PRACTICE CHANGER
When a parent brings in a child (ages 1-5 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 (RCT)
Cohen HA, Rozen J, Kristal H, et al. Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study. Pediatrics. 2012;130:465-471.
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 4 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?
For primary care physicians, office visits for coughing kids with URIs are commonplace. In addition to the cost of such visits, Americans spend some $3.5 billion a year on over-the-counter (OTC) cough and cold remedies, and often give them to young children.
It’s not enough to tell parents what not to do
As physicians (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 3-year span (2005-2008), the American Association of Poison Control Centers received 64,658 calls for exposures to cough and cold remedies in children younger than 2 years of age, 28 of which resulted in a major adverse reaction or death.3
The US Food and Drug Administration 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 years.5 But warning parents of the dangers of giving them to young children without offering an alternative doesn’t satisfy anyone’s needs, and many parents continue to use these medications.
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 recommending honey 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 one and 5 years—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 any 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 5-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 in 2 of the 3 questions related to cough were included in the trial.
The study had a double-blind randomized design, with 4 treatment arms. Three groups received 10 g (about 1.5 tsp) of one of 3 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.
