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SGEM#26: Honey, Honey (Pediatric Cough)

SGEM#26: Honey, Honey (Pediatric Cough)

Podcast Link:SGEM26
Date:  3 March 2013
Title: Honey, Honey (Pediatric Cough)

Guest Skeptic: Dr. Anthony Crocco MD FRCPC, Deputy Chief, Pediatric Emergency Department, McMaster Children’s Hospital Assistant Clinical Professor, McMaster University, Member of the BEEM Dream Team.


Case Scenario: Five year old boy presents to the emergency department with a 2 day history of rhinorrhea and congestion. He has been coughing and it is especially bad at night. Mild fever is reported at home. He is eating and drinking well. On examination he looks well, is in no apparent distress and vital signs are all normal. Chest exam reveals no focal crackles or wheeze. You diagnose him with an upper respiratory tract infection (URI) “cold”.

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Dr. Anthony Crocco

Background: Brief differential diagnosis for child with cough presenting to the emergency department.

  • Infectious:
    • Upper (pharangitis, otitis media, croup)
    • Lower (bronchiolitis or pneumonia)
  • Non-Infectious:
    • Asthama
    • Foreign body aspiration
    • Gastro esophageal reflux disease (GERD)

Question: Do Over the Counter (OCT) medications work for cough in Children and Adults?

Reference: Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922

  • Population: 18 adult and 8 children trials with total of 4,037 patients
  • Intervention: Variety ofOTC cough medications
  • Comparison: Placebo
  • Outcome: Symptom relief of cough

Results: Pharmaceutical industry sponsored 11 of the 26 trials. Eight of the 11 industry sponsored trials showed positive results and only 3 of the non-industry sponsored trials showed benefits.

Authors Conclusions: There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due to differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self care treatments for acute cough.”

BEEM Comments:  Heterogenicity was too high to perform a meta-analysis in this systematic review. The overall results of the review was that there was insufficient evidence that cough medicines provide any benefit over placebo. In their study, the authors’ systematic review found conflicting evidence, with the majority of the studies that found in favour of beneficial effect having been funded by the pharmaceutical industry.

HARM: There are significant dangers to child cough and cold medicine. Data from 2011 National Poison Data System in the USA documented the following for child over the counter cough and cold medicines:

  • 35,000 calls to poison control centres
  • 3% of all pediatric poison control calls
  • 5 pediatric deaths
  • 10% of all pediatric toxicological deaths

In 2011 the Food and Drug Administration (FDA) pulled 500 cough/cold/allergy medicines off the market. The FDA sent a specifically advisory warning that OTC cough medicines should not be used in children under 2 years of age.

“FDA has completed its review of information about the safety of over-the-counter (OTC) cough and cold medicines in infants and children under 2 years of age.  FDA is recommending that these drugs not be used to treat infants and children under 2 years of age because serious and potentially life-threatening side effects can occur.”

The American Association of Family Physicians(AAFP) in 2012 recommend that these treatment not be used in children under the age of four.

“In children, there is a potential for harm and no benefits with over-the-counter cough and cold medications; therefore, they should not be used in children younger than four years.”

Question: What about honey for cough in children?

Reference: Oduwole et al. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub3.22419319

  • Population: Two randomized control trials of 265 children age 2 to 18 in ambulatory setting with cough from upper respiratory infection
  • Intervention: Honey +/- antibiotics
  • Comparison: Placeobo, cough medication or no treatment
  • Outcome: Primary outcome was duration of cough and symptomatic relief. Secondary outcomes included quality of sleep for children and care givers, adverse effects and other issues.


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Authors Conclusions: “Honey may be better than ’no treatment’ and diphenhydramine in the symptomatic relief of cough but not better than dextromethorphan. There is no strong evidence for or against the use of honey.”

BEEM Commentary: Well performed systematic review. However, only two small studies were included. These suggested honey may be of benefit over no treatment. However, these two studies had high risk of bias.

Reference: Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; DOI: 10.1542/peds.2011-3075 cohen-honey-cough

  • Population: 300 children age 1-5 years with upper respiratory infection
  • Intervention: Three different types of honey
  • Comparison: Placebo
  • Outcome: Cough


Screen Shot 2013-03-03 at 2.34.05 PM

Authors Conclusions: “Parents rated the honey products higher than the silan date extract for symptomatic relief of their children’s nocturnal cough and sleep difficulty due to URI. Honey may be a preferable treatment for cough and sleep difficulty associated with childhood URI.”

BEEM Bottom Line: If you have a child with a cough older than 1 year of age try a teaspoon of honey every 6 to 8 hours as needed.



Honey should not be given to children under the age of 1 year of age due to the risk of botulism.


KEENER KONTEST: Last weeks winner was Jaci Duszynski from USA. She has learned from TheSGEM that all bleeding stops…eventually:)

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.



  • I have been recommending honey for viral pharyngitis but I will not be recommending for URTI. Great read, thanks!

    • ken

      Good to hear from you Dawid
      Sounds like you are giving SWEET treatment

  • Can you elaborate on the honey-botulism connection? I’ve been told that there is no good evidence to prevent young children from eating honey….

    • ken

      Thanks for the question. I have sent it off to our BEEM ped expert Dr. Anthony Crocco to respond. Hope to have an answer back in the next 24hrs.

  • TheSGem

    Our BEEM Dream Team Peds expert Dr. Anthony Crocco responds to the botulism/honey/kids <1yr issue:


    Firstly, due to ethical reasons, a randomized study on the risks of honey exposure causing botulism in infants is not possible. We are left with epidemiological data, which we know is not perfect evidence, but is the the best evidence available. We know that honey is a reservoir for C. botulinum and Health Canada quotes 5% of Canadian honey containing the bacteria. ( Infants are felt to be at high risk due to the lack of competitive bacteria in the normal gut flora and the presence of C. botulinum in the gut has been identified in cases of SIDS.

    Koepke 2009 did a review on worldwide infant botulism. There has been a decrease in the rates of honey exposure in infants diagnosed with botulism in California from 40% in the 1970's to 5% in the 1990's. This rate drop is likely related to the increasing awareness of potential honey risks in infants and the dissemination of recommendations such as that from the American Academy of Pediatrics: "The American Academy of Pediatrics (AAP) recommends that you do not give honey to a baby younger than 12 months." (

    Worldwide, however, the rates of honey exposure in infants with botulism is much higher.

    Of course, this imperfect data raises a number of questions relating to cause-and-effect. In the absence of perfect data, however, we are left with 1) a known source of C. botulinum (honey), 2) a vulnerable host (infant) and 3) a rare, but potentially fatal disease (botulism).


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