Background: Dextromethorphan (Robitussin) is a non-prescription drug used to treat cough associated with upper respiratory infections (URIs). However, it has not been shown to improve cough or sleep quality in children, and is not recommended by the American Academy of Pediatrics or the American College of Chest Physicians for use in this age group. Honey is cited by the World Health Organization as being potentially effective in controlling cough in children. It also is used in many cultures worldwide to treat URI symptoms; however, controlled trials examining this are lacking. Paul and colleagues examined the effects of a single dose of honey or honey-flavored dextromethorphan versus no treatment in children with nocturnal cough from URIs, and its associated sleep difficulties.

The Study: For this blinded, randomized study, patients two to 18 years of age with cough attributed to a URI (rhinorrhea and cough for up to seven days) were recruited from the same university-affiliated pediatric practice. Patients had to have abstained from antihistamine or dextromethorphan use for at least 24 hours before presentation, and had to have a cough that did not arise from another condition such as pneumonia, sinusitis, asthma, or allergic rhinitis.

Patients were age-matched and randomized to receive the study medication (buckwheat honey or artificially honey-flavored dextromethorphan) 30 minutes before bedtime. The dextromethorphan and honey groups received equivalent volumes of their respective medications appropriate for their age. In the dextromethorphan group, dosage approximated over-the-counter labeling recommendations (i.e., 8.5 mg per dose [1/2 teaspoon] for children two to five years of age; 17 mg per dose [one teaspoon] for children six to 11 years of age; and 34 mg per dose [two teaspoons] for children 12 to 18 years of age). In the honey group, honey was dispensed in an amount equivalent to the age-driven amount dispensed for dextromethorphan. A third control group received no treatment. Parents were asked to rate the severity of their child's cough and sleep difficulty on the night before the study and on the night they had received the study medication (or no treatment for the control group).

Results: Overall, 105 children with URIs were divided into the three groups, with 35 in the honey group, 33 in the dextromethorphan group, and 37 in the no treatment group. There were no differences in symptom severity or duration of illness in the groups at baseline. All three groups showed significant symptom improvement (see accompanying table), with the honey group reporting the greatest improvement in all measured outcomes and the no treatment group experiencing the least improvement. Pairwise comparisons of the groups were performed, with no significant differences in outcomes observed between the honey and dextromethorphan groups, or the dextromethorphan and no treatment groups. However, honey significantly improved all outcomes compared with no treatment.

Conclusion: Compared with no treatment, buckwheat honey is better at relieving nocturnal cough and sleep difficulty in children with URIs, and is equivalent to dextromethorphan in improving symptoms. The authors conclude that, given recent concerns about dextromethorphan's lack of effectiveness in children, buckwheat honey is a reasonable alternative in this age group.

editor's note: The use of dextromethorphan in children has been criticized recently for dubious effectiveness and potential side effects including respiratory depression. Although it improves coughing in adults, it has not been shown to work in children younger than 12 years.^1,2 Although the study by Paul and colleagues showed no significant symptom improvement in head-to-head comparisons between buckwheat honey and dextromethorphan, and dextromethorphan versus no treatment, honey was more effective than no treatment. Although honey may only modestly improve symptoms, it is at least as effective as dextromethorphan, and is likely to have a better side-effect profile than the potential respiratory or central nervous system effects that can occur with dextromethorphan.

About 100 cases of infantile botulism occur each year; ingestion of honey accounts for about 20 percent of these. Therefore, honey should be avoided in children younger than 12 months, although it is generally considered safe after this age.³—k.t.m.