Effect Measure

Honey, cough and caution

There is a determined honey lobby out there touting the health benefits of honey. That’s fine with me, as I am not an enemy of honey. On the other hand, honey, while “natural,” is not a completely harmless foodstuff, especially for infants. You wouldn’t know it reading the spate of news articles on a Penn State study touting the benefits of honey over cough medicine for kids:

The study found that a small dose of buckwheat honey given before bedtime provided better relief of nighttime cough and sleep difficulty in children than no treatment or dextromethorphan (DM), a cough suppressant found in many over-the-counter cold medications.

Honey did a better job reducing the severity, frequency and bothersome nature of nighttime cough from upper respiratory infection than DM or no treatment. Honey also showed a positive effect on the sleep quality of both the coughing child and the child’s parents. DM was not significantly better at alleviating symptoms than no treatment. (Medical News Today)

The study in question was a randomized trial involving 105 2 to 18 year olds seen for conditions that caused cough (presumably upper respiratory infections). The first night parents provided baseline information on how both they and their child slept. The next night they were randomized into groups that received honey, honey flavored DM or nothing. Outcome questions were the same as for the baseline (first) night. The honey and fake honey DM groups didn’t know the treatment, while those that received nothing obviously did. The press reports were that there was uniformly better sleep for both children and parents in the honey group.

Fine. But buried in the press reports (I haven’t seen the original paper) was a single sentence that usually stated that honey is safe for children over 12 months old. What it really should have said, however, is that honey may not be safe for children younger than 12 months. For a long time pediatricians have been warning parents that honey may be a source of infant botulism. Most botulism is caused by ingestion of botulinum toxin, an extremely potent poison that paralyzes muscles, including the muscles that are used to breathe. The toxin is produced by the botulism organism (Clostridium botulinum), which forms hardy spores when the environment is unfavorable but when it finds itself in airless environments with the right temperature and other features it needs for growth (say in an improperly canned food) it reverts to a vegetative form and produces toxin. Thus most botulism is caused by ingestion of the toxin [corrected]. Ingesting the organism either in spore form or vegetative form is not a risk.

Unless you are an infant. Infant botulism was first described in the 1970s. Its cause appeared to be ingestion of botulism spores which then were able to make toxin in the infant’s digestive tract. Apparently this can happen in infants but not older children or adults. The typical symptoms were babies that became constipated, had floppy arms, legs and neck, a weak cry and poor sucking and seemed lethargic. Where did the botulism spores come from? A series of epidemiologic studies (concise review here) identified honey as a major (although not the only) risk factor. The case fatality rate for infant botulism isn’t as high as the adult variety (less than 5%) but this is still a serious disease.

A recent FDA directive that cold and cough medicines not be given to children under 6 years of age will likely prompt many parents to use “natural” remedies and the publicity that honey is effective in reducing cough is likely to send many in that direction. It is unfortunate that study authors didn’t do more in their press releases and interviews to alert parents of infants that adding honey to their child’s diet if they are under a year old is not considered safe.

Many scientists worry (unduly in my view) they might “get burned” talking to reporters. I worry more the public will get burned when scientists who are too enthusiastic or too eager to promote their work talk to the press. Usually nothing bad happens, but this one has me a bit worried.

Comments

  1. #1 lmr
    January 10, 2008

    Thus most botulism is caused by ingestion of the virus.

    Clostridium botulinum is a bacteria, not a virus.

  2. #2 revere
    January 10, 2008

    lmr: Jeez. My face is red. I am so used to typing “virus” I think it got frozen into my keyboard. Of course I know C. botulinum is a bacterium. Thanks for pointing out that piece of stupidity on my part.

  3. #3 Doug Alder
    January 10, 2008

    Even pasteurization doesn’t kill the spores

    Botulism spores and Pasteurized Honey

    Honey has a high sugar content which does not support the growth of bacteria. One of the benefits of honey is that it can be used as a bactericide and a healing agent for minor cuts, burns and intestinal upsets. Despite this fact, it is possible for Clostridium botulinum spores to exist in honey. Pasteurization or heat treatment of honey does not kill these spores. Many medical professional mistakenly associate the term pasteurization with the heat sterilization method used in the dairy and apple juice industry. Pasteurization in the honey industry is a process that kills sugar tolerant yeasts in order to extend the shelf life. The heating process is not high enough to break the tough coat of a botulism spore.

    The good news is that a recent Health Canada study of Canadian honey from various sources across the country showed no botulism spores.

  4. #4 M. Randolph Kruger
    January 10, 2008

    Funny this should come up right now Revere. A kid down the street has that exact condition and was hospitalized for a month from botulism. Suggested cause was honey and it kept on getting worse and worse. The parents being uninformed just kept right on giving it to the 9 months old. The natural honey they were using was unpasteurized.

  5. #5 revere
    January 10, 2008

    Randy: As Doug notes, pasteurization doesn’t kill the spores. Nor does boiling. You have to pressure cook the stuff (get it above 121 degrees C.). But the spores are inactive and won’t grow in honey (the water activity is too low because of the sugar). It needs to get into a favorable (and airless) environment.

    The paradox is that botulinum toxin is very sensitive to heat, so that if there is toxin in a food (as opposed to the spores or the vegetative form of the organism) and you heat the food up it inactivates the toxin. The infant variety is different in that ingestion of the intact organism can produce disease by the organism producing toxin in the intestines. That doesn’t happen in older children or adults.

  6. #6 phytosleuth
    January 10, 2008

    Curiouser and curiouser…now WHY do older children and adults have resistance to botulism in honey? How do they develop this resistance? Would love to know the mechanism of action here or developmental protection.

  7. #7 revere
    January 10, 2008

    phyto: I believe it has something to do with the conditions in the small intestine allowing germination and toxin production in infants. Their gi tracts are different. Soon the gi tract gets to the point where the spores won’t germinate and produce toxin.

  8. #8 gharris
    January 10, 2008

    Perhaps it has something to do with the rest of the stuff in the gut of very young baby being mostly ‘lactic’ – older guts have more varied constituents?
    just a thought from a mum not a scientist!

  9. #9 Chemgeek
    January 10, 2008

    How timely. I was just about to do a search on why honey is bad for infants. Then I read your blog. Search done. Ah, serendipity.

    Thanks for the info.

  10. #10 M. Randolph Kruger
    January 10, 2008

    So as I understand it, the toxin is formed by the bacteria and left lying around. Are you saying that cooking at high temps breaks the toxin down and the bacteria that formed it? Is the bacteria anaerobic or aerobic?

    The spores are just “there” or do we have a problem with spores in US honey? I raise bees and my wife passes our honey out every couple of months. I use a pressure cooker but only because thats what the book calls for. Procedures, procedures, procedures. I knew there was a reason but it was only a suggestion from Dadants. Is there any way to know if you have the spores or is like I asked… Just there?

  11. #11 revere
    January 11, 2008

    Randy: The spores are fairly common in the environment but sometimes there and sometimes not. Most honey probably doesn’t have them. They are very resistant to heat which is why you need to pressure cook. They are strict anaerobes. Even moderate heat for fairly short times inactivates the toxin. Even if your honey has spores it is not a problem unless you are an infant.

  12. #12 mathmom
    January 11, 2008

    This version of the story is much more explicit about not giving honey to infants and why.

    “Children less than 12 months old should not be fed honey since it can cause botulism in infants.”

  13. #13 Twigs
    March 11, 2008

    I’ve been reading things that say honey can kill flu germs and stop a flu before it starts. I was wondering if anyone knows this to be true … and also, if it is true, is it a good idea? Isn’t it better to just get the flu and ride it out so that your immune system will be boosted regularly, as with colds? Or, once you have the flu, even if you use honey and kill it right away, will your body already have built up an immunity?
    I hope this makes sense. My real questions is whether or not it’s a good idea to use a cure for the flu at all, because bodies need to get the flu occasionally in order to stay healthy for the majority of the time.

  14. #14 revere
    March 11, 2008

    Twigs: Honey will not do a thing for the flu. Period. As for better to get the flu, no. It is better to not get the flu. If you have ever had the real flu, you will know why. Among other things it can kill you.

  15. #15 Phyllis
    February 1, 2009

    I have a lot of questions regarding food spoilage/botulism if anyone has the answers.

    I have read that honey is one food product that does not spoil no matter how long you’ve had it. Is that true? I have older honey on hand and now I worry about using it because of botulism. There are no babies or young children in our family.

    Also, if there is a power outage for several days, should you throw out everything in your refrigerator or would the acidic products such as pickles (things containing vinegar), be okay to use?

    I’m also curious about olives and botulism (both black and green). Also, black olives are always in cans. Why? How long can you safely keep black olives and their brine in a plastic food container if you’ve only used half a can?

  16. #16 revere
    February 1, 2009

    Phyllis: Ordinary botulism is poisoning by a toxin that is elaborated in the food by botulism organisms growing there. Honey has too little “available water” so the botulism bugs don’t grow in it and don’t produce toxins. For non infants, the spores, once ingested, don’t become toxin producers, either, so we don’t worry about eating them. However babies under a year old may allow the spores to turn into a vegetative form and produce “infant botulism,” hence the recommendations regarding honey and infants. So if you aren’t feeding it to a baby, you can use it.

    As for other stuff, the refrigerator prevents bacteria from growing but it doesn’t kill them. Many food poisoning episodes is from ingestion of massive amounts of pathogens that are present in the food when eaten. Sometimes small numbers of bugs can also infect you, and if they are in the food that is in the refrigerator (they should never be), then they can make you sick, too, although the refrigeration won’t prevent it. But it does prevent pathogens commonly present from growing to large amounts. Even if there are large quantities of salmonella or E. coli, if you cook the food (say above 160 degrees F. for 5 minutes) then you kill them. But food that is eaten uncooked or raw or was precooked and then contaminated can be a problem if left for long periods unrefrigerated.

    The other problem is aesthetic, i.e., food spoilage, the action of non pathogenic bacteria that makes the food unappealing. Those bacteria will grow better unrefrigerated.

    As for olives, pickling and brining are traditional methods of food preservation, so they should be fine. I eat olives in my refrigerator that are in open containers after months. Mrs. R. is appalled by that, but I’m still here.

  17. #17 Lea
    February 1, 2009

    Phyllis: If you read this you may want to food network dot com.

    http://www.foodnetwork.com/shows/index.html

    I cannot, for the life of me, remember the guys name on TV, but he’s a comedian of sorts, first name starts with S?
    Anyway, I just saw one of his shows on olives, it was late at night and very interesting but I was tired, and if I’d have known your question on olives would have come up I would have written it down.

    revere-be: Be careful kiddo, not everyone has an Iron-Gut (olives). There are so many foods now that I cannot tolerate anymore. Old age? Genetics? Gut problems?
    Who knows, but I am excited about a new doctor of Gastroenterologist that my Retired Military Insurance Provider has referred me to, DR. UMA KARNAM.

  18. Hi,
    Yes, honey is an amazing healing and wellness food. There is scientific evidence that it will eliminate MRSA superbugs (especially manuka honey). As well, manuka honey has been shown to destroy the H. Pylori that cause stomach ulcers. Hence, in this regard, it is probably as effective as antibiotics used for this purpose.

    I use honey as a cough medicine. I normally combine it with the sap from Balsam Fir blisters. I use a third teaspoon of Fir sap to two-thirds of honey, and mix together. It’s a good natural cough medicine.

    But, my main reason for commenting, concerns the botulism discussed here. I just want to say that a prime reason why such botulism does not effect older infants and adults is because as the digestive system developes, it becomes too acidic to allow the germination of the spores. I would not give honey to infants under 18 months, to be on the safe side of the equation.

    My best regards,
    Laurie

  19. #19 Vania Melamed
    Camp Pendleton Marine Corps Base
    September 13, 2012

    NatGeo also has an article about Raw Manuka honey, only harvested in New Zealand, cures MRSA. If this honey is not cultivated in an environment that favours botulism, and honey has no shelf-life and thus doesn’t spoil, how can it cause botulism? Couldn’t this just be a fluke from non-sterile honey mason jars or plastic bottles, since we have no medicinal purpose for jams, sauerkraut, or pickles for infants? I mean, if we could theoretically feed a baby pickles or Gerber meatsticks or jelly or peanut butter, we could know if botulism is a risk associated more with spores carried in the packaging plants and not necessarily inherent with honey, right? Have any tribal cultures reported any deaths associated with honey fed to infants under one year? And to the one reader who asked, the only honey with medicinal properties such as 15+ bioactive cultures (or 10 or 25) is Manuka honey, which only comes as I said, from NZ.

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