How is honey used to treat cough in children?

How Honey is Used to Treat Cough in Children

Honey should be given to children over 12 months of age with acute cough at a dose of approximately 10 mL (2.5 mL for younger children, up to 10 mL for older children) given before bedtime, which provides superior relief compared to no treatment, placebo, or diphenhydramine. 1, 2

Dosing and Administration

• Give honey as a single evening dose before bedtime to maximize symptom relief during the night when cough is most bothersome 3, 4
• Typical dosing: 10 mL of wildflower honey mixed with 90 mL of milk, or honey can be given alone 3
• Treatment duration: Honey can be given for up to three consecutive nights, with most benefit seen within the first 1-3 days 3, 4, 5
• Age-appropriate dosing: Adjust volume based on child's age (2.5 mL for younger children, up to 10 mL for older children) 5

Evidence for Efficacy

Honey provides moderate-certainty evidence of benefit over placebo and no treatment for reducing cough frequency (mean difference -1.62 on a 7-point scale compared to placebo) 5. The American College of Chest Physicians guidelines specifically state that honey offers more relief than no treatment, diphenhydramine, or placebo 1, 2.

• Honey performs similarly to dextromethorphan in reducing cough frequency, though the evidence is of lower certainty 5
• Honey is superior to diphenhydramine for cough relief (mean difference -0.57 on symptom scores) 5
• Multiple studies show honey reduces cough severity, frequency, and improves sleep quality for both children and caregivers 6, 4, 5

Critical Safety Precautions

Never give honey to infants under 12 months of age due to the risk of infant botulism 2, 7. This is an absolute contraindication and represents a potentially fatal complication.

• Lozenges should also be avoided in young children due to choking hazard 7
• Honey is safer than codeine-containing medications, which should be strictly avoided in all children due to risk of respiratory distress 1, 2, 8

Adverse Events

Honey has a favorable safety profile with minimal adverse events:

• Gastrointestinal symptoms occur in approximately 12% of children receiving honey versus 11% with placebo (not statistically significant) 5
• Honey causes fewer adverse events than OTC cough medications containing antihistamines or dextromethorphan 1, 8
• No serious adverse events have been reported with honey use in children over 12 months 5

When Honey is Preferred Over Alternatives

Honey should be the first-line treatment for acute cough in children over 12 months because:

• OTC cough and cold medicines have little to no proven benefit and carry risk of serious adverse events including death in young children 1, 8
• The FDA has issued warnings against OTC cough medications in children under 4 years, and restricted opioid cough medicines to adults 18 years and older 1, 8
• Antihistamines have minimal to no efficacy for cough relief in children 1, 8

Follow-Up and Re-evaluation

• If cough persists beyond 2-4 weeks, re-evaluate the child for emergence of specific etiological pointers that may indicate underlying respiratory or systemic illness 1, 2
• Consider medical evaluation if cough is accompanied by difficulty breathing, persistent fever, changes in mental status, or refusal to eat/drink 2
• The focus should shift to identifying and treating underlying causes rather than continued symptomatic treatment if cough becomes chronic 1, 8

Common Pitfalls to Avoid

• Do not increase honey doses beyond recommended amounts or extend treatment indefinitely without re-evaluation 1
• Do not combine honey with OTC cough medications, as this adds no benefit and increases risk of adverse events 1, 8
• Do not assume all cough requires treatment—most acute coughs from upper respiratory infections are self-limiting 1, 8