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International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 922
International Journal of Community Medicine and Public Health
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
http://www.ijcmph.com
pISSN 2394-6032 | eISSN 2394-6040
Original Research Article
Effect of honey on nocturnal cough among children in Taif city
Hanan Al-Juaid1*, Aljwharah AlJuaid2, Walaa Abuharba2, Ayman Abouhamda3
INTRODUCTION
Nocturnal cough is a common disturbing symptom
experienced by children with upper respiratory tract
infections (URTI). It often causes disruption of sleep for
both children as well as parents. Consequently, it results
in high rates of school absenteeism among the affected
children. Thus, caregivers and parents usually attempt to
give their children herbal regimens and over the counter
(OTC) medications to relieve their symptoms even if they
know that viral upper respiratory tract infections are
generally self-limited.1
A variety of herbal regimens and home remedies are
commonly administered to children with cough to treat
their symptoms, particularly honey, lemon, liquorice, and
clove.2,3 In spite of being not approved by the Food and
Drug Administration (FDA), honey has been long
considered a safe inexpensive demulcent that can relieve
cough among pediatric population. Honey is an
antioxidant with antimicrobial properties that can
increase cytokine release and modulate inflammatory
responses.4-6
ABSTRACT
Background:
Nocturnal cough is a common disturbing symptom that affects children during upper respiratory tract
infections and can have a major negative impact on child and parents’ sleep quality. Many pharmaceutical
medications, herbal regimens, and non-pharmaceutical advice are prescribed to reduce nocturnal cough. The aim of
this research was to study the impact of honey on nocturnal cough in children.
Methods:
A descriptive study was conducted on 226 children in Taif city, KSA using a pre-prepared questionnaire to
assess the cough severity and response to honey in comparison to other treatment modalities. Data collected were
then analyzed using SPSS software.
Results:
The study was conducted on 226 children (51.77% were females). Children who used honey were
significantly older (mean age 7.64±3.8 years) than those who used medications (mean age 6.98±60) (p=0.025).
Children who used honey had a higher prevalence of headache (p=0.001) and malaise (p<0.001) than children who
did not receive honey. The use of honey was also significantly associated with high cough severity scores. The use of
honey seemed to significantly reduce both the cough severity score and combined severity scores, with odd’s ratios of
0.46 and 0.19, respectively (p=0.020 and <0.001). However, it was associated with fewer satisfaction rates and fewer
intentions to re-use in next attacks (p=0.025).
Conclusions:
Honey has a beneficial effect on treating nocturnal cough in children. It decreases the severity of cough
as well as the frequency of cough. It is commonly used among older Saudi children who have cough associated with
malaise and fever. However, it is not satisfactory for patient and parental relief in Taif city because it doesn’t improve
the sleep quality of patients or parents.
Keywords: Honey, Nocturnal cough, Children, Taif, Saudi Arabia
Department of Family Medicine, 1Taif University, 2King Faisal Hospital, Taif, Saudi Arabia
3College of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia
Received: 11 January 2018
Accepted: 29 January 2018
*Correspondence:
Dr. Hanan Al-Juaid,
E-mail: dr.h.aljuaid66@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20180402
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 923
The aim of this work was to study the effect of honey on
nocturnal cough as well as sleep quality among Saudi
children in Taif city and to compare the cough frequency
and severity scores among children who were
administered honey with those who did not.
METHODS
This was a cross-sectional study that was conducted on
children suffering from night cough attending pediatric
and family medicine outpatient clinics in King Faisal
Hospital in Taif city, Saudi Arabia on October 2017 using
a pre-designed questionnaire. The pre-specified
questionnaire was distributed as hard copies by research
collaborators. Our questionnaire was structured by a
series of questions about night cough and related
symptoms as well as treatment used. Honey was
specifically asked about in details. The questionnaire was
translated into Arabic and the questions were re-phrased
in everyday language whenever needed. We measured
cough severity and control with a Likert scale with
maximum score of 6 for each question. The options were
“Extremely”, “Very much”, “A lot”, “Somewhat”, A
little”, “Not much” and “Not at all”, respectively.
Surveys were conducted by local teams at each hospital.
The survey packet contained a cover letter and a
questionnaire with Arabic and English versions. The
survey was handed to each patient to read and decide
whether to participate or not. Participants recruited to this
study were all potential children suffering from night
cough with no restrictions on severity, race, gender or
socio-economic status.
Statistical analysis
All collected data were transferred into a spread sheet for
further analysis. Standard descriptive measures were
calculated for each question/item individually. For data
analysis, SPSS 24 for Windows (SSPS Inc., Chicago, IL,
USA) was used. Chi-square test was used to measure the
significance of difference between different groups.
Regression analysis was used to assess association
between using honey and the severity of the disease.
Independent sample t-test was used to compare mean
efficacy and disease control between honey and other
treatments.
RESULTS
The study was conducted on 226 children suffering from
nocturnal cough. Males constituted 48.23% (n=109) and
females constituted 51.77% (n=117). The children were
classified into two groups according to the use of honey
for treatment of cough symptom. Honey was used more
frequently among older children (p=0.025). The mean
age of children who used honey was 7.64±3.8 years, and
the mean age for those who did not use honey was
6.98±93 years. The socioeconomic status of the recruited
patients was measured by the average monthly income of
their caregiver (below 5000 SAR, between 5000 and
10000 SAR, or above 10000 SAR) and there was no
statistically significant difference between the two-
studied group (p=0.360) (Table 1).
Table 1: Baseline demographic and disease characteristics of participants.
Characteristics
Patients receiving honey
Patients receiving other
P value¥
Age: mean (SD)
7.64 (3.8)
6.98 (3.60)
0.025*
Gender: N (%)
Male
31 (45.6)
78 (49.4)
0.602
Female
37 (54.4)
80 (50.6)
Relation of
participant to
child
Mother
19 (27.9)
19 (12.0)
0.033*
Father
16 (23.5)
42 (26.6)
Brother or sister
18 (26.5)
66 (41.8)
Grandma or grandpa
5 (7.4)
10 (6.3)
Other
10 (14.7)
21 (13.3)
Socioeconomic
Below 5000 SAR
13 (19.4)
31 (20.9)
0.360
5000 -10000 SAR
30 (44.8)
78 (52.7)
Above 10000 SAR
24 (35.8)
39 (26.4)
Cough frequency score, mean (SD)
2.22 (1.42)
2.68 (1.39)
0.022*
Cough severity score, mean (SD)
3.07 (1.64)
2.94 (1.36)
0.214
Cough effect on child sleep score, mean
(SD)
3.25 (1.58)
2.79 (1.68)
0.059
Cough effect on parent sleep score,
mean (SD)
3.06 (1.52)
2.98 (1.61)
0.820
Combined symptom score, mean (SD)
3.18 (2.08)
2.17 (1.36)
>0.001**
Frequency of hospitalization, mean
(SD)
3.09 (3.29)
3.53 (3.476)
0.379
Improvement after mean (SD)
2.13 (0.809)
1.80 (0.93)
0.002*
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 924
Table 2: Symptoms difference between patients using honey vs. other treatments.
Symptoms
Treatment used
P value¥
Honey
Other treatments
Congestion
Yes
19 (27.9)
38 (24.1)
0.537
No
49 (72.1)
120 (75.9)
Fatigue and weakness
Yes
29 (42.6)
51 (32.3)
0.135
No
39 )57.4)
107 (67.7)
Discharge
Yes
22 (32.4)
56 (35.4)
0
No
46 (67.6)
102 (64.6)
Sneezing
Yes
19 (27.9)
35 (22.2)
0.349
No
49 (72.1)
123 (77.8)
Headache
Yes
22 (32.4)
22 (13.9)
0.001*
No
46 (67.6)
136 (86.1)
Wheezing
Yes
44 (64.7)
105 (66.9)
0.752
No
24 (35.3)
52 (33.1)
Malaise
Yes
43 (63.2)
0 (0.0)
>0.001**
No
25 (36.8)
158 (100.0)
Fever
Yes
16 (23.5)
32 (20.3)
0.581
No
52 (76.5)
126 (79.7)
¥Chi-square test; *statistically significant (>0.05); ** statistically significant (>0.001).
Table 3: How often honey was used for cough.
Frequency
Gender
Male
Female
Total
N
%
N
%
N
%
Honey
times
Once
12
38.7
7
18.9
19
27.9
Twice
13
41.9
21
56.8
34
50.0
Three times
2
6.5
7
18.9
9
13.2
More than 3
4
12.9
2
5.4
6
8.8
Table 4: Disease progression and control comparing honey to other treatments.
Characteristics
Honey
Other treatments
P value¥
Diagnosis
Yes
46 (67.6)
105 (66.9)
0.910
No
22 (32.4)
52 (33.1)
Extra
treatments
used
Non
40 (58.8)
107 (67.7)
0.200
Bronchodilator
9 (13.2)
9 (5.7)
Ginger
0 (0.0)
7 (4.4)
Antibiotics
6 (8.8)
13 (8.2)
Syrup (don’t know the name)
8 (11.8)
16 (10.1)
Soolan syrup
1 (1.5)
1 (0.6)
Antihistamine
0 (0.0)
2 (1.3)
Lemon
2 (2.9)
2 (1.3)
Ventolin + O2
2 (2.9)
1 (0.6)
Controlled
Yes
44 (68.8)
109 (74.1)
0.419
No
20 (31.3)
38 (25.9)
Hospitalized
Yes
26 (38.8)
43 (27.2)
0.085
No
41 (61.2)
115 (72.8)
Satisfying
Yes
50 (73.5)
135 (86.0)
0.025*
No
18 (26.5)
22 (14.0)
Next attack
Yes
50 (73.5)
135 (86.0)
0.025*
No
18 (26.5)
22 (14.0)
¥Chi-square test; *statistically significant (>0.05).
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 925
Table 5: Linear regression testing association between honey use and different cough parameters.
Predictors
B
S.E.
Adjusted OR (95% CI) †
P value
Cough frequency score
0.21
±0.25
0.1 (-0.29-0.7)
0.410
Cough effect on child sleep score
0.33
0.19
0.24 (-0.05-0.7)
0.087
Cough severity score
-0.52
0.17
-0.39 (-0.86--0.17)
0.004 *
Cough effect on parent sleep score
-0.01
0.18
-0.01 (-0.36-0.35)
0.966
Combined symptom score
-0.96
0.78
-0.17 (-2.51-0.59)
0.220
B=Regression coefficient; S.E.=Standard error of regression coefficient; OR=Odds Ratio; CI=Confidence Interval; *statistically
significant (>0.05).
Table 6: Comparison efficacy of honey and other treatments in different aspects of cough.
Predictors
t
S.E.
Mean difference (95% CI) †
P value
Cough frequency score
-2.24
0.2
-0.46 (-0.86--0.05)
0.026 *
Cough effect on child sleep score
1.9
0.21
0.46 (-0.02-0.93)
0.059
Cough severity score
0.66
0.24
0.14 (-0.28-0.55)
0.513
Cough effect on parent sleep score
0.34
0.23
0.08 (-0.38-0.53)
0.735
Combined symptom score
0.84
0.05
0.19 (0.01-0.92)
<0.001**
t=t statistics; S.E.=Standard error difference; CI=Confidence Interval; *statistically significant (>0.05); **statistically significant
(>0.001).
Figure 1: Comparison of the mean effect of honey and other treatments on cough scores.
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 926
The cough frequency score among children who did not
use honey was significantly higher than those who used
it, with figures of 2.68 and 2.22 among the two groups,
respectively (p=0.0022). Similarly, the combined
symptom score was higher among patients who did not
use honey (3.53) in comparison to those who used honey
(3.05) with a probability value of <0.001. However,
children who used honey improved slower than those
who did not use honey; with a mean time to improvement
of 2.43 days among those who used honey compared to
1.8 among those who did not (p=0.002). The
demographic data are detailed in Table 1.
The symptoms investigated in this study included
congestion, fatigue and weakness, discharge, sneezing,
headache, wheezing, malaise, and fever (Table 2). Of
significance, headache was more prevalent among
children who were using honey (32.4%) in comparison to
those who did not (13.9%) (p=0.001). Similarly, malaise
was only experienced by children who used honey
(p<0.001), with percentage of how often the honey was
used in Table 3.
There was no statistically significant difference between
patients who used honey and those who did not as regards
the disease diagnosis, outcome, control, hospitalization
rates, and the need for using other treatments (Table 4).
However, the satisfaction rates, as well as the intention to
use honey versus other medical treatments in future
attacks, were significantly lower among patients who
received honey in comparison to those who did not
(p=0.025).
As regards the correlation of cough severity with honey
use, Table 5 demonstrates that using honey was
significantly correlated with the cough severity. Patients
who used honey were 0.026 times vulnerable to have
higher cough frequency scores than those who did not
receive honey (p=0.026). On the other hand, when the
impact of honey on different cough severity scores was
evaluated, it was found that the use of honey had
significantly reduced the cough severity score and the
combined severity score (for both severity and frequency)
(Figure 1). The impact of honey on several scores was
evaluated including the cough frequency score, the cough
severity score, the combined cough severity and
frequency score, child's sleep quality, and parents' sleep
quality scores. Of note, the use of honey had a
significantly beneficial effect on reducing the cough
severity score and the combined cough severity and
cough frequency scores. The odd’s ratio of cough
frequency was 0.46 (p=0.026) and that for combined
severity and frequency score was 0.19 (p<0.001) (Table
6). However, there was no statistically significant
difference between the two groups as regards the impact
on cough effect on child’s or parents’ sleep quality,
child's sleep quality, or cough severity score.
DISCUSSION
Honey has been long considered a safe, inexpensive, and
popular demulcent that can relieve cough, propose anti-
microbial actions, and modulate inflammatory response
and cytokine release. It is a complex natural remedy that
contains at least 181 different substances.7-9 Thus, parents
and caregivers commonly administer it to their sick
children even without seeking medical advice. This study
aimed to explore the effect of honey on children’s
nocturnal cough and sleep quality. Results from this
study showed that Saudi parents seemed to tend to use
honey in older children (p=0.025); they might have been
careful about cough symptoms in younger children for
fear of being more vulnerable to complications if not
promptly treated with pharmaceutics. However, previous
researchers did not find a statistically significant
difference for using honey among children of different
age groups.10-12 The difference encountered in this study
may be attributed to the cultural background and
knowledge about honey use as several Saudi parents
worry about the risk of infantile botulism with honey use
in younger children. Honey is generally not
recommended to be given for infants under the age of one
year for the risk of infantile botulism, but there is no
consensus against its use beyond this age.13 Some
researchers do not recommend the use of honey for long
periods because it increases the risk for dental caries.1
Another reason behind the avoidance of honey use in
young children in this study might be the fact that honey
seemed to take more time to improve the child’s
symptoms than medications (p=0.002), which might have
lead the caregivers to use other alternatives to fasten their
children recovery. The use or non-use of honey, however,
did not seem to have a statistically significant impact on
disease control or frequency of hospitalization.
Of note, parents used to use honey for their children
when they had more severe symptoms particularly
headache and malaise (p=0.001 and <0.001,
respectively). However, it was not frequently used when
children had higher nocturnal cough severity (OR=0.39,
p=0.0041).
The use of honey was found to have beneficial impact on
nocturnal cough frequency, and combined cough severity
and frequency scores. Children who received honey were
less likely to have high nocturnal cough severity scores
(OR=0.45, p=0.026) or high combined nocturnal cough
severity and frequency scores (OR=0.19, p<0.001). In
agreement with our results, Paul et al, in their study on
the effect of honey, dextromethorphan, and placebo on
nocturnal cough and sleep quality among children,
reported that parents reported significant improvement in
their children cough severity and sleep quality when they
used honey in comparison to those who used
dextromethorphan or placebo.10 Similarly, Cohen et al
stated that honey had significantly improved cough
symptom severity and sleep quality among the studied
Al-Juaid H et al. Int J Community Med Public Health. 2018 Mar;5(3):922-928
International Journal of Community Medicine and Public Health | March 2018 | Vol 5 | Issue 3 Page 927
patients.1 Other studies had also reported similar
results.11,12,14-21
In spite of the significant improvement in nocturnal
cough severity and frequency among the studied sample,
parents and caregivers reported less satisfaction rates
(p=0.025), and fewer intentions to re-use it in future
attacks (p=0.025). This may be attributed to the fact that
using honey, in spite of improving the nocturnal cough
frequency and severity scores, did not have a significant
impact on the quality of sleep either of children or their
parents. In disagreement with our results, parents used to
rate honey as a favorable regimen that improves their
children’s nocturnal cough and sleep quality.1,11,14,22 The
difference may be attributed to different cultures,
different concepts about symptom relief and expectations,
different types of honey used, and different dosage and
compliance.
The effect of honey on improving cough severity is
probably related to its immunomodulatory actions. Honey
was found to stimulate the monocytes to release
cytokines and chemokines particularly inter interleukin 6,
interleukin 1 beta, and tumor necrosis factor alpha (TNF-
alpha).8 Given the known role of these cytokines in
healing and tissue repair, honey can improve the cough
symptom. Furthermore, different fractions of the honey
were proved to have antioxidant properties. For instance,
honey contains ascorbic acid, gluconic acid,
hydroxymethylfuraldehyde, several peptides, phenolic
compounds, and many enzymes such as peroxidases,
catalases, and glucose oxidases which are known for their
antioxidant capacity.9
Limitations of the study
The main limitation of this study was a cross-sectional
study, it did not measure the impact of honey on
prospective more objective follow-up basis. The scores
used depended mainly on parents' memory about their
children condition and their subjective judgement.
Additionally, it was not blinded to reduce the bias. It
focused on children and patients' subjective evaluation of
their own symptoms and improvement. Finally, it was
limited to one city in KSA and did recruit patients from
different cities. So that, further multicenter prospective
double-blinded studies are still recommended to confirm
the results of this study and to be confident about
generalizing the results to the Saudi community.
CONCLUSION
Honey can improve children’s nocturnal cough severity
and frequency. It is commonly used among older Saudi
children who have cough associated with malaise and
fever. However, it didn’t improve the sleep quality of
patients or parents. So that, it is associated with lower
satisfaction rates and fewer intentions to be used in future
attacks among Saudi individuals.
ACKNOWLEDGEMENTS
The authors would like to thank the ministry of health of
Saudi Arabia and King Faisal Hospital for providing the
necessary access and tools to search and complete this
article.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Al-Juaid H, AlJuaid A,
Abuharba W, Abouhamda A. Effect of honey on
nocturnal cough among children in Taif city. Int J
Community Med Public Health 2018;5:922-8.
