On The Shelf

Aina Abell

Honey may be a better treatment for upper respiratory tract infections than many common remedies, according to a systematic review and meta-analysis published online in BMJ Evidence-Based Medicine on August 18. Honey is already a well-known lay remedy for cough and cold symptoms, but scientific evidence of its effectiveness historically has been lacking.

The study

In the study, Abuelgasim and colleagues—researchers from Oxford University Medical School, University of Oxford in the United Kingdom—reviewed existing literature to evaluate honey’s effectiveness in relieving symptoms for upper respiratory tract infections such as acute cough, colds, and flu-like illnesses. They searched Pubmed, Embase, Web of Science, AMED, Cab abstracts, Cochrane library, LILACS, and CINAHL for relevant studies that involved patients of any age and gender, in any setting, with clinically or laboratory diagnosed infections and atopic upper respiratory tract conditions.

They looked for randomized clinical trials or in vivo observational studies that compared honey with at least one other intervention: no treatment, usual care, or placebo. Of the 1345 unique records the researchers identified, they selected 14 to include in the review.

The authors found that honey was superior to usual care when it came to improving cough severity, cough frequency, and combined symptoms. Upon examining usual-care remedies separately, they found that honey outperformed diphenhydramine and had similar outcomes to dextromethorphan.

They also noted that “two of the three studies comparing honey with placebo indicated a beneficial effect of honey,” but the evidence base from comparisons of honey against placebo was not strong.

To date, this study is the most comprehensive systematic review of honey’s effect on a range of upper respiratory tract infection symptoms. However, the study has a number of limitations, such as a risk of bias in the included studies.

Most of the studies also involved children, so the application of the evidence to adults may be limited.

In addition, while most studies in the meta-analysis used pure honey, the review also included other “honey interventions” such as Grintuss syrup (a cough suppressant syrup containing honey and plant complexes), Honitus syrup (an Aveyerdic honey-based syrup containing herb extracts), and honey combined with milk and coffee. “[K]nowing how much of any effect is due to honey, and how much might be due to the other ingredients” may be difficult in these cases, wrote the authors. However, they also noted that they included these studies because they “could find no clinical evidence of effectiveness of the other ingredients.”

What to tell patients

Upper respiratory tract infections are common and are the most frequent reason providers prescribe antibiotics. While the majority of these infections are viral—meaning antibiotics are both ineffective and inappropriate—the desire to preserve the patient–physician relationship and the lack of effective alternative treatments drive antibiotic overprescription. This contributes to the public health risk of antimicrobial resistance.

Honey “provides a widely available and cheap alternative to antibiotics [and] could help efforts to slow the spread of antimicrobial resistance,” wrote the authors. What’s more, the authors found that most patients who received honey experienced no adverse effects; any adverse reactions were relatively mild, such as nausea.

Honey is also low cost, commercially available and accessible, and safe for use and consumption by the majority of the population, except individuals with hypersensitivities and infants younger than 1 year, they wrote.

Given the evidence of the available literature, the authors concluded, “When clinicians wish to prescribe for [upper respiratory tract infections], we would recommend honey as an alternative to antibiotics. Honey is more effective and less harmful than usual care alternatives and avoids causing harm through antimicrobial resistance.”

More robust studies and placebo-controlled trials are necessary to assess honey’s effects on upper respiratory tract infections. 

Pharmacists should inform patients with acute cough, colds, and flu-like illnesses that honey may be effective in relieving their symptoms. Patients should understand that most upper respiratory tract infections are viral, so antibiotics will not be effective; treatment should focus on alleviating symptoms until their conditions improve.

Patients allergic to honey should not take it. Due to risks of infant botulism, parents should not give honey to infants younger than 1 year.