You diagnose a viral URI, and she requests a strong cough medicine so he (and she) can get a good night’s sleep. What can you recommend that is both safe and effective for a child of this age?
Primary care office visits by coughing kids with URIs are common. In addition to the cost of such visits, Americans spend about $3.5 billion a year on OTC cough and cold remedies—often giving them to young children.
It’s not enough to tell parents what not to do
As clinicians (and parents), we understand the desire to give a coughing child something to ease the symptoms. We also know that OTC cough and cold medications can lead to serious complications and even death. Between 1983 and 2007, 118 pediatric deaths were attributed to the misuse of such preparations.2 And in a three-year span (2005 to 2008), the American Association of Poison Control Centers received 64,658 calls related to exposure to cough and cold remedies in children younger than 2; 28 of them resulted in a major adverse reaction or death.3
The FDA recommends against the use of OTC cough and cold medications in children younger than 2 years,4 and the American Academy of Pediatrics has issued strict warnings about the use of OTC cough and cold preparations in children younger than 6.5 But warning parents of the dangers of giving these remedies to young children without offering an alternative doesn’t satisfy anyone’s needs, and many parents continue to use them.
What about honey?
A study published in 2007 evaluated buckwheat honey and found it to be superior to no treatment and equal to honey-flavored dextromethorphan in reducing cough severity and improving sleep for children and their parents.6 Honey is known to have both antioxidant and antimicrobial properties—a possible scientific explanation for its effect. Before honey could be recommended for kids with URIs, however, more evidence of its efficacy was needed.
STUDY SUMMARY
Honey reduces cough frequency and severity
Cohen et al sought to determine whether honey, administered before bedtime, would decrease coughing in children between the ages of 1 and 5—and improve sleep for both the children and their caregivers.1 They enrolled 300 children with a nocturnal cough of < 7 days’ duration and a diagnosis of URI in a one-night study.
Children were excluded if they had signs or symptoms of asthma, pneumonia, sinusitis, allergic rhinitis, or laryngotracheobronchitis, or if they had been given any cough remedy (including honey) the night before. Parents completed a five-question survey, using a 7-point Likert scale, to assess the child’s cough and both the child’s and parents’ sleep the previous night. Only children whose parents rated their child’s cough severity ≥ 3 for two of the three related questions were included in the trial.
The study had a double-blind randomized design, with four treatment arms. Three groups received 10 g (about 1.5 tsp) of one of three types of honey: eucalyptus, citrus, or labiatae (derived from plants including sage, mint, and thyme); the fourth group received a placebo of silan date extract, which is similar to honey in color, texture, and taste.
Children in all four groups received the preparation 30 minutes before bedtime. Neither the parents, the physicians, nor the study coordinators knew which preparation the children received. The following day, research assistants telephoned the parent who had completed the initial survey and asked the same five questions. The primary outcome measure was the change in cough frequency from the night before to the night after treatment. Secondary measures included cough severity and the effect on sleep for both the child and the parent.
Of the 300 children initially enrolled, 270 (90%) completed the trial, with an even distribution among the groups. While there were improvements across all outcomes for both the treatment and placebo groups, the changes were statistically significant only in the treatment groups.
There were no significant differences in efficacy noted among the three types of honey. Adverse effects (stomachache, nausea, or vomiting) were noted by four parents in the treatment groups and one in the placebo group, a difference that was not statistically significant.