Honey may offer safer, more effective and yummier cough relief than many over-the-counter (OTC) medicines.
As winter inches closer, pharmacists are seeing more patients seeking relief from coughs associated with cold and flu season, often asking for an OTC cough syrup or suppressant, or the Pharmacist Only medicine dihydrocodeine (Rikodeine).
But mounting evidence suggests the best therapeutic recommendation might come from the pantry rather than the dispensary.
1. Efficacy and safety of cough medicine called into question
The evidence for oral OTC cough preparations for acute cough is, at best, inconclusive – with clinical trials failing to demonstrate efficacy.
Cough medicines are contraindicated in children under 6 years of age, and use in older children discouraged – with product labels emphasising they should only be used in children aged 6–11 on the advice of a health professional (e.g. pharmacist, nurse, medical practitioner).
They should only be considered if the benefit of their use outweighs the risk, noting that the Therapeutic Goods Administration review that informed these changes highlighted significant safety and efficacy concerns.
Cough medicines are also not appropriate for many adult patients due to medicine interactions, risk of abuse, adverse effects, and other co-existing medical conditions (e.g. asthma, Chronic Obstructive Pulmonary Disease).
Additionally, the Australian Pharmaceutical Formulary and Handbook (APF) advises against combination cough products that mix an antitussive with an expectorant, an antihistamine, or both.
These products tend to contain subtherapeutic doses of each ingredient, and can increase the risk of adverse effects without adding meaningful therapeutic benefit.
2. Honey goes down more than a treat
Most acute coughs are self-limiting, and non-pharmacological management can be recommended, with the aim of chronic cough management being identifying and treating the underlying cause.
Honey is often the superior clinical choice if symptomatic relief is needed. According to the APF, honey relieves cough symptoms in children better than no treatment or placebo, acting as a demulcent by forming a soothing, bioadhesive film over irritated pharyngeal mucosa to blunt the sensory tickle that triggers a cough.
Interestingly, it is thought that the high placebo response seen in trials of cough medicines may be related to the demulcent content (or syrup) of the cough mixture.
A 2022 systematic review found honey to be an effective treatment for cough in children above 12 months of age, with a 2010 randomised controlled trial even finding it to be more effective than dextromethorphan or diphenhydramine at relieving nocturnal cough in children related to upper respiratory tract infections.
The 2023 Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA) Australian Chronic Cough Position Statement Update also strongly recommends minimising the use of other medications for nonspecific or refractory cough in children other than demulcents (i.e. honey).
While honey is a safe first-line recommendation for many patients, including children, it must not be given to infants under 12 months of age due to the risk of infant botulism from Clostridium botulinum spores.
Demulcents like honey are also a safe treatment option for:
- older patients
- those on multiple medications (honey carries no clinically significant drug interactions)
- pregnant or breastfeeding patients, for whom honey is considered safe in normal food amounts.
However, pharmacists should advise patients with known pollen allergies to use honey carefully, and it should be used judiciously in patients with diabetes.
3. When a spoonful of sugar is the medicine
When honey is the chosen path, advise patients or caregivers that 1–2 teaspoons before bed – taken undiluted or dissolved in liquid (e.g. juice) – is an effective, comforting dose.
Pair the recommendation with evidence-based non-pharmacological strategies, including:
- plenty of water and warm fluids to help thin mucus and soothe an irritated throat
- steam inhalation during a hot shower to promote expectoration.
Brush up on your knowledge about managing and treating cough by reading the APF ‘Cough’ Treatment Guideline for Pharmacists.
