Heart and lungs

Honey, not antibiotics, recommended for coughs

"Use honey first for a cough, new guidelines say," reports the BBC, referring to new guidelines on the best ways to treat acute short-term coughs.

The guidelines from the National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) have been developed after looking at the best available scientific evidence.

The evidence showed that honey could be effective at reducing the symptoms of acute coughs due to upper respiratory tract infections (infections of the airways), including how often people coughed and how bad their cough was.

The guidance applies to adults and children over 5 years of age. It's important to note that honey is not safe for children under the age of 1.

Other remedies which were also found to give some benefit included the herbal remedy pelargonium, and cough medicines containing either guaifenesin or antitussive dextromethorphan (for those aged 12 years and over).

Most acute coughs are self-limiting viral infections that will get better by themselves. And antibiotics are ineffective in treating viral infections but can still cause unpleasant side effects.

Antibiotics will only usually be used if people are very unwell or have increased risk of complications due to an underlying health condition such as cystic fibrosis.

Importantly we should only use antibiotics when they are really needed. Increasing antibiotic resistance may mean we might not benefit from these treatments in the future.

Why is the story in the news?

This story has made the news because NICE and PHE have produced new guidelines for how doctors should treat acute coughs. These guidelines give clear best practice recommendations for doctors and other healthcare professionals.

These recommendations are based on the best evidence available at the time. This means guidelines get updated over the years. The guideline on acute coughs is still at the draft or consultation stage, which means the recommendations may change slightly based on feedback from specialists, but they are not likely to change significantly.

What is meant by acute cough?

Acute coughs last for a short period of time (days or weeks, rather than months). This guideline focused on acute coughs related to infections of the upper respiratory tract (for example; common cold or flu), acute bronchitis (temporary infection of the airways that is usually viral) and other lower respiratory tract or chest infections (excluding pneumonia).

This guideline provides recommendations relating to acute coughs in adults, young people and children. For children under 5, NICE refers to its guidance on managing fever in young children.

What evidence did NICE look at?

Across the guideline, NICE and PHE looked at a range of scientific evidence. The preferred choice of study was randomised controlled trials, as these are usually the best way of comparing different treatments. Other types of study can be used if randomised controlled trials are not available, but these may lead to weaker recommendations.

For all types of study, the quality of the research was assessed against standard criteria. This in turn helped decide how strong the recommendations should be.

Why are antibiotics not recommended?

Antibiotics can be used to treat infections caused by bacteria. However, most acute coughs are caused by viruses which neither need nor respond to antibiotics. Even if a person has a bacterial infection, sometimes these can clear up without needing antibiotics.

As NICE says, when antibiotics are used for acute cough, they don't make much difference to how bad the symptoms are, or how long they last. Antibiotics can also have side effects which some people may find unpleasant.

Antibiotics should only be used when the infection is bacterial and isn't going away by itself. A lower threshold for use of antibiotics may also be used if the person is clearly unwell, or for those who have other serious illnesses or weakened immune systems so are at greater risk of complications.

It's important that antibiotics are only used when absolutely necessary. This is because bacteria are starting to develop resistance to antibiotics which means that these drugs are no longer working as well as they used to. The more we use them, the bigger this problem will become.

Although researchers are trying to develop new antibiotics, resistance is developing at a faster rate than we are able to find new treatments. The risk is that we may reach a point where we no longer have effective antibiotics to treat infections and even standard procedures, such as surgery, could become more hazardous in the future.

Why is honey recommended?

NICE and PHE found evidence from 3 randomised controlled trials, all of which looked at using honey in children and young people. Two of the studies compared it with no treatment, and one allowed "supportive treatment" if needed, which included saline (salt water), nose drops, water vapour and paracetamol.

In both comparisons, children given honey coughed less often and had less severe coughs compared with those given no treatment. No study found any difference in quality of sleep for either the children or for their adult carers. The quality of the evidence found was classified as low to moderate.

This evidence led NICE and PHE to suggest that honey can be used to relieve cough symptoms, but only in people over 1 year of age. It should not be given to children under the age of 1 due to the risks of infant botulism (a rare and serious type of food poisoning that can affect babies). The guideline also noted that honey is a sugar and therefore can pose a risk of tooth decay.

How can I use honey to treat a cough?

While there are many over-the-counter cough medicines that include honey, you can also mix it with hot lemon yourself at home to obtain a similar effect:

  • squeeze half a lemon into a mug of boiled water
  • add 1 to 2 teaspoons of honey
  • drink while still warm (don't give hot drinks to small children)

Are any other treatments also recommended?

The guideline also found evidence supporting the use of a number of other remedies people can use to look after themselves at home without having to see a doctor. These include:

  • pelargonium (a herbal remedy, thought to be most effective in liquid form)
  • cough medicines containing the expectorant guaifenesin (in people over 12 years of age)
  • cough medicines containing the antitussive dextromethorphan (in people over 12 years of age) so long as the cough is not persistent, such as in asthma, or accompanied by excessive phlegm

All of these remedies can be used to reduce the symptoms of an acute cough but won't cure the underlying infection. This usually gets better on its own within 3 weeks. If after 3 weeks your cough hasn't got any better, you should see your GP.

NHS Attribution