Summary:

• There is no strong evidence supporting the efficacy of many over-the-counter cough medications. 
• Research suggests that honey may be beneficial and can be tried as a home remedy to relieve acute cough in children, however, the studies have limitations.
• Honey might help by soothing throat irritation and inflammation.
• Children younger than one-year-old should not be served honey due to the risk of infant paralysis.

The so-called home remedies are a popular way of dealing with a cold or sore throat. With this article, we aim to explore one in particular – honey – and its effectiveness for the relief of acute cough.

A cough is a protective mechanism used by the body to get rid of excessive secretions, mucus, and foreign material present in the throat, as well as a result of inflammation and irritation of the upper airways. Acute cough in children usually lasts for up to two weeks and is the most common symptom of an upper respiratory tract infection (URTI). Viral infections are behind most URTIs, while only 10% of cases are caused by bacteria [1]. A URTI is usually a self-resolving condition, nevertheless, a cough can impact the quality of life and sleep of both children and parents, so a quick-acting remedy to relieve symptoms is frequently searched for [2].

Many over-the-counter (OTC) acute cough medications are used by the public and often recommended by general practitioners as first-line treatment. The two most common are dextromethorphan (DM), which relieves cough by acting on the part of the brain that causes coughing, and diphenhydramine (DH), which is an anti-histamine. Nevertheless, there is no strong evidence supporting their efficacy for this specific symptom. Indeed, when OTC cough preparations were compared with placebo in adults and children suffering from acute cough, it was concluded that there is no solid evidence for or against their effectiveness for these symptoms [3].

Even though not a drug, honey has been thoroughly researched to evaluate its effectiveness on acute cough. The general aim of the studies was to serve children suffering from acute cough either honey, an OTC medication or placebo, and observe the progress of their cough. The results were obtained through questionnaires filled out mostly by parents. In one study, a single dose of honey before sleep was presented as more effective in relieving a URTI-related cough in small children than DM and DH OTC cough medications [4]. This effect was lost when doses were given for three consecutive days, and honey and OTC medications performed in a similar manner [5]. When comparing honey alone or honey-flavoured DM, no differences were observed in cough relief or sleep, however, honey was rated more favourably by parents for improving their child’s symptoms [6]. In line with this, in another study, three different types of honey were investigated versus a placebo (a date syrup). Even though a single dose in all conditions led to improvement of symptoms, all three honey products seemed to perform better and were again rated higher by parents than the placebo in relieving their child’s nocturnal cough [7].

In a 2018 review of six small trials (899 children total), the authors aimed at combining the data from previous studies to form a solid conclusion on the effects of honey on acute cough. They concluded that honey is likely to be better in relieving cough symptoms and improving cough severity and sleep quality than placebo or no treatment. In addition, it may perform as well as DM and better than DH. The observed side effects were comparable between the conditions [2]. Honey was deemed to be safe in infants older than one year of age, as small babies younger than 12 months are not yet fully protected against a potential contaminant in the honey which could cause infant paralysis [8]. Nevertheless, due to the limitations of the studies, the authors could not confidently reach a conclusion of whether there is strong evidence for or against the use of honey. These limitations include the size of studies (usually small), unvalidated or unclear cough scales, ambiguous or different questions for parents to answer, a preference bias from parents judging the effects of a non-drug versus a drug, parents administering the treatments, as well as comparing different honey doses and types [2]. Of note, this review is a part of the Cochrane Database of Systematic reviews in the Cochrane library, which collects high-quality databases to advise healthcare decision-making [9].

Honey may help improve cough symptoms in several ways. It is a complex natural product containing mostly sugars, but also a wide range of proteins (including enzymes), vitamins, minerals, anti-oxidants, and phenolic compounds. Its unique composition leads to anti-inflammatory, anti-bacterial, anti-viral, anti-fungal, metabolic, and anti-oxidant properties, which can be exploited in specific, mostly external, applications [10, 11, 12, 13, 14, 15, 16]. However, factors such as bee species, flower source, geographical location, climate, and processing method can create differences in the composition of the honey. As an example, honey from the same floral source collected in neighbouring countries was different in the anti-oxidant activity and chemical properties [17]. Even though there are commercial therapeutic types of honey (such as manuka honey), it has been shown that some locally-produced honey can have equivalent anti-bacterial activity [11]. The consumer should also be aware that honey is very frequently adulterated by mixing with cheap sweet syrups, lowering the quality of the product [18].

The effects of honey might also be due to its demulcent, or soothing, activity. Primarily composed of sugars, demulcents may briefly act through the triggering of saliva production, swallowing, and coating the mucosal membrane, thereby soothing the irritation and inflammation. Indeed, honey has already been mentioned in 2001 by the World Health Organization (WHO) as a potentially useful demulcent in paediatric URTI-associated cough [19]. Similar in consistency to honey are common cough syrups. Interestingly, most of the beneficial effects of cough syrup may be due to the composition of the syrup, such as glycerol, and its chemical properties, such as demulcent activity, lubrication, and sweetness, rather than the active pharmacological ingredients present [20].

In conclusion, even though many studies have investigated the effects of honey on acute cough and have mostly seen beneficial results, the research does have limitations and does not provide solid evidence. Nevertheless, due to the many general benefits of honey, as well as its consistency and sweet taste, it will most likely be well received by children and could be a simple home remedy for children over the age of one.