Cough is a very common symptom in children. Certainly, we need to consider that an ominous cause may be lurking (Asthma, Occult Aspirated Foreign Body, Croup, Sinusitis, Pneumonia, Acute Chest Syndrome, etc.). Most often, though, the cough is due to a viral illness, but remember viral illnesses can become complicated (see, Myocarditis, Guillaine-Barre). So, take care not to be dismissive. Additionally, while you are doing your best to avoid the phrase “just a virus,” prepare yourself to address the parent’s next question: “What can be used to make the cough better?”  Unfortunately, there are not many medications that are safe to use in young children… but this may be an opportunity to “prescribe” Winnie the Pooh’s favorite: Honey for Cough.

Honey: Not for < 1 year of age

Before we get carried away by Winnie’s obsession… don’t overlook a real danger… Infantile Botulism

• Infantile botulism is the most common form of botulism in the USA. [Brown, 2012]
• Due to ingested Clostridium botulinum spores
  • Spores colonize the GI tract and the produce toxin.
  • Toxin prevents release of acetylcholine from the presynapse.

• Presents with vague symptoms, but can be deadly (yup… your job is difficult).
  • Poor feeding
  • Constipation
  • Weakness (ex, weak cry, can’t hold head up) – Descending Weakness.
  • Hypotonia
  • Cranial Nerve palsies (ex, ptosis, poor suck, sluggish pupillary reflexes)
  • Respiratory Depression
    • ~50% of all infantile botulism cases require mechanical ventilation. [Brown, 2012]
  • May initially be first managed as if sepsis/serious bacterial infection is present, but child is afebrile and has negative cultures.

• Treatment consists of:
  • Early recognition! Stay Vigilant my Friends!
  • Supportive care – being mindful of potential respiratory depression
  • Botulism ImmuneGlobulin (“BabyBIG”)
    • Maintained by the California Department of Public Health’s Infant Botulism Treatment and Prevention Program
    • Do not need to wait for confirmatory studies to give. [Brown, 2012]

• Honey consumption is the classically associated with infantile botulism, but as with many cases of “classical” medical associations, this is not the full story.
  • 85% of cases have no known honey exposure.
  • Botulinum spores are ubiquitous.
  • Honey should still be avoiding in children < 1 year of age… and don’t overlook honey being used as oral pacifier. [Benjamins, 2013]

Honey for Cough

Ok, now that we are clear that Honey should not be recommended for a child < 1 year of age, let’s get back to how it may help your older child with a cough!

• Cough Medications from Over the Counter (OTC) [Paul, 2012]
  • Many have been around for a long time (and their associated studies have inadequate methodologies by today’s standards).
  • Cochrane review has found not clear benefit to their use.
  • Dosing strategies for many have not been modernized. (See Teaspoon of Sugar Morsel)
  • OTC preparations are often a combination of medications, which makes dosing even more fraught with potential hazards.
  • Many OTC cough medications have numerous adverse effects, particularly in overdose.
  • Since the risks outweigh the benefits (Some risk vs No benefit), the AAP does not recommend use of OTC cough/cold medications for children 4 years and under. For those 4-6 years, caution should be used.

• Honey for Cough
  • Honey has been reported to have many health benefits (because the Bee Lobby is very active).
    • Antimicrobial activity
    • Wound Care
    • Post-Tonsillectomy Pain Management [Mohebbi, 2014; Boroumand, 2013; Ozlugedik, 2006]
  • Several small studies have shown the honey can compare favorably to the OTC cough preparations. [Cohen, 2016; Paul, 2012; Cohen 2012; Paul 2007]
  • Honey may:
    • Decrease cough frequency and severity
    • Improve child and parent sleep quality 
  • The literature may still have inadequacies [Allan, 2011], but honey is generally deemed safe with good side-effect profile.

Moral of the Morsel

• Once again, don’t say “it’s just a virus.”
• Be vigilant and think about ominous causes of cough… and think out loud.
• Appreciate the persistent coughing, even if merely due to a viral infection, disturbs the entire household. Do not be dismissive of this.
• Anticipate the question about what “medication” can be used to help.
• Weigh the risks and benefits and know that the scales tip toward avoiding OTC cough/cold medications in the young.
• The risk:benefit scales may not slant dramatically toward use of Honey, but as long as the child is > 1 year of age, it is safe so even some minor benefit may be worth it.  Plus… honey is delicious!

References