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#24 Pediatric Cough: Do Honey or OTC cough suppressants help?

Do Over-The-Counter (OTC) cough suppressants or Honey improve cough due to Upper Respiratory Tract Infection (URTI) in children? 

OTC cough suppressants should not be used in children under six and are likely ineffective in older children. The evidence supporting honey is positive for a small effect but the evidence is at high risk of bias.  

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OTC Cough Suppressants: A systematic review1 considered 10 randomized controlled trials (RCTs) with 1036  children, mean ages 2-7.5. Studies were done primarily in pediatric/primary clinics and were generally poor quality.   
  • Statistical improvements were infrequent, inconsistent and of doubtful clinical significance.   
Honey: Four RCTs. 
  • 105 children, mean age five (range 2-17): one night-time dose of honey, dextromethorphan (DM), or nothing.2 
    • Statistically significant cough/sleep score improvement in: 
      • Five of five three-way comparisons: superiority in order of honey over DM over nothing.  
    • Neither honey or DM reached clinically important improvement  
      • 139 children, mean age three (range 2-5): one night-time dose of honey, DM, diphenhydramine (DPH), or supportive care.3   
    • Statistically significant improvement in: 
      • All groups after 24 hours: Mean improvements were 59% for honey, 45% for DM and DPH, and 31% for supportive care. 
    • Honey superior to DM and DPH, which were superior to supportive care. 
  • 270 children, median age 2.4 (range 1-5): one night-time dose of three different types of honey or placebo (silan date extract).4 
    • Statistically significant cough/sleep score improvement in: 
      • Five of five comparisons for all honey types over placebo with no difference between honey types. 
  • 134 children, age range 2-14 years: 3 night-time doses of milk with honey, or DM or levodropropizine (another antitussive).5 
    • No statistically significant difference between groups in cough relief.  
  • A meta-analysis6 of 3 of the included trials2-4 found that honey reduced cough frequency more than diphenhydramine and placebo, but not dextromethorphan. 
  • The magnitude of honey’s benefit cannot be determined due to study design. 
  • Methodological issues in honey trials: randomization not assured,2-5 no blinding,3,5 excluded patients deviating from protocol,3 substituting clinicians rating for parent/child,3,4 funding by the Honey Board,2,4 and limited clinical significance.2-5 
  • There is a strong placebo effect in treating pediatric cough; an RCT of 120 children found no significant difference between agave nectar and placebo, however, both reduced cough frequency and severity compared to no treatment.7 
  • Due to poor evidence of benefit and possible harms, Health Canada8 recommends OTC cough and cold medicines not be used in children under six 
  • Honey should not be used in children in age ≤1 due to risk of infantile botulism.

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  • G. Michael Allan MD CCFP
  • Michael R Kolber MD CCFP MSc

1. Smith SM, Schroeder K, Fahey T. Cochrane Database Syst Rev 2012;11:CD001831.

2. Paul IM, Beiler J, McMonagle A, et al. Arch Pediatr Adolesc Med 2007; 161:1140–6.

3. Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. J Altern Complement Med. 2010 Jul; 16(7):787–93.

4. Cohen HA, Rozen J, Kristal H, et al. Pediatrics 2012;130(3):465–71.

5. Miceli Sopo S, Greco M, Monaco S, et al. Allergol Immunopathol 2015;43:449-55.

6. Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE. Cochrane Database Syst Rev 2014;12:CD007094.

7. Paul IM, Beiler JS, Vallati JR, Duda LM, King TS. JAMA Pediatr 2014;168:1107-13.

8. Health Canada Drugs and Health Products. Last accessed on October 22, 2013.

Authors do not have any conflicts of interest to declare.