THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 16, Number 7, 2010, pp. 787793

Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2009.0311

A Comparison of the Effect of Honey, Dextromethorphan,

and Diphenhydramine on Nightly Cough
and Sleep Quality in Children and Their Parents
Mahmood Noori Shadkam, MD,1 Hassan Mozaffari-Khosravi, PhD,2 and Mohammad Reza Mozayan, MSc 3

Abstract

Objectives: Coughing is a prevalent symptom of upper respiratory infections (URIs) that cause disturbance in
the sleep of children and their parents. There is as yet no reliable treatment to control URIs and their related
cough; however, drugs such as dextromethorphan (DM) and diphenhydramine (DPH) are now mainly used in
the world. The aim of this study is to compare the effect of honey, DM, and DPH on the nightly cough and sleep
quality of children and their parents.
Design: This was a clinical trial study in which 139 children aged 2460 months suffering from coughing due to
URIs were selected and assigned randomly to 4 groups. The first group received honey (HG), the second one
DM (DMG), the third DPH (DPHG), but the fourth group or control group (CG) was assigned to a supportive
treatment.
Outcome measures: After approximately a 24-hour intervention, the 4 groups were reexamined and their cough
frequency, cough severity, and sleep quality in children and their parents were recorded by using the questionnaire with Likert-type questions.
Results: The mean of cough frequency score HG is 4.09
0.72 and 1.93
0.65 before and after the intervention,
respectively, while these figures for the CG are 4.11
0.78 and 3.11
0.57, respectively. After the intervention,
the difference of the mean score of the variables in all groups became statistically significant. The mean score of
all variables in HG has stood significantly higher than those in other groups. There is also a significant relationship between the DMG and CG groups, even though there is no statistically difference between DMG and
DPHG groups.
Conclusions: The result of the study demonstrated that receiving a 2.5-mL dose of honey before sleep has a more
alleviating effect on URIs-induced cough compared with DM and DPH doses.

Introduction

pper respiratory tract infections (URIs) are the

prevalent diseases among children, sending many of
these patients to physicians every year.1,2 Each year, children
are usually affected 68 times by the disease; however, its
prevalence among adults is 23 times.2 Normally, viruses,
and in less than 10% of the cases, bacteria, are the producers
of these infections.1 The URIs are usually ameliorated
spontaneously. Even though they are not associated with
disability and mortality, they can cause morbidity and
medical costs. The typical signs and symptoms of the disease
are the following: rhinorrhea, sneeze, malaise, a slight fever,
and cough.2 These, in around 50% of people, are in the form
of dry and sore throat, while in 40% others they appear in the

form of cough. Most of the symptoms emerge during the first

3 days but are fortunately relieved in a week; the cough,
however, may remain for a longer time.3 Coughing, especially during the night, can cause trouble and disturbance for
the childrens and parents sleep.4 Each year, billions of
dollars are spent to control and cure cough while the cough
medicines real effect is not clear.5
There is as yet no appropriate and acceptable treatment
for URIs and the resultant cough. The antitussive drug that is
frequently utilized for children is dextromethorphan (DM);
however, this drug has not yet been confirmed by the Pediatrics Academy of America.6,7 Diphenhydramine (DPH) is
also another drug that is used in relation to coughs, but its
relieving effect is controversial.1 In the present study, the
effect of both DM and DPH has been compared with honey

Departments of Pediatrics,1 Nutrition,2 and English Language,3 Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

787

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NOORI SHADKAM ET AL.

especially in a larger population, whereas in Pauls study4

there is no such comparison.
In traditional medicine, honey is used to treat the signs
and symptoms of URIs, especially coughing.4,8,9 Honey has
also been used to repair sores and injuries in children.4,1013
Also, the World Health Organization recently recommended
honey for controlling cough and other URI symptoms.14
Compared with the drugs, honey is less expensive, more
available, and especially safer to be used for children. The
relieving effect of honey has been known to be from its antioxidant and cytokine-releasing features, thus justifying its
antimicrobial effect.1519 Regardless of these, honey is also
considered a food substance consisting of various nutrients,
energy, and different phytochemicals, which have both curing and nutritive effects.
In view of the prevalent problems of coughing due to
URIs in children and the fact that a reliable treatment for this
has not yet been found, the aim of this study was to compare
the effects of DM, DPH, and honey on the nightly cough and
sleep quality of children and their parents.

antihistamine, DPH, or DM 4 hours before sleep or had

consumed cytochrome P450 inhibitors simultaneously (i.e.,
serotonin-reabsorption selective inhibitors) were also excluded from the study. Parents were also excluded if they
were using a drug and herbal that had an effect on sleeping,
such as sedatives.
Measurements
A standard researcher-made questionnaire previously
designed for the purpose and formerly used in other studies
was filled in by asking questions of the childrens mothers.4,8
The questionnaire in the first part included demographic
variables such as age and gender. In the second part (i.e., the
main part), it included four key questions related to cough,
severity of cough, sleep quality of the child as well as those of
parent, respectively (Fig. 1). The answers to the questions
were categorized on the basis of a Likert-type scale graded
from 0 ( not at all) to 6 ( extremely). The questionnaire
was completed by each mother in the presence of a pediatrician before and after a 1-night intervention. (Note that in
Iran, children are referred to physicians mostly through their
mothers; mothers also take care of children at home.) Any
ambiguous question for the mother, if any, was answered by
a pediatrician. Thus, after a physician visited the patient, the
questionnaire was completed and on the following day each
mother and child revisited the doctor and the relevant
questionnaire was completed once more but after the intervention.

Materials and Methods

Design and subjects
This is a clinical trial study that began in December 2008
and ended in May 2009. The subjects were 160 children aged
2460 months suffering from URI-induced cough. On the
basis of the previous studies (i.e., power 80% and a 0.05),
a total of 140 children were randomly assigned to 4 groups
(35 in each group). To be on the safe side (i.e., if a subject
would not come back or would not perform the medical
orders appropriately), 5 others were added to each group,
thus totaling 160 children (40 in each group) who participated in the study. All or some of these children were suffering from symptoms such as rhinorrhea, sneeze, sore
throat, and stuffed nose. Their coughing had lasted 5 days.
Those with the diseases such as asthma, pneumonia, laryngotracheobronchitis, sinusitis, allergic rhinitis, chronic lung
disease, congenital heart disease, malignancy, and diabetes
were not included in the study. Those who had consumed

Dosage and prescriptions

Using Table of Random Numbers, the subjects were
placed in 1 of the 4 groups. The first group (HG) received
2.5 mL of natural honey from Kafi-Abad (a village in Yazd)
before sleep. The second (DMG) and third (DPHG) groups
received 2.5 mL of DM syrup (7.5 mg, Pour-Sina drug
manufacturing company in Tehran, registered No.
1228051241), and 2.5 mL of DPH syrup (6.25 mg, RamooFarmon drug manufacturing company, Registered No.
1228056772), respectively, before sleep. The honey and other

1) How frequent was your childs cough last night?

6

Constant

Very Much

A lot

Somewhat

A little

Occasional

Not at

all

2) How much did last nights cough affect your childs ability to sleep?
6

Extremely

Very Much

A lot

Somewhat

A little

Occasional

Not at all

3) How much did last nights cough affect your ability to sleep?
6

Extremely

Very Much

A lot

Somewhat

A little

Occasional

Not at all

A little

Occasional

Not at all

4) How severe was your childs cough last night?

6

Extremely

Very Much

A lot

Somewhat

FIG. 1. Survey questions about nightly cough and sleep difficulty. Adapted with permission from the study by Paul et al.,4
Arch Pediatr Adolesc Med 2007;16(12):11401146. 2007 American Medical Association. All rights reserved.

HONEY AND COUGHING

789

Table 1. Mean and Frequency of Variables of the 4 Groups at the Beginning of the Study
Variables
Duration of illness (day)
Cough frequency score
Cough severity score
Cough impact on child sleep score
Cough impact on parent sleep score
Age (month)
Gender
Male
Female

HG
(N 33)

DMG
(N 36)

DPHG
(N 34)

CG
(N 36)

3.03
1.16b
4.09
0.76
3.85
0.83
3.67
0.69
3.94
0.70
37.7
11.4
17 (51.5)c
16 (49)

3.14
1.12
4.08
0.91
3.86
0.93
3.64
0.68
3.92
0.70
37.4
11.1
17 (47.2)
19 (53)

3.09
1.16
4.23
0.70
3.94
0.74
3.62
0.70
3.91
0.71
38.0
11.4
17 (50.0)
17 (50)

3.0
1.26
4.20
0.79
3.90
0.80
3.64
.72
3.86
0.64
37.8
10.9
17 (47.2)
19 (53)

p-valuea
0.98
0.81
0.96
0.99
0.97
0.99
0.98d

One-way analysis of variance.

Mean
standard deviation.
c
N (%).
d 2
w.
HG, honey group; DMG, dextromethorphan group; DPHG, diphenhydramine group; CG, control group.
b

drugs are usually used at room temperature of about 22

268C. The fourth group (CG), however, was given only
supportive treatment recommended for other groups as well.
The supportive treatments included saline nose drops, water
vapor, cleaning a blocked nose, and using acetaminophen if
fever existed. All mothers were offered the same standard on
the disease and how to use liquids, nose drops, and humidifier by a pediatrician. All 4 groups were examined the
following day and the same questionnaire was completed for
them once more. The subjects who for any reason had consumed an inappropriate dose of the drugs were excluded
from the survey.
Data analysis
Data were analyzed by SPSS software version 11 (SPSS
Inc., Chicago, IL). For comparing the average mean of each
of the quantifiable variables for pre- and postintervention, a
paired t-test was used; one-way analysis of variance and
multiple comparison tests were used for comparing the average mean of quantifiable variables between groups; w2 test

was used to compare the frequency distribution between

groups. The p-values were considered significant at p < 0.05.
Ethical considerations
A consent form was obtained from each childs mother.
They could quit the study freely whenever they liked. The
Research Ethics Committee of the Shahid Sadoughi University of Medical Sciences approved the relevant research
proposal.
Results
Of 160 participants, 21 were excluded from the study
for not visiting the physician as scheduled or inappropriately using the drugs (7, 4, 6, and 4 patients from HG,
DMG, DPHG, and CG groups, respectively), so 139 patients data were finally analyzed. In general, the average mean age of the children was 37.75
11.12 months. Of
the patients, 71 (51.1%) were girls and 68 (48.9%) were
boys.

Table 2. Mean of Variables of the Four Groups Before and After the Study
Variables
Cough frequency score
Before
After
p-valuea
Cough severity score
Before
After
p-value
Cough impact on child sleep score
Before
After
p-value
Cough impact on parent sleep score
Before
After
p-value

HG

DMG

DPHG

CG

4.09
0.76
1.93
0.65
<0.001

4.08
0.90
2.47
0.72
<0.001

4.23
0.63
2.50
0.70
<0.001

4.19
0.78
3.11
0.57
<0.001

3.84
0.83
1.51
0.61
<0.001

3.86
0.93
2.16
0.69
<0.001

3.94
0.73
2.11
0.68
<0.001

3.86
0.79
2.69
0.66
<0.001

3.66
0.66
1.42
0.56
<0.001

3.63
0.68
1.91
0.69
<0.001

3.61
0.69
1.97
0.62
<0.001

3.63
0.72
2.50
0.65
<0.001

3.93
0.70
1.54
0.56
<0.001

3.91
0.69
1.94
0.53
<0.001

3.91
0.71
2.02
0.52
<0.001

3.86
0.63
2.44
0.69
<0.001

a
Paired t-test.
HG, honey group; DMG, dextromethorphan group; DPHG, diphenhydramine group; CG, control group.

790

NOORI SHADKAM ET AL.

Table 3. Mean of Variables of the 4 Groups at the End of the Study

Variables
Cough
Cough
Cough
Cough

frequency score
severity score
impact on child sleep score
impact on parent sleep score

HG

DMG

DPHG

CG

p-valuea

1.93
0.65
1.51
0.61
1.42
0.56
1.54
0.56

2.47
0.72
2.16
0.69
1.91
0.69
1.94
0.53

2.50
0.70
2.11
0.68
1.97
0.62
2.02
0.52

3.11
0.57
2.69
0.66
2.50
0.65
2.44
0.69

<0.001
<0.001
<0.001
<0.001

One-way analysis of variance.

HG, honey group; DMG, dextromethorphan group; DPHG, diphenhydramine group; CG, control group.

The mean and frequency of variables of the 4 groups at the

beginning of the study are shown in Table 1. As is indicated,
none of the variables were statistically significant between
the 4 groups.
In Table 2 the mean scores of cough frequency, cough
severity, and sleep quality in children and their parents in all
groups have been compared and as demonstrated the difference in each group before and after the intervention is
statistically significant. This difference is not, however, the
same in all groups. As an example, the mean of cough frequency for HG is 4.09
0.76 and 1.93
0.65 before and after
the intervention, respectively, while these figures for the CG
are 4.19
0.78 and 3.11
0.57, respectively.
A comparison of the average mean score of the dependent
variables in all groups after the intervention is also shown in
Tables 3 and 4. As is evident from Table 3, after approximately a 24-hour intervention the difference of the mean
score of the variables in all groups has become statistically
different. However, in order to check the difference among

the groups, the multiple comparison test was used, the result
of which is summarized in Table 4. According to the results,
the mean score of all variables in the HG has stood significantly higher than those in other groups. On the other hand,
there is also a significant relationship between DMG and CG
group even though there is no statistically significant difference between the DMG and DPHG groups.
Discussion
The results of this study demonstrated that honey compared with other groups had a significantly more effective
curing impact on cough frequency, cough severity, and sleep
quality of children and their parents. DM and DPH had also a
relieving effect on the factors mentioned compared with CG.
However, no difference was found between the two groups
statistically. Also, in a study by Paul et al., it was demonstrated that honey could have a curing effect on cough and
sleep pattern of children and their parents; however, the study

Table 4. Multiple Comparisons Between Groups at the End of the Study

Dependent variables

Group

Cough frequency score

HG
DMG

Cough severity score

DPHG
HG
DMG

Cough impact on child sleep score

DPHG
HG
DMG

Cough impact on parent sleep score

DPHG
HG
DMG
DPHG

vs

Groups

Mean difference

p-valuea

DMG
DPHG
CG
DPHG
CG
CG
DMG
DPHG
CG
DPHG
CG
CG
DMG
DPHG
CG
DPHG
CG
CG
DMG
DPHG
CG
DPHG
CG
CG

0.53
0.56
1.17
0.02
0.63
0.61
0.65
0.60
1.17
0.04
0.52
0.57
0.49
0.54
1.07
0.05
0.58
0.52
0.39
0.48
0.89
0.08
0.50
0.41

0.001
0.001
<0.001
0.86
<0.001
<0.001
<0.001
<0.001
<0.001
0.36
0.001
<0.001
0.002
0.001
<0.001
0.72
0.001
0.001
0.005
0.001
<0.001
0.50
<0.001
0.003

a
Post hoc multiple comparisons.
HG, honey group; DMG, dextromethorphan group; DPHG, diphenhydramine group; CG, control group.

HONEY AND COUGHING

found that DM compared with the no-treatment group did not
have a better effect on URI-induced cough.4 In another study
carried out by Yoder et al. on 37 children aged 618 years old,
no significant relationship was found for the relieving effect of
DM and DPH and placebo on the cough produced by URIinduced cough.20 Also, the results of the study by Bjornsdotlir et al. indicated that DM and DPH would have no
relieving effect on the nightly symptoms of URI.21
Our study confirmed the results of the previous studies
regarding the curing effect of honey on childrens nightly
cough induced by URIs. This study, however, indicated that
DM and DPH also have a relieving effect on this cough but
compared with honey, their effect is less, which is statistically significant.
Several studies have also reported the antimicrobial and
antioxidant effect of honey.15,17,22,23 It has been suggested
that these effects can lead to healing of wound, thus justifying our results. Honey possesses various phenolic compounds as well, which are related to its antioxidant
feature.17, 18,24 Eccles has recently demonstrated some useful
effects of honey.25 He has suggested that the sweet substances of honey normally reflexively secrete saliva, which
might cause secretion of mucus in the airways. The secretion
of mucus can have a relieving effect on the larynx and
pharynx, thus alleviating cough, especially the dry cough.
He also adds that consuming sweet substances causes the
production of internal opioids as well. The interaction effect
between the sensory fibers responding to opioids and gustatory sensory fibers may help in producing the antitussive
effect of the sweet substances associated with a central nervous system mechanism.
DM is currently used to treat coughs in the United
States.57,2629 Although in a cohort study it was found that
this is well tolerated, over-the counter studies reveal that
this drug can produce side-effects such as dystonia,30 anaphylaxis,31 mastocytosis,32 dependence,33,34 psychosis,35
mania,36,37 hallucination,38 ataxia,39,40 somnolence,40 insulindependent diabetes,41 peripheral neuropathy,42 cerebral degeneration,19 megaloblastic anemia, and death43 if used at a
high dose. There are reports that DPH is increasingly misused by adults.44,45 DPH, as the first-generation antihistamine, also has its own side-effects. This type of antihistamine
has been known to cause somnolence but occasionally it may
also create restlessness, nervousness, and sleeplessness.46,47
Standard doses of DPH have some relation with acute dystonia48 and impaired driving ability.49,50 Long-term use and
high dose of this drug can cause habit formation,51,52 psychosis,5355 cardiac dysrhythmia and long QT,53,5659 rhabdomyolysis,60,61 epilepsy,53,56 and death.62,63
In this study, 2 children, who had been affected by otitis
media on their following visit, were then treated by antibiotic. Otitis is seemingly a side-effect of URIs and has nothing
to do with DPH. Although our study demonstrated that DM
and DPH have a relieving effect on childrens cough, honey
is apparently more effective. However, in children younger
than a year old, honey may cause botulism.61,62,64,65 The
parents of 2 children in the honey group complained of their
childrens nervousness. Paul et al. also indicated that hyperactivity, nervousness, and loss of sense of smell were
more prevalent in those treated with honey.4
The parents of 3 children in the DPH group also complained of their childrens somnolence. In addition, in a

791
study by Yoder et al., it was indicated that somnolence can
be taken as one of the complications of DPH.20 No complication was found for the DM group in our study.
A limitation of this study has been its intervention period.
As was explained, each patient received just one dose of
honey or drugs, and it is clear that if the intervention period
had been longer (i.e., each patient had used more than one
dose of drugs), the results would be more reliable and of
more value. On the other hand, there would be more opportunity for the demonstration of complications, if any.
Therefore, for further studies this limitation has to be taken
into consideration. The fact that this study was not blinded
can be regarded as another limitation for this study, thus
affecting the results.
In conclusion, the finding of the study suggests that receiving a 2.5-mL dose of honey before sleep has a more relieving effect on the nightly cough of children and others
compared with DM or DPH. Thus, in these conditions it is
recommended to be used.
Acknowledgments
We would like to thank all those who have assisted in the
fulfillment of this study, including mothers and their children for their participation in the survey as well as the
Deputy for Health Services in Shahid Sadoughi University of
Medical Sciences in Yazd, Iran.
Disclosure Statement
The authors declare that they have no conflicts of interest.
This study was fully funded by the Department of Research
Administration, Shahid Sadoughi University of Medical
Sciences (SSUMS) in Yazd, Iran.
Dr. Mahmood Noori Shadkam is a scientific member of
the Pediatric Department at SSUMS that participated in case
selection and supervising the study. Dr. Hassan MozaffariKhosravi is a Senior Lecturer in the Human Nutrition Department at SSUMS and facilitated with the designing, data
analysis, and writing the manuscript. Mohammad Reza
Mozayan facilitated with writing the manuscript. All of authors are employed by SSUMS and all critically reviewed the
manuscript and approved the final version submitted for
publication.
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Address correspondence to:

Hassan Mozaffari-Khosravi, PhD
Department of Nutrition
Shahid Sadoughi University of Medical Sciences
Deputy for Research Building No. 2
Bahonar Square
P.O. Box 734
Yazd 8916278477
Iran
E-mail: mozaffari.kh@gmail.com

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