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How sweet it is — honey as medicine
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Honey has been used for a variety of nutritional, gustatory and medicinal uses during the past several thousand years, but its use in modern times has recently been highlighted in the medical arena and news. Perhaps most applicable to pediatrics is the evaluation of honey for treatment of acute cough.
Honey can improve cough
Three randomized controlled trials have recently evaluated honey as an antitussive agent in children. Paul and colleagues randomly assigned a single bedtime dose of buckwheat honey to children and adolescents (n=105, aged 2 to 18 years) with cough secondary to upper respiratory tract infection. Children not randomly assigned to honey received a single bedtime dose of compounded dextromethorphan liquid (similar in appearance and taste to honey) or no treatment, in a partially double blind manner. A validated Likert scale assessment tool was used to compare cough frequency and severity, along with child and parent sleep, from one night before treatment use with just after treatment. The outcomes evaluated demonstrated honey to yield the greatest improvement in cough outcomes overall. Dextromethorphan did not demonstrate improvement in any outcome assessed when compared with no treatment. When honey was compared with dextromethorphan, a significant difference was not seen. In an interesting accompanying editorial, Warren and colleagues used published medical literature guidelines to rigorously evaluate Paul’s study and concluded that this study was conducted in a methodologically valid manner.
Edward A. Bell
Another controlled trial that evaluated the antitussive effects of honey was published in 2010. This randomized controlled study compared honey with dextromethorphan, diphenhydramine and a control group. Shadkam randomly assigned 139 children (aged 24 to 60 months) in Iran who were seen for upper respiratory tract infection and cough. Study participants received honey (obtained from a region in Iran), dextromethorphan, diphenhydramine or symptomatic care (this included nasal saline and suctioning, humidification and acetaminophen as needed) in a non-masked manner. Treatment groups also could receive symptomatic care as needed, although which children received additional symptomatic care was not stated. The same validated assessment scale was used as in Paul’s study.
Also similar to Paul’s study, children were assessed one night before treatment administration, and again after administration of one treatment dose. Compared with the previous night, all children, including children randomly assigned to the control group, improved, although children who received honey improved more (P<.05). Results of this study are weakened by several limitations: 1) all treatments were given in a non-masked manner; 2) the type of honey used was not well described and was indigenous to Iran (and may not be available in other countries); 3) all treatment groups also could have received symptomatic care (although who received this care was not detailed), which may have influenced outcome; and 4) diphenhydramine dosing was low.
Cohen compared a single nocturnal dose of three different types of honey with placebo (silan date extract) in Israeli children (n=270, aged 1 to 5 years) with upper respiratory tract infection and cough in a randomized, double blind manner. The honey used was eucalyptus, citrus or labiatae varieties. Silan date extract was used as placebo due to its similar appearance and taste as honey. A validated Likert scale assessment tool was used. Similar to the other studies I mentioned, assessment of cough was made on one night, and on the next night after a dose of honey or placebo before bedtime. Improvement in cough and sleep (child and parent) improved in all groups from one night to the next, although improvement was greatest in children receiving honey (P<.05). No differences were seen between the honey groups.
Treatment of acute wounds
Honey has been used for wound care for thousands of years, and the past several years have seen a specific honey-based product entering the commercial market. Medihoney (Derma Sciences) is available over-the-counter in a variety of dosage forms (gel, paste, pads) and is labeled for treatment of diabetic foot and other ulcers (eg, venous stasis, pressure), first- and second-degree burns, and traumatic and surgical ulcers. These products contain Leptospermum honey and are gamma-irradiated to destroy bacterial spores. Studies yielding evidence to support the use of honey have included mostly adult participants, although some children have been evaluated.
Several controlled, open-label studies of adult participants with various wounds provide some supportive data. In a Cochrane review of 25 trials, honey was found to be possibly more effective for treatment of acute wounds than conventional dressings, but no more effective for treatment of venous leg ulcers than compression. Overall, this Cochrane review found mixed results on honey’s effectiveness — benefit may be seen from its use in the treatment of some types of burns, although evidence from studies to support its various uses was deemed largely to be at high risk of bias.
Summary and conclusions
Data from two controlled, methodologically sound studies provide evidence that honey can effectively treat cough from upper respiratory tract infection in children aged as young as 1 year. Dosing of honey used in these trials was approximately one-half to one teaspoonful for children aged 1 to 5 years, one teaspoonful for children aged 6 to 11 years, and two teaspoons for older children. Frequency of dosing has not been evaluated. What is largely unknown, however, is what type of honey is most effective, or if the type of honey used is significantly important.
Buckwheat honey was used in Paul’s study, and several other types of honey were used in Cohen’s trial. Honey is classified by the floral source of the nectar used for its production. The type of honey most readers are likely familiar with is clover honey (amber in color), which has not been evaluated in clinical trials. How honey functions to soothe upper respiratory tract infection-induced cough also is unknown. Proposed mechanisms include its antioxidant and antimicrobial effects, and its demulcent actions. Honey’s sweet taste has additionally been described as potentially having an antitussive mechanism, as sweet substances may cause increased airway mucous to have a demulcent effect, or sweet taste may induce changes in central sensory nerves, reducing the urge to cough. If honey’s antioxidant effects are important, then the type of honey can be significant because some honey types (such as buckwheat) may contain more antioxidant compounds than other varieties.
Adverse effects from honey administration reported in clinical trials have been mild, including hyperactivity or nervousness in several children. Honey should not be given to infants younger than 12 months due to its potential for contamination with Clostridium botulinum spores and its toxicities in young infants. Given that data from published controlled trials in children do not support the efficacy of dextromethorphan, honey seems to be a reasonable alternative for treatment of upper respiratory tract infection-induced cough. Because of its sweet taste, honey also may be more welcoming to caregivers and children when it is administered. Very few data exist to define and support the use of honey applied topically to children for treatment of various wounds. Additional controlled trials are needed.
References:
Cohen HA. Pediatrics. 2012;130:465-471.
Jull AB. Cochrane Database Syst Rev. 2013;doi:10.1002/14651858.CD005083.pub3.
Paul IM. Arch Pediatr Adolesc Med. 2007;161:1140-1146.
Shadkam MN. J Altern Complement Med. 2010;16:787-793.
Warren MD. Arch Pediatr Adolesc Med. 2007;161:1149-1153.
Wijesinghe M. N Z Med J. 2009;122:47-60.
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Disclosure: Bell serves on the speakers’ bureau for Sanofi-Pasteur (Sklice) and MedImmune (FluMist Quad).