Dr Seb Gray, Paediatric Consultant, Salisbury NHS Foundation Trust
Twitter: @SebJGray Email: Sebastian.Gray@nhs.net
Honey, the nectar of the bee gods, has been hailed for centuries as the bees’ knees when it comes to natural health remedies. Apitherapy is the over-arching name of complementary and alternative medicine that uses bee products; primarily honey but also pollen, propolis, royal jelly and bee venom. Touted therapeutic benefits from Aristotle and friends include anti-microbial, anti-fungal, anti-inflammatory, anti-cancer, anti-inflammatory, anti-oxidant, anti-parastic and wound healing.
Anecdotally, the idea that ingesting locally-produced honey can eliminate symptoms of hay fever is spreading fast – but is there the evidence to make it stick?
Hay fever is the common name for a pollen allergy and is used interchangeably with allergic rhinitis. Symptoms include continuous sneezing, itchy nose/mouth/eyes/throat, watering eyes, nasal congestion, coughing and headaches. It’s unlikely to kill you but it makes millions of people feel miserable every year. There are thought to be approximately 30 different types of culprit pollen types, which can be grouped into seasons. Most people in the UK with hay fever are allergic to grass pollen peaking in late spring and early summer. Tree pollen follows affecting approximately a quarter of those with hay fever and released in spring. Weed pollen is in third place and released throughout sping until late autumn.
How could it work?
Immunotherapy
Theoretically, ingesting processed pollen in the form of honey could desensitise the immune system and magically cure hay fever. The problem is that bees are selective and tend to opt for the prettier, more attractive pollen of flowering plants than the big hay fever culprits. I don’t want to label bees as being superficial; they are wonderful pollinators and belong to a group of pollinators thought to be responsible for 1 in 3 mouthfuls of UK produced food. However, the pollen appeal of the grass, tree and weeds just doesn’t do it for most of our buzzing friends and the direct immunotherapy-type proposed mechanism of action won’t explain it.
Secret Ingredients
Honey can be classified by the source of nectar – and its colour, smell, consistency and importantly taste is dependent on this and a variety of other factors. The species of bee is one factor but other things such as the weather, geographical location and harvesting season (all of which are impacted by climate change) play a role. The hero constituents within honey felt to be of most benefit are the phytochemical compunds such as quercetin, kaempferol, chrysin and apigenin found in higher volumes in Tualang, Manuka and Gelam honeys.
Placebo
Or Placebee-bo. Like anything, if you’re told something is magical and going to work, it’s more likely to. There is a tricky equipoise in healthcare balancing evidence-based medicine with placebo. Given we know the placebo effect is powerful, can you argue that promoting something which lacks evidence to enhance it’s placebo effect is actually evidence-based medicine?
What’s the research say?
So honey has been used for medicinal purposes as long as people can remember and up to 30% of the worlds population have hay fever… so there must be pretty big studies looking at the link, right?
Incredibly, there are very few studies looking at honey and hay fever: In Connecticut back in 2002, 36 particpants with symptoms of allergic rhinitis were randomised into one of three groups; one group had locally collected, unpasteurised, unfiltered honey, another group received nationally collected, filtered and pasteurised honey and the control/placebo group received corn syrup with synthetic honey flavouring. A teaspoon a day on top of their usual management was given and particpants kept a symptom diary. The study found no benefit of either honey group over placebo.
The other well publicised study into the association between honey and allergic rhinitis is from 2013 and looked at 40 patients with allergic rhinitis in the East coast of Peninsular Malaysia, finding that ingestion of 1g/kg daily of honey for 4 weeks (alongside 10mg Loratadine) resulted in the reduced symptoms compared to the honey-flavoured corn syrup placebo group. This improvement continued for a month after cessation of treatment.
What if we can’t sweet talk the bees into making honey from less attractive flora? This study bypassed the bees’ tastebuds by adding birch pollen to honey to create a birch pollen honey. 44 adult patients with confirmed birch pollen allergy were randomised to either birch pollen honey or regular honey and compared to 17 control patients who remained on their usual allergy medications. The honey was introduced incrementally prior to the birch pollen season and was found to be statistically superior to the control group in terms of symptom score (60% lower; p<0.01), asymptomatic days (twice as many; p<0.01), fewer days with severe symptoms (70% fewer; p<0.001) and less anti-histamine use (50% less; p<0.001). However, other than reduced antihistamines use, the addition of birch pollen did not have any other statistically significant benefits over regular honey. 11 of the 61 participants dropped out, one with severe mouth itching in the pollen group, one with worsening eczema in the regular honey group and interestingly only two who didn’t like the taste.
We know of the strong affiliation between allergic rhinitis/hay fever and asthma so it’s not surprising that honey has also been explored as a treatment for asthma. This study found that nebulising honey in saline at two different concentrations using an ovalbumin-induced asthma model in rabbits resulted in histopathological improvement with fewer inflammatory airway cells from broncho-alveolar lavage and inhibited goblet cell hyperplasia. The authors called for further research to explore this a promising treatment for human asthma.
Reviewing ‘grey’ literature sometimes creates more questions than answers – as it does in this case with the report of bee honey being nebulised to children with acute bronchial asthma. The abstract suggests there was no control, comparative group but 300 infants and children received bee honey nebulisation for 30 minutes. The mean age of participants was 2 1/2 years (suggesting potential overlap with bronchiolitis/pre-school wheeze) and the method of honey nebulisation is not outlined in the abstract. (Interestingly, neither steroids nor bronchodilators were given… which raises questions about usual asthma management). However, the results reported 94% of patients having improvement in their dyspnoea as well significant increase in oxygen saturations and reduction in respiratory rate and heart rate after 60 minutes. From the abstract, it sounds like the main benefit for these children was inducing coughing, which produced expectoration and a following improvement in symptoms. In order to extrapolate anything from this study, a lot more details would be required.
It’s likely that ethically, a standard of care baseline would be required with complimentary rather than alternative interventions tested. There are other references (dating back to 1970, with no abstract available) on honey for chronic bronchitis and bronchial asthma, but other than that, there is very little out there relating to honey and asthma. Searching the International Clinical Trials Registry platform, there are all sorts of other honey-related studies in the pipeline looking at improving sleep quality, sinus rinsing (utilising the excellent Sino-Nasal Outcome Test (SNOT) score), paediatric pneumonia and general health in well people, but nothing specifically looking at a relationship between honey and hay fever.
The bee-all and end-all
Honey has been used to treat various ailments for more than 200 years, but we still lack a convincing evidence-base to prove its benefit for hay fever. Has the buzz died down or are we waiting for a Queen Bee researcher to emerge to delve a bit further to finally answer the question, does local honey really help with alleviating hay fever symptoms? No specific studies have been done in children and with so many people suffering from hay fever, I hope there’ll be lots of researchers itching to get started. Whether proven to be beneficial for hay fever or not, honey is safe over the age of one and undoubtedly good as part of a healthy balanced diet. Honey consumption is also likely to aid and encourage the push to conserve bees and reverse some of the decimation caused by the climate emergency. With the added bonus of supporting local businesses, and no real risks, I hope you’ll join me in continuing to recommend local honey.
B+ from me.
Dr Seb Gray, Paediatric Consultant at Salisbury NHS Foundation Trust & CYP Asthma Lead for Bath, North-East Somerset, Swindon & Wiltshire (BSW)