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Honey for acute cough in children

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References

Cohen 2012 {published data only}

Cohen HE, Rozen J, Kristal H, Laks Y, Berkovitch M, Uziel Y, et al. Effect of honey on nocturnal cough and sleep quality: a double‐blind, randomised, placebo‐controlled study. Pediatrics 2012;130(3):465‐71. [DOI: 10.1542/peds.2011‐3075]

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Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin CM. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Archives of Pediatrics and Adolescents Medicine 2007;161(12):1140‐6. [NCT00127686:]

Shadkam 2010 {published data only}

Shadkam MN, Mozaffari‐Khosravi H, Mozayan MR. A comparison of the effect of honey, dextromethorphan, and diphenhydramine on nightly cough and sleep quality in children and their parents. Journal of Alternative and Complimentary Medicine 2010;16(7):787‐93. [DOI: 10.1089/acm.2009.0311]

Ahmed 2013 {published data only}

Ahmed N, Sutcliffe A, Tipper C. Feasibility study: honey for treatment of cough in children. Pediatric Reports 2013;5(e8):31‐4. [DOI: 10.4081/pr.2013.e8]

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Sopo 2014 {published data only}

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IRCT201110247882N1 {published data only}

IRCT201110247882N1. Comparison study of honey versus diphenhydramine effect on cough alleviation in 2‐5 years old children with viral upper respiratory tract infection. http://www.irct.ir/searchresult.php?id=7882&number=1 (accessed 04 November 2014).

NCT01356693 {published data only}

NCT01356693. Randomized, double‐blind, placebo‐controlled clinical trial to evaluate the efficacy of the phytotherapic compound "Bromelin" on acute irritative cough. https://clinicaltrials.gov/ct2/show/NCT01356693 (accessed 04 November 2014).

IRCT2014090819037N1 {published data only}

IRCT2014090819037N1. Comparison of the effect of two kinds of Iranian honey and diphenhydramine on nocturnal cough and sleep quality in coughing children and their parents. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=IRCT2014090819037N1 (accessed 04 November 2014).

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References to other published versions of this review

Oduwole 2008

Oduwole O, Meremikwu MM, Oyo‐Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2008, Issue 2. [DOI: 10.1002/14651858.CD007094]

Oduwole 2010

Oduwole O, Meremikwu MM, Oyo‐Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD007094.pub2]

Oduwole 2012

Oduwole O, Meremikwu MM, Oyo‐Ita A, Udoh EE. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2012, Issue 3. [DOI: 10.1002/14651858.CD007094.pub3]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Cohen 2012

Methods

RCT

Participants

300 children (75 allocated to each treatment arm of eucalyptus honey, citrus honey, labiatae honey and placebo); 1 to 5 years with URTIs, nocturnal cough and illness duration of 7 days or less, attending general paediatric community clinics

Interventions

Single dose of 10 g of eucalyptus honey, citrus honey, labiatae honey or placebo administered 30 minutes before bedtime

Outcomes

Cough frequency, cough severity, bothersome nature of cough, child and parent sleep quality

Notes

This study was supported in part by a research grant from Israel Ambulatory Paediatric Association, Maternal Infant Nutrition Research Institute and the Honey board of Israel

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

The 3 honeys and the placebo were prepared by someone not involved in the study, interventions were packed in small plastic containers marked A, B, C and D and distributed to the paediatric community clinics in blocks of 4

Allocation concealment (selection bias)

Low risk

Silan date extract was used by the authors as a placebo because its structure, brown colour and taste are similar to that of honey. Interventions were packed in plastic containers labelled with the letters A, B, C and D

Blinding (performance bias and detection bias)
change in cough frequency

Low risk

The parents, physicians and investigators did not know the content of the preparation that was dispensed. The envelopes containing the codes for the study preparations were stored at the office of the Ministry of Agriculture, Extension service, Bee keeping Department and were not opened until after the statistical analysis was completed

Blinding (performance bias and detection bias)
the effect of the cough on sleep of the child

Low risk

The parents, physicians and investigators did not know the content of the preparation that was dispensed. The envelopes containing the codes for the study preparations were stored at the office of the Ministry of Agriculture, Extension service, Bee keeping Department and were not opened until after the statistical analysis was completed

Blinding (performance bias and detection bias)
the effect of cough on sleep of parents

Low risk

The parents, physicians and investigators did not know the content of the preparation that was dispensed. The envelopes containing the codes for the study preparations were stored at the office of the Ministry of Agriculture, Extension service, Bee keeping Department and were not opened until after the statistical analysis was completed

Selective reporting (reporting bias)

Low risk

All outcomes were adequately reported

Other bias

Unclear risk

Participants lost to follow‐up or withdrawn were not included in the final analysis

Follow‐up

Low risk

14, 13, 2 and 4 participants were lost to follow‐up in the eucalyptus honey, citrus honey, labiatae honey and placebo group respectively because they discontinued the intervention

Paul 2007

Methods

RCT

Participants

108 participants (35 allocated to honey, 34 allocated to dextromethorphan and 39 who received 'no treatment'); 2 to 18 years of age with URTIs, nocturnal symptoms and illness duration of 7 days or less

Interventions

A single dose of buckwheat honey, honey flavoured dextromethorphan or 'no treatment' administered 30 minutes prior to bedtime

Outcomes

Cough frequency, cough severity, bothersome nature of cough, cough impact on sleep quality for children and parents

Notes

This study was supported by an unrestricted research grant from the National Honey Board, an industry‐funded agency of the United States Department of Agriculture. It is possible that participants in the 'no treatment' group showed the least improvement because they were aware that they did not receive the active treatment, which could have been a source of bias in their responses

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

The randomisation sequence was done by a statistician not affiliated with the study and was then used by the study co‐ordinators to assign the treatment groups

Allocation concealment (selection bias)

Low risk

Treatment allocation was concealed in opaque brown envelopes

Blinding (performance bias and detection bias)
change in cough frequency

High risk

The syringes used for all the 3 treatment groups were opaque and placed in a brown paper bag to conceal the treatments from the investigators. The 'no treatment' group was not blinded to their treatment but the honey and dextromethorphan arms were blinded

Blinding (performance bias and detection bias)
the effect of the cough on sleep of the child

High risk

Though all participants were given syringes in brown paper bags the 'no treatment' group had empty syringes, which could influence the assessment of the outcome

Blinding (performance bias and detection bias)
the effect of cough on sleep of parents

High risk

The 'no treatment' group were not blinded to the intervention they received

Selective reporting (reporting bias)

Low risk

All outcomes were adequately reported

Other bias

Unclear risk

It is unclear whether any of the 'no treatment' group revealed to any of the assessors during phone conversations that they were given 'no treatment'. Participants lost to follow‐up or withdrawn were not included in the final analysis

Follow‐up

Low risk

2 participants from the 'no treatment' group were lost to follow‐up; 1 was withdrawn from the dextromethorphan group because the participant did not take the treatment

Shadkam 2010

Methods

RCT

Participants

160 participants (40 allocated to honey, 40 allocated to dextromethorphan, 40 allocated to diphenhydramine and 40 were in the 'no treatment' group (but who received the supportive treatment given to the others); 2 to 5 years of age with URTIs, nocturnal symptoms and illness duration of 5 days

Interventions

A single dose of natural honey from Kafi‐Abad (a village in Yazd, Iran), dextromethorphan, diphenhydramine or 'no treatment' (all treatment arms were advised to take supportive treatment with saline nose drops, water vapour, cleaning of a blocked nose and use of acetaminophen for fever, if necessary)

Outcomes

Cough frequency, cough severity, cough impact on sleep quality for children and parents

Notes

160 participants were randomised into the 4 groups but only 139 were finally analysed

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomisation was by random numbers table

Allocation concealment (selection bias)

Unclear risk

It was not clear whether treatment allocation was concealed

Blinding (performance bias and detection bias)
change in cough frequency

High risk

Both the investigators and caregivers were not blinded to the treatment given, which could greatly influence the assessment of outcome

Blinding (performance bias and detection bias)
the effect of the cough on sleep of the child

High risk

Both the investigators and caregivers were not blinded to the treatment given, which could greatly influence the assessment of outcome

Blinding (performance bias and detection bias)
the effect of cough on sleep of parents

High risk

Investigators and caregivers were not blinded to the treatment given, which could greatly influence the assessment of outcome

Selective reporting (reporting bias)

Low risk

All outcomes were adequately reported

Other bias

Unclear risk

Some of the questions put to mothers were answered by the paediatrician because the questions were ambiguous, which could also be an influence on the assessment of outcomes. Since mothers were filling in the questionnaire in the presence of the physician, this could also be a source of influence on the assessment of outcomes. No ITT analysis. Participants that were withdrawn or lost to follow‐up were also not included in the final analysis, which could also have made a difference in the effect of the interventions

Follow‐up

Low risk

7 participants from the honey group, 4 from the dextromethorphan group, 6 from the diphenhydramine group and 4 from the control group were either lost to follow‐up or withdrawn for violating the protocol

ITT: intention‐to‐treat
RCT: randomised controlled trial
URTI: upper respiratory tract infection

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Ahmed 2013

This is a feasibility study of honey for the treatment of cough in children. It is not a clinical trial

Gilbert 2008

This is a non‐Cochrane review on the included study selected from www.inforpoem.com by the study authors

Sopo 2014

The participants were randomised into "honey and milk" versus dextromethorphan and "honey and milk" versus levodropropizine

Warren 2007

This study is a non‐Cochrane review on the included study Paul 2007

Characteristics of studies awaiting assessment [ordered by year of study]

NCT01356693

Methods

RCT

Participants

Patients aged 2 to 15 years with acute irritative cough

Interventions

Bromelin versus placebo

Outcomes

Symtopmatic relieve of cough

Notes

Cough less than 24 hours

IRCT201110247882N1

Methods

RCT

Participants

2‐5 years old with viral acute respiratory infection

Interventions

Honey versus diphenhydramine

Outcomes

Cough severity and frequency

Notes

Comparison study of honey versus diphenhydramine effect on cough alleviation in 2‐5 years old children with viral upper respiratory tract infection

RCT: randomised controlled trial

Characteristics of ongoing studies [author‐defined order]

IRCT2014090819037N1

Trial name or title

Comparison of the effect of two kinds of Iranian honey and diphenhydramine on nocturnal cough and sleep quality in coughing children and their parents

Methods

Randomised, double‐blind

Participants

2‐5 years

Interventions

Honey versus diphenhydramine

Outcomes

Cough frequency and severity

Starting date

23 September, 2010

Contact information

Dr. Mahshid Ahmadi

Gamero building, Soltan tooye st, Velayat st, Saade Salman Sq

4818914799 Sari, Islamic Republic Of Iran

Notes

Data and analyses

Open in table viewer
Comparison 1. Pre‐ and postintervention comparison

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Cough frequency (mean improvement) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

Analysis 1.1

Comparison 1 Pre‐ and postintervention comparison, Outcome 1 Cough frequency (mean improvement).

Comparison 1 Pre‐ and postintervention comparison, Outcome 1 Cough frequency (mean improvement).

1.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.68, ‐1.25]

1.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.49 [‐2.09, ‐0.88]

1.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.73 [‐2.72, ‐0.74]

1.4 Placebo (silan dates extract)

1

75

Mean Difference (Fixed, 95% CI)

‐1.0 [‐1.82, ‐0.18]

1.5 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐0.98 [‐1.38, ‐0.59]

1.6 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐1.89 [‐2.96, ‐0.81]

1.7 Natural honey from Kafi‐Abad (Iran)

1

40

Mean Difference (Fixed, 95% CI)

‐2.16 [‐3.40, ‐0.92]

1.8 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.77 [‐3.22, ‐0.32]

1.9 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.82 [‐3.30, ‐0.34]

1.10 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.95 [‐3.55, ‐0.35]

2 Severity of cough (mean improvement) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

Analysis 1.2

Comparison 1 Pre‐ and postintervention comparison, Outcome 2 Severity of cough (mean improvement).

Comparison 1 Pre‐ and postintervention comparison, Outcome 2 Severity of cough (mean improvement).

2.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.70, ‐1.24]

2.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.52 [‐2.24, ‐0.80]

2.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.83 [‐2.88, ‐0.78]

2.4 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐1.13 [‐1.54, ‐0.72]

2.5 Placebo (silan date extract)

1

75

Mean Difference (Fixed, 95% CI)

‐0.99 [‐1.81, ‐0.17]

2.6 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐1.80 [‐2.88, ‐0.72]

2.7 Natural honey from Kafi‐Abad(Iran)

1

40

Mean Difference (Fixed, 95% CI)

‐2.33 [‐3.67, ‐0.99]

2.8 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.78 [‐2.82, ‐0.74]

2.9 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.94 [‐3.07, ‐0.81]

2.10 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.77 [‐2.74, ‐0.80]

3 Bothersome cough (mean improvement) reduction Show forest plot

2

Mean Difference (Fixed, 95% CI)

Subtotals only

Analysis 1.3

Comparison 1 Pre‐ and postintervention comparison, Outcome 3 Bothersome cough (mean improvement) reduction.

Comparison 1 Pre‐ and postintervention comparison, Outcome 3 Bothersome cough (mean improvement) reduction.

3.1 Honey

2

260

Mean Difference (Fixed, 95% CI)

‐2.18 [‐3.24, ‐1.13]

3.2 Dextromethorphan

1

34

Mean Difference (Fixed, 95% CI)

‐1.94 [‐3.05, ‐0.83]

3.3 No treatment

1

39

Mean Difference (Fixed, 95% CI)

‐1.30 [‐2.07, ‐0.53]

3.4 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐1.25 [‐2.39, ‐0.11]

3.5 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐2.23 [‐3.50, ‐0.96]

3.6 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.0 [‐3.82, ‐0.18]

3.7 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.07 [‐4.03, ‐0.11]

3.8 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.16 [‐4.20, ‐0.12]

4 Children's sleep (cough impact on children's sleep score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.4

Comparison 1 Pre‐ and postintervention comparison, Outcome 4 Children's sleep (cough impact on children's sleep score).

Comparison 1 Pre‐ and postintervention comparison, Outcome 4 Children's sleep (cough impact on children's sleep score).

4.1 Honey

3

300

Mean Difference (Random, 95% CI)

‐2.27 [‐3.13, ‐1.41]

4.2 Dextromethorphan

2

74

Mean Difference (Random, 95% CI)

‐1.75 [‐2.46, ‐1.04]

4.3 Diphenhydramine

1

40

Mean Difference (Random, 95% CI)

‐1.64 [‐2.58, ‐0.70]

4.4 No treatment

2

79

Mean Difference (Random, 95% CI)

‐1.28 [‐1.81, ‐0.76]

4.5 Placebo

1

75

Mean Difference (Random, 95% CI)

‐1.21 [‐2.46, 0.04]

5 Parents' sleep (cough impact on parents' sleep score) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

Analysis 1.5

Comparison 1 Pre‐ and postintervention comparison, Outcome 5 Parents' sleep (cough impact on parents' sleep score).

Comparison 1 Pre‐ and postintervention comparison, Outcome 5 Parents' sleep (cough impact on parents' sleep score).

5.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐2.30 [‐3.18, ‐1.43]

5.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.77, ‐1.17]

5.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.89 [‐2.97, ‐0.81]

5.4 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐1.46 [‐2.06, ‐0.87]

5.5 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐1.28 [‐2.64, 0.08]

6 Combined improvement Show forest plot

2

Mean Difference (Fixed, 95% CI)

Subtotals only

Analysis 1.6

Comparison 1 Pre‐ and postintervention comparison, Outcome 6 Combined improvement.

Comparison 1 Pre‐ and postintervention comparison, Outcome 6 Combined improvement.

6.1 Honey

2

260

Mean Difference (Fixed, 95% CI)

‐9.11 [‐11.31, ‐6.90]

6.2 Dextromethorphan

1

34

Mean Difference (Fixed, 95% CI)

‐8.39 [‐10.95, ‐5.84]

6.3 No treatment

1

39

Mean Difference (Fixed, 95% CI)

‐6.41 [‐8.82, ‐3.99]

6.4 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐5.82 [‐10.76, ‐0.88]

Open in table viewer
Comparison 2. Pair‐wise comparison

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Honey versus dextromethorphan Show forest plot

2

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 2.1

Comparison 2 Pair‐wise comparison, Outcome 1 Honey versus dextromethorphan.

Comparison 2 Pair‐wise comparison, Outcome 1 Honey versus dextromethorphan.

1.1 Frequency of cough (mean improvement)

2

149

Mean Difference (Random, 95% CI)

‐0.07 [‐1.07, 0.94]

1.2 Severity of cough (mean improvement)

2

149

Mean Difference (Random, 95% CI)

‐0.13 [‐1.25, 0.99]

1.3 Bothersome cough (mean improvement)

1

69

Mean Difference (Random, 95% CI)

0.29 [‐0.56, 1.14]

1.4 Children's sleep (cough impact on children's sleep score)

2

149

Mean Difference (Random, 95% CI)

0.03 [‐1.12, 1.19]

1.5 Parents' sleep (cough impact on parents' sleep score)

2

149

Mean Difference (Random, 95% CI)

‐0.16 [‐0.84, 0.53]

1.6 Combined mean improvement

1

69

Mean Difference (Random, 95% CI)

2.32 [‐1.24, 5.88]

2 Honey versus diphenhydramine Show forest plot

1

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 2.2

Comparison 2 Pair‐wise comparison, Outcome 2 Honey versus diphenhydramine.

Comparison 2 Pair‐wise comparison, Outcome 2 Honey versus diphenhydramine.

2.1 Frequency of cough (mean improvement)

1

80

Mean Difference (Random, 95% CI)

‐0.57 [‐0.90, ‐0.24]

2.2 Severity of cough (mean improvement)

1

80

Mean Difference (Random, 95% CI)

‐0.6 [‐0.94, ‐0.26]

2.3 Children's sleep (cough impact on children's sleep score)

1

80

Mean Difference (Random, 95% CI)

‐0.55 [‐0.87, ‐0.23]

2.4 Parents' sleep (cough impact on parents' sleep score)

1

80

Mean Difference (Random, 95% CI)

‐0.48 [‐0.76, ‐0.20]

3 Honey versus 'no treatment' Show forest plot

2

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 2.3

Comparison 2 Pair‐wise comparison, Outcome 3 Honey versus 'no treatment'.

Comparison 2 Pair‐wise comparison, Outcome 3 Honey versus 'no treatment'.

3.1 Frequency of cough (mean improvement score)

2

154

Mean Difference (Random, 95% CI)

‐1.05 [‐1.48, ‐0.62]

3.2 Severity of cough (mean improvement)

2

154

Mean Difference (Random, 95% CI)

‐1.03 [‐1.59, ‐0.47]

3.3 Bothersome cough (mean improvement)

1

74

Mean Difference (Random, 95% CI)

‐0.93 [‐1.98, 0.12]

3.4 Children's sleep (cough impact on children's sleep score)

2

154

Mean Difference (Random, 95% CI)

‐1.04 [‐1.57, ‐0.51]

3.5 Parents' sleep (cough impact on parents' sleep score)

2

154

Mean Difference (Random, 95% CI)

‐0.88 [‐1.23, ‐0.52]

3.6 Combined mean improvement

1

74

Mean Difference (Random, 95% CI)

‐4.31 [‐6.77, ‐1.85]

4 Honey versus placebo (silan dates extract) Show forest plot

1

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 2.4

Comparison 2 Pair‐wise comparison, Outcome 4 Honey versus placebo (silan dates extract).

Comparison 2 Pair‐wise comparison, Outcome 4 Honey versus placebo (silan dates extract).

4.1 Frequency of cough (mean improvement score)

1

300

Mean Difference (Random, 95% CI)

‐1.85 [‐3.36, ‐0.33]

4.2 Severity of cough (mean improvement)

1

300

Mean Difference (Random, 95% CI)

‐1.83 [‐3.32, ‐0.34]

4.3 Bothersome cough (mean improvement) reduction

1

300

Mean Difference (Random, 95% CI)

‐2.08 [‐3.97, ‐0.19]

4.4 Children's sleep (cough impact on children's sleep score)

1

300

Mean Difference (Random, 95% CI)

‐1.94 [‐3.93, 0.06]

4.5 Parents' sleep (cough impact on parents' sleep score)

1

300

Mean Difference (Random, 95% CI)

‐2.05 [‐4.24, 0.13]

Open in table viewer
Comparison 3. Adverse events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Nervousness, insomnia, hyperactivity Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

2.94 [0.74, 11.71]

Analysis 3.1

Comparison 3 Adverse events, Outcome 1 Nervousness, insomnia, hyperactivity.

Comparison 3 Adverse events, Outcome 1 Nervousness, insomnia, hyperactivity.

2 Stomach ache, nausea and vomiting Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

4.86 [0.24, 97.69]

Analysis 3.2

Comparison 3 Adverse events, Outcome 2 Stomach ache, nausea and vomiting.

Comparison 3 Adverse events, Outcome 2 Stomach ache, nausea and vomiting.

3 Drowsiness Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

2.92 [0.12, 69.20]

Analysis 3.3

Comparison 3 Adverse events, Outcome 3 Drowsiness.

Comparison 3 Adverse events, Outcome 3 Drowsiness.

4 Somnolence Show forest plot

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.68]

Analysis 3.4

Comparison 3 Adverse events, Outcome 4 Somnolence.

Comparison 3 Adverse events, Outcome 4 Somnolence.

5 Stomach ache, nausea and vomiting Show forest plot

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.15, 11.74]

Analysis 3.5

Comparison 3 Adverse events, Outcome 5 Stomach ache, nausea and vomiting.

Comparison 3 Adverse events, Outcome 5 Stomach ache, nausea and vomiting.

5.1 Honey

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.15, 11.74]

'Risk of bias' graph for included studies
Figures and Tables -
Figure 1

'Risk of bias' graph for included studies

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Pre‐ and postintervention comparison, Outcome 1 Cough frequency (mean improvement).
Figures and Tables -
Analysis 1.1

Comparison 1 Pre‐ and postintervention comparison, Outcome 1 Cough frequency (mean improvement).

Comparison 1 Pre‐ and postintervention comparison, Outcome 2 Severity of cough (mean improvement).
Figures and Tables -
Analysis 1.2

Comparison 1 Pre‐ and postintervention comparison, Outcome 2 Severity of cough (mean improvement).

Comparison 1 Pre‐ and postintervention comparison, Outcome 3 Bothersome cough (mean improvement) reduction.
Figures and Tables -
Analysis 1.3

Comparison 1 Pre‐ and postintervention comparison, Outcome 3 Bothersome cough (mean improvement) reduction.

Comparison 1 Pre‐ and postintervention comparison, Outcome 4 Children's sleep (cough impact on children's sleep score).
Figures and Tables -
Analysis 1.4

Comparison 1 Pre‐ and postintervention comparison, Outcome 4 Children's sleep (cough impact on children's sleep score).

Comparison 1 Pre‐ and postintervention comparison, Outcome 5 Parents' sleep (cough impact on parents' sleep score).
Figures and Tables -
Analysis 1.5

Comparison 1 Pre‐ and postintervention comparison, Outcome 5 Parents' sleep (cough impact on parents' sleep score).

Comparison 1 Pre‐ and postintervention comparison, Outcome 6 Combined improvement.
Figures and Tables -
Analysis 1.6

Comparison 1 Pre‐ and postintervention comparison, Outcome 6 Combined improvement.

Comparison 2 Pair‐wise comparison, Outcome 1 Honey versus dextromethorphan.
Figures and Tables -
Analysis 2.1

Comparison 2 Pair‐wise comparison, Outcome 1 Honey versus dextromethorphan.

Comparison 2 Pair‐wise comparison, Outcome 2 Honey versus diphenhydramine.
Figures and Tables -
Analysis 2.2

Comparison 2 Pair‐wise comparison, Outcome 2 Honey versus diphenhydramine.

Comparison 2 Pair‐wise comparison, Outcome 3 Honey versus 'no treatment'.
Figures and Tables -
Analysis 2.3

Comparison 2 Pair‐wise comparison, Outcome 3 Honey versus 'no treatment'.

Comparison 2 Pair‐wise comparison, Outcome 4 Honey versus placebo (silan dates extract).
Figures and Tables -
Analysis 2.4

Comparison 2 Pair‐wise comparison, Outcome 4 Honey versus placebo (silan dates extract).

Comparison 3 Adverse events, Outcome 1 Nervousness, insomnia, hyperactivity.
Figures and Tables -
Analysis 3.1

Comparison 3 Adverse events, Outcome 1 Nervousness, insomnia, hyperactivity.

Comparison 3 Adverse events, Outcome 2 Stomach ache, nausea and vomiting.
Figures and Tables -
Analysis 3.2

Comparison 3 Adverse events, Outcome 2 Stomach ache, nausea and vomiting.

Comparison 3 Adverse events, Outcome 3 Drowsiness.
Figures and Tables -
Analysis 3.3

Comparison 3 Adverse events, Outcome 3 Drowsiness.

Comparison 3 Adverse events, Outcome 4 Somnolence.
Figures and Tables -
Analysis 3.4

Comparison 3 Adverse events, Outcome 4 Somnolence.

Comparison 3 Adverse events, Outcome 5 Stomach ache, nausea and vomiting.
Figures and Tables -
Analysis 3.5

Comparison 3 Adverse events, Outcome 5 Stomach ache, nausea and vomiting.

Summary of findings for the main comparison. Honey versus dextromethorphan for acute cough in children

Honey versus dextromethorphan

Patient or population: children with acute cough
Settings: ambulatory
Intervention: honey
Comparison: dextromethorphan

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Dextromethorphan

Honey

Cough frequency (mean improvement in symptom score)
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean cough frequency (mean improvement in symptom score) in the control groups was
2.1

The mean cough frequency (mean improvement in symptom score) in the intervention groups was
0.14 lower
(0.33 lower to 0.06 higher)

137
(2 studies)

⊕⊕⊕⊝
moderate1

Cough severity (mean improvement in symptom score)
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean cough severity (mean improvement in symptom score) in the control groups was
1.5

The mean cough severity (mean improvement in symptom score) in the intervention groups was
0.61 higher
(0.27 to 0.94 higher)

137
(2 studies)

⊕⊕⊕⊝
moderate1

Child's sleep (mean improvement score)
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean child's sleep (mean improvement score) in the control groups was
1.26

The mean child's sleep (mean improvement score) in the intervention groups was
0.66 higher
(0.53 to 0.8 higher)

137
(2 studies)

⊕⊕⊕⊝
moderate1

Parents' sleep (mean improvement score)
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean parents' sleep (mean improvement score) in the control groups was
1.97

The mean parents' sleep (mean improvement score) in the intervention groups was
0.36 higher
(0.23 to 0.49 higher)

137
(2 studies)

⊕⊕⊕⊝
moderate1

Improvement in quality of life: combined effect (mean improvement in symptom score)
7‐poit Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean improvement in quality of life: combined effect (mean improvement in symptom score) in the control groups was
8.39

The mean improvement in quality of life: combined effect (mean improvement in symptom score) in the intervention groups was
2.31 higher
(1.7 to 2.92 higher)

68
(1 study)

⊕⊕⊕⊕
high

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1It was unclear if Shadkam 2010 had allocation concealment and there was no blinding in the study, which could increase the risk of bias in the study outcomes, although there was allocation concealment and partial double‐blinding in Paul 2007.

Figures and Tables -
Summary of findings for the main comparison. Honey versus dextromethorphan for acute cough in children
Summary of findings 2. Honey compared to diphenhydramine for acute cough in children

Honey compared to diphenhydramine for acute cough in children

Patient or population: children with acute cough
Settings: ambulatory
Intervention: honey
Comparison: diphenhydramine

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Diphenhydramine

Honey

Frequency of cough (mean improvement score)
7‐point Likert scale

Scale from: 0 to 6 Follow‐up: mean 1 day

The mean frequency of cough (mean improvement) in the control groups was
‐1.73

The mean frequency of cough (mean improvement) in the intervention groups was 0.57 lower
(0.9 to 0.24 lower)

80
(1 study)

⊕⊕⊝⊝
low

Severity of cough (mean improvement score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean severity of cough (mean improvement) in the control groups was
‐1.83

The mean severity of cough (mean improvement) in the intervention groups was 0.6 lower
(0.94 to 0.26 lower)

80
(1 study)

⊕⊕⊝⊝
low1

Children's sleep (cough impact on children's sleep score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean children's sleep quality (cough impact on children's sleep score) in the control groups was
‐1.64

The mean children's sleep quality (cough impact on children's sleep score) in the intervention groups was
0.55 lower
(0.87 to 0.23 lower)

80
(1 study)

⊕⊕⊝⊝
low

Parents' sleep (cough impact on parents' sleep score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean parents' sleep quality (cough impact on parents' sleep score) in the control groups was
‐1.89

The mean parents' sleep quality (cough impact on parents' sleep score) in the intervention groups was
0.48 lower
(0.76 to 0.2 lower)

80
(1 study)

⊕⊕⊝⊝
low

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95%) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1None of the treatment arms were blinded by Shadkam 2010 and allocation concealment was unclear. It was the same for the other outcomes.

Figures and Tables -
Summary of findings 2. Honey compared to diphenhydramine for acute cough in children
Summary of findings 3. Honey compared to 'no treatment' for acute cough in children

Honey compared to 'no treatment' for acute cough in children

Patient or population: children with acute cough
Settings: ambulatory
Intervention: honey
Comparison: 'no treatment'

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

'No treatment'

Honey

Frequency of cough (mean improvement score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean frequency of cough (mean improvement) in the control groups was
‐0.97

The mean frequency of cough (mean improvement score) in the intervention groups was
1.07 lower
(1.53 to 0.6 lower)

154
(2 studies)

⊕⊕⊕⊝
moderate1

Severity of cough (mean improvement score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean severity of cough (mean improvement) in the control groups was
‐1.13

The mean severity of cough (mean improvement) in the intervention groups was
0.97 lower
(1.47 to 0.46 lower)

154
(2 studies)

⊕⊕⊕⊝
moderate2

Bothersome cough (mean improvement score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean bothersome cough (mean improvement) in the control groups was
‐0.93

The mean bothersome cough (mean improvement) in the intervention groups was
0.93 lower
(1.77 to 0.09 lower)

74
(1 study)

⊕⊕⊕⊝
moderate2

Childrens' sleep (cough impact on children's sleep score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean children's sleep quality (cough impact on children's sleep quality score) in the control groups was
‐1.37

The mean children's sleep quality (cough impact on children's sleep quality score) in the intervention groups was
1.02 lower
(1.52 to 0.52 lower)

154
(2 studies)

⊕⊕⊕⊝
moderate2

Parents' sleep (cough impact on parents' sleep score)
7‐point Likert scale

Scale from: 0 to 6

Follow‐up: mean 1 day

The mean parents' sleep quality (cough impact on parents' sleep score) in the control groups was
‐1.48

The mean parents' sleep quality (cough impact on parents' sleep score) in the intervention groups was
0.93 lower
(1.41 to 0.46 lower)

154
(2 studies)

⊕⊕⊕⊝
moderate2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1The 'no treatment' group were not blinded in either of the studies; allocation concealment was unclear in the Shadkam 2010 study.
2No explanation was provided.

Figures and Tables -
Summary of findings 3. Honey compared to 'no treatment' for acute cough in children
Summary of findings 4. Honey compared to placebo for acute cough in children

Honey compared to placebo for acute cough in children

Patient or population: children with acute cough
Settings: ambulatory
Intervention: honey
Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Honey

Frequency of cough (mean improvement score)
7‐point Likert scale Scale from: 0 to 6
Follow‐up: mean 1 day

The mean frequency of cough (mean improvement score) in the control groups was
‐1.00

The mean frequency of cough (mean improvement score) in the intervention groups was
1.85 lower
(3.36 to 0.33 lower)

300
(1 study)

⊕⊕⊕⊕
high

We downgraded quality of evidence to moderate because only 1 high quality RCT compared honey to placebo

Severity of cough (mean improvement score)
7‐point Likert scale Scale from: 0 to 6
Follow‐up: mean 1 day

The mean severity of cough (mean improvement score) in the control groups was
‐0.99

The mean severity of cough (mean improvement score) in the intervention groups was
1.83 lower
(3.32 to 0.34 lower)

300
(1 study)

⊕⊕⊕⊕
high

Downgraded (same reason as above)

Bothersome cough
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean bothersome cough in the control groups was
‐1.25

The mean bothersome cough in the intervention groups was
2.08 lower
(3.97 to 0.19 lower)

300
(1 study)

⊕⊕⊕⊕
high

Downgraded (same reason as above)

Child's sleep (cough impact on child's sleep
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean child's sleep (cough impact on child's sleep in the control groups was
‐1.21

The mean child's sleep (cough impact on child's sleep in the intervention groups was
1.94 lower
(3.93 lower to 0.06 higher)

300
(1 study)

⊕⊕⊕⊕
high

Downgraded (same reason as above)

Parents' sleep (cough impact on parents' sleep score)
7‐point Likert scale. Scale from: 0 to 6
Follow‐up: mean 1 day

The mean parents' sleep (cough impact on parents' sleep score) in the control groups was
‐1.28

The mean parents' sleep (cough impact on parents' sleep score) in the intervention groups was
2.05 lower
(4.24 lower to 0.13 higher)

300
(1 study)

⊕⊕⊕⊕
high

Downgraded (same reason as above)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Figures and Tables -
Summary of findings 4. Honey compared to placebo for acute cough in children
Summary of findings 5. Adverse events

Adverse events

Patient or population: children with acute cough
Settings: ambulatory
Intervention: honey

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Honey

Nervousness, insomnia, hyperactivity (honey versus dextromethorphan)
Fixed‐effect Mantel‐Haenszel (M‐H) risk ratio
Follow‐up: mean 1 day

Study population

RR 2.94
(0.74 to 11.71)

149
(2 studies)

⊕⊕⊕⊝
moderate

27 per 1000

79 per 1000
(20 to 316)

Moderate

29 per 1000

85 per 1000
(21 to 340)

Stomach ache, nausea and vomiting (honey versus dextromethorphan)
Fixed‐effect Mantel‐Haenszel (M‐H) risk ratio
Follow‐up: mean 1 day

Study population

RR 4.86
(0.24 to 97.69)

149
(2 studies)

⊕⊕⊕⊝
moderate1

0 per 1000

0 per 1000
(0 to 0)

Moderate

0 per 1000

0 per 1000
(0 to 0)

Drowsiness (honey versus dextromethorphan)
Fixed‐effect Mantel‐Haenszel (M‐H) risk ratio
Follow‐up: mean 1 day

Study population

RR 2.92
(0.12 to 69.2)

149
(2 studies)

⊕⊕⊕⊝
moderate1

0 per 1000

0 per 1000
(0 to 0)

Moderate

0 per 1000

0 per 1000
(0 to 0)

Somnolence (honey versus diphenhydramine)
Fixed‐effect Mantel‐Haenszel (M‐H) risk ratio
Follow‐up: mean 1 day

Study population

RR 0.14
(0.01 to 2.68)

80
(1 study)

⊕⊕⊕⊝
moderate2

75 per 1000

10 per 1000
(1 to 201)

Moderate

75 per 1000

10 per 1000
(1 to 201)

Stomach ache, nausea and vomiting (honey versus placebo)
Fixed effect Mantel‐Haenszel (M‐H) risk ratio
Follow‐up: mean 1 day

Study population

RR 1.34
(0.15 to 12.17)

300
(1 study)

⊕⊕⊕⊕
high

We downgraded the evidence because only 1 high quality RCT compared honey versus placebo

13 per 1000

18 per 1000
(2 to 162)

Moderate

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1No explanation was provided.
2None of the treatment arms were blinded in Shadkam 2010.

Figures and Tables -
Summary of findings 5. Adverse events
Comparison 1. Pre‐ and postintervention comparison

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Cough frequency (mean improvement) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

1.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.68, ‐1.25]

1.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.49 [‐2.09, ‐0.88]

1.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.73 [‐2.72, ‐0.74]

1.4 Placebo (silan dates extract)

1

75

Mean Difference (Fixed, 95% CI)

‐1.0 [‐1.82, ‐0.18]

1.5 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐0.98 [‐1.38, ‐0.59]

1.6 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐1.89 [‐2.96, ‐0.81]

1.7 Natural honey from Kafi‐Abad (Iran)

1

40

Mean Difference (Fixed, 95% CI)

‐2.16 [‐3.40, ‐0.92]

1.8 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.77 [‐3.22, ‐0.32]

1.9 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.82 [‐3.30, ‐0.34]

1.10 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.95 [‐3.55, ‐0.35]

2 Severity of cough (mean improvement) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

2.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.70, ‐1.24]

2.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.52 [‐2.24, ‐0.80]

2.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.83 [‐2.88, ‐0.78]

2.4 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐1.13 [‐1.54, ‐0.72]

2.5 Placebo (silan date extract)

1

75

Mean Difference (Fixed, 95% CI)

‐0.99 [‐1.81, ‐0.17]

2.6 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐1.80 [‐2.88, ‐0.72]

2.7 Natural honey from Kafi‐Abad(Iran)

1

40

Mean Difference (Fixed, 95% CI)

‐2.33 [‐3.67, ‐0.99]

2.8 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.78 [‐2.82, ‐0.74]

2.9 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.94 [‐3.07, ‐0.81]

2.10 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐1.77 [‐2.74, ‐0.80]

3 Bothersome cough (mean improvement) reduction Show forest plot

2

Mean Difference (Fixed, 95% CI)

Subtotals only

3.1 Honey

2

260

Mean Difference (Fixed, 95% CI)

‐2.18 [‐3.24, ‐1.13]

3.2 Dextromethorphan

1

34

Mean Difference (Fixed, 95% CI)

‐1.94 [‐3.05, ‐0.83]

3.3 No treatment

1

39

Mean Difference (Fixed, 95% CI)

‐1.30 [‐2.07, ‐0.53]

3.4 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐1.25 [‐2.39, ‐0.11]

3.5 Buckwheat honey

1

35

Mean Difference (Fixed, 95% CI)

‐2.23 [‐3.50, ‐0.96]

3.6 Eucalyptus honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.0 [‐3.82, ‐0.18]

3.7 Labiatae honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.07 [‐4.03, ‐0.11]

3.8 Citrus honey

1

75

Mean Difference (Fixed, 95% CI)

‐2.16 [‐4.20, ‐0.12]

4 Children's sleep (cough impact on children's sleep score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

4.1 Honey

3

300

Mean Difference (Random, 95% CI)

‐2.27 [‐3.13, ‐1.41]

4.2 Dextromethorphan

2

74

Mean Difference (Random, 95% CI)

‐1.75 [‐2.46, ‐1.04]

4.3 Diphenhydramine

1

40

Mean Difference (Random, 95% CI)

‐1.64 [‐2.58, ‐0.70]

4.4 No treatment

2

79

Mean Difference (Random, 95% CI)

‐1.28 [‐1.81, ‐0.76]

4.5 Placebo

1

75

Mean Difference (Random, 95% CI)

‐1.21 [‐2.46, 0.04]

5 Parents' sleep (cough impact on parents' sleep score) Show forest plot

3

Mean Difference (Fixed, 95% CI)

Subtotals only

5.1 Honey

3

300

Mean Difference (Fixed, 95% CI)

‐2.30 [‐3.18, ‐1.43]

5.2 Dextromethorphan

2

74

Mean Difference (Fixed, 95% CI)

‐1.97 [‐2.77, ‐1.17]

5.3 Diphenhydramine

1

40

Mean Difference (Fixed, 95% CI)

‐1.89 [‐2.97, ‐0.81]

5.4 No treatment

2

79

Mean Difference (Fixed, 95% CI)

‐1.46 [‐2.06, ‐0.87]

5.5 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐1.28 [‐2.64, 0.08]

6 Combined improvement Show forest plot

2

Mean Difference (Fixed, 95% CI)

Subtotals only

6.1 Honey

2

260

Mean Difference (Fixed, 95% CI)

‐9.11 [‐11.31, ‐6.90]

6.2 Dextromethorphan

1

34

Mean Difference (Fixed, 95% CI)

‐8.39 [‐10.95, ‐5.84]

6.3 No treatment

1

39

Mean Difference (Fixed, 95% CI)

‐6.41 [‐8.82, ‐3.99]

6.4 Placebo

1

75

Mean Difference (Fixed, 95% CI)

‐5.82 [‐10.76, ‐0.88]

Figures and Tables -
Comparison 1. Pre‐ and postintervention comparison
Comparison 2. Pair‐wise comparison

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Honey versus dextromethorphan Show forest plot

2

Mean Difference (Random, 95% CI)

Subtotals only

1.1 Frequency of cough (mean improvement)

2

149

Mean Difference (Random, 95% CI)

‐0.07 [‐1.07, 0.94]

1.2 Severity of cough (mean improvement)

2

149

Mean Difference (Random, 95% CI)

‐0.13 [‐1.25, 0.99]

1.3 Bothersome cough (mean improvement)

1

69

Mean Difference (Random, 95% CI)

0.29 [‐0.56, 1.14]

1.4 Children's sleep (cough impact on children's sleep score)

2

149

Mean Difference (Random, 95% CI)

0.03 [‐1.12, 1.19]

1.5 Parents' sleep (cough impact on parents' sleep score)

2

149

Mean Difference (Random, 95% CI)

‐0.16 [‐0.84, 0.53]

1.6 Combined mean improvement

1

69

Mean Difference (Random, 95% CI)

2.32 [‐1.24, 5.88]

2 Honey versus diphenhydramine Show forest plot

1

Mean Difference (Random, 95% CI)

Subtotals only

2.1 Frequency of cough (mean improvement)

1

80

Mean Difference (Random, 95% CI)

‐0.57 [‐0.90, ‐0.24]

2.2 Severity of cough (mean improvement)

1

80

Mean Difference (Random, 95% CI)

‐0.6 [‐0.94, ‐0.26]

2.3 Children's sleep (cough impact on children's sleep score)

1

80

Mean Difference (Random, 95% CI)

‐0.55 [‐0.87, ‐0.23]

2.4 Parents' sleep (cough impact on parents' sleep score)

1

80

Mean Difference (Random, 95% CI)

‐0.48 [‐0.76, ‐0.20]

3 Honey versus 'no treatment' Show forest plot

2

Mean Difference (Random, 95% CI)

Subtotals only

3.1 Frequency of cough (mean improvement score)

2

154

Mean Difference (Random, 95% CI)

‐1.05 [‐1.48, ‐0.62]

3.2 Severity of cough (mean improvement)

2

154

Mean Difference (Random, 95% CI)

‐1.03 [‐1.59, ‐0.47]

3.3 Bothersome cough (mean improvement)

1

74

Mean Difference (Random, 95% CI)

‐0.93 [‐1.98, 0.12]

3.4 Children's sleep (cough impact on children's sleep score)

2

154

Mean Difference (Random, 95% CI)

‐1.04 [‐1.57, ‐0.51]

3.5 Parents' sleep (cough impact on parents' sleep score)

2

154

Mean Difference (Random, 95% CI)

‐0.88 [‐1.23, ‐0.52]

3.6 Combined mean improvement

1

74

Mean Difference (Random, 95% CI)

‐4.31 [‐6.77, ‐1.85]

4 Honey versus placebo (silan dates extract) Show forest plot

1

Mean Difference (Random, 95% CI)

Subtotals only

4.1 Frequency of cough (mean improvement score)

1

300

Mean Difference (Random, 95% CI)

‐1.85 [‐3.36, ‐0.33]

4.2 Severity of cough (mean improvement)

1

300

Mean Difference (Random, 95% CI)

‐1.83 [‐3.32, ‐0.34]

4.3 Bothersome cough (mean improvement) reduction

1

300

Mean Difference (Random, 95% CI)

‐2.08 [‐3.97, ‐0.19]

4.4 Children's sleep (cough impact on children's sleep score)

1

300

Mean Difference (Random, 95% CI)

‐1.94 [‐3.93, 0.06]

4.5 Parents' sleep (cough impact on parents' sleep score)

1

300

Mean Difference (Random, 95% CI)

‐2.05 [‐4.24, 0.13]

Figures and Tables -
Comparison 2. Pair‐wise comparison
Comparison 3. Adverse events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Nervousness, insomnia, hyperactivity Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

2.94 [0.74, 11.71]

2 Stomach ache, nausea and vomiting Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

4.86 [0.24, 97.69]

3 Drowsiness Show forest plot

2

149

Risk Ratio (M‐H, Fixed, 95% CI)

2.92 [0.12, 69.20]

4 Somnolence Show forest plot

1

80

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.68]

5 Stomach ache, nausea and vomiting Show forest plot

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.15, 11.74]

5.1 Honey

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.15, 11.74]

Figures and Tables -
Comparison 3. Adverse events