What's the Big Deal with Honey?

You may ask, “what’s the big deal with honey?” and “why do physicians warn me about giving it to my infant?” Honey is a staple in any household and used as a home remedy for a sore throat, cough, and other health-related maladies. Also, it tastes pretty good in a cup of tea! So, why all the fuss?

To understand why honey is discouraged in infants, a brief story may be helpful. I had seen a 4-month-old infant who was not feeding well. His mother said that over the last few days, he had been more tired appearing and weak. But, he had no fever or other signs or symptoms of illness. On exam, he appeared weak and floppy. At the top of my list of concerns was sepsis. Sepsis is an overwhelming infection of the body that travels through the blood and affects other organs. Usually, bacteria are the cause of sepsis and infants with sepsis can present with behavior changes, such as poor feeding, poor muscle tone, decreased activity, agitation, fever or low body temperature, and other nonspecific findings. So, a high index of suspicion is needed to evaluate this population because it is easy to miss something very serious.

Nonetheless, the possible causes for this clinical scenario include more than just sepsis. In this particular instance, this infant was suffering from botulism. Botulism is a paralytic disease that is caused by the release of a toxin from a specific bacterium, Clostridium botulinum.

You may ask yourself, “isn’t botulinum toxin what they use in Botox to smooth wrinkles and lines on adult faces?”

The answer would be, “yes.”

Botulinum toxin, in very small doses, is used for a number of medical conditions other than for cosmetic purposes. The toxin prevents the release of neurotransmitters to prevent the contraction of muscles and causes paralysis. In individuals poisoned with botulinum toxin and afflicted with botulism, the source of the poisoning is usually from ingesting improperly stored foods that are contaminated with Clostridium botulinum, absorbing the toxin from an inappropriately cleaned wound that is infected with Clostridium botulinum, or poisoning with the botulinum toxin as a bioterrorism event. In children, these situations are quite rare. However, the most common botulism presentation that we see in pediatrics is with infants who accidentally ingest spores that were aerosolized either from soil or dust (living near or spending time in close proximity to a construction site) or from infected food sources, most commonly honey. Infants are more susceptible to botulism through ingestion of spores because they don’t have the same defenses as older children or adults to eliminate the spores in their digestive system.

Infants with botulism usually present with constipation and a descending paralysis (head to toe). They will have a poor suck and not be able to feed well, have a weak cry, exhibit overall weakness and floppiness, and the eyelids may be droopy and look partially closed. Eventually, the weakness worsens and these infants can have trouble breathing and require mechanical ventilator support to help them breathe while they recover.

The treatment for botulism is mostly supportive, in that the breathing and other functions of the body need to be supported until the paralysis wears off. There is a medication, intravenous botulism immune globulin, that is used to treat infantile botulism. It decreases the need for mechanical ventilation, duration of stay in the pediatric ICU, and duration of stay in the hospital. It blocks the toxin from blocking the release of neurotransmitters by binding to the toxin that is circulating in the body, but it can’t reverse the toxin that has already stopped the release of neurotransmitters. Therefore, early administration of the intravenous botulism immune globulin is critical to the recovery of these infants. The paralysis is only temporary, but recovery can take weeks to months.

While honey and soil or dust are high risk sources for infants developing botulism, the actual source is not found in most cases of botulism. However, it is still wise to avoid giving honey to infants. So, when your primary physician tells you not to give your infant honey, you now know what the big deal is with honey.