So my topic choice for this week was pretty much decided by mulling over which would be the simplest topic to tackle. It’s pretty straight forward, kind of like my last research post on listeria (see: Listeria Mysteria and Pregnancy).

Honey and infants. I feel like it’s pretty common knowledge that when it comes to infant feeding, though recommendations regarding allergies have shifted over the years from avoiding to now encouraging foods like peanut butter, eggs, citrus, etc., the warning to not feed honey babies under 1 year old has remained consistent. Studying nutrition/dietetics in college, the “no honey for infants” rule was a black and white issue – no honey for infants! Plain and simple. Oh, you wanna give your baby something with honey? Nope, you just don’t do it. 

But, with today’s society leaning a bit more towards the natural, homeopathic, and non-medicated route, and with desperate parents hoping to make food more palatable by “sweetening it up,” I was a bit confused when I saw lots of moms recommending other panicked moms of sick infants Zarbee’s Naturals Children’s Cough Syrup. The main ingredient was dark honey, for soothing throat relief. Not good for infants! But, after a quick search on Google, I saw that the Baby version of the product was made with Agave syrup, rather than honey, but these moms were recommending the Children’s formula (dark honey). I actually can’t even find the Baby version on their website anymore, but it can now be purchased on walmart’s website, Amazon.com, and other pharmacies.

On a side note, through researching the availability of the Baby version, I found that in June of 2014, Zarbee’s got in trouble with the FDA because of its claims or clearing mucus congestion, coughs, etc. which were not approved by the FDA and were “not generally recognized as safe and effective for [their claimed] uses…” They received a written citation from the FDA about their labeling violations, threatening legal action! They published testimonials on their website and on social media, statements from moms claiming how their products cured their child’s ADHD (really?) cleared irritated and red eyes, etc. So the FDA was very unhappy about this. (Zarbee’s now has the phrase, “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.” on their website and packaging.)

So anyway, back to the topic… 

Infant feeding. There are various ways that parents choose to go about introducing their infant to “people food.” There’s the baby-led weaning route (going straight to “normally prepared” foods, like pasta salad, turkey meatballs, veggies, and skipping purées altogether) and there’s also the traditional puréed food route (sometimes skipping infant cereal, but feeding meats, veggies, and fruits in puréed form, one-by-one to easily identify and rule out allergies/intolerances). Certain countries tend to start with meat as a first food to replenish iron sources. Methods vary country to country, region by region, person to person. 

Thinking back, our pediatrician didn’t even ask how we were planning on introducing solid foods to Jia. They didn’t seem to do any assessment for where our knowledge baseline was, when it came to infant feeding. We didn’t get any written material or guidance as to which precautions to take (like cutting pieces really small, avoiding added sugar, juices, etc) or ANYTHING.

I’d like to think that they assumed that as a nurse, maybe I didn’t need instruction and that I would ask if I had any questions, but I know PLENTY of nurses who don’t have the slightest clue on what to do when it comes to infant feeding, nutrition, or even pediatrics in general! I was an ICU nurse – how did they expect me to know what to do with a baby? Our pediatricians didn’t know that I studied dietetics in college. They didn’t know I’d worked at WIC and even saved all my WIC education materials from 10 years ago, from back when I worked there as an intern. They didn’t know that I worked in Maternal, Child and Adolescent Health department for LA County, designing nutrition and physical education materials.

I know that many of my well-educated friends (some of them doctors) did their own research to find out what to do and how to do it. Why not a little more guidance for the general public? There’s a huge knowledge gap in the general public when it comes to proper nutrition for infants and toddlers, and judging by the posts I see on Facebook mom groups, the general public could definitely stand to know a bit more about what to do and why. Especially when it comes to something like avoiding honey the first 12 months.

(note: well, that IS why I started Little Sproutings in the first place!)

Wait – Why Honey?

Why? Microbiological testing, according to the American Family Physician, reported that up to 25% of honey products (raw or pasteurized, straight honey, and even honey-containing products) contain clostridium botulinum spores. The spore-forming bacteria (not a virus) is common in nature, and is found in contaminated soil, dust, and certain foods, particularly honey (and corn syrup).

Spore-forming bacteria are very resilient, because in adverse and unfavorable conditions for that bacteria to thrive, the active bacteria can FORM into inactive SPORES, therefore protecting themselves with many tough layers, when it needs to. Then, when conditions become favorable, like when it finds its way to into your baby’s immature and vulnerable gut, it no longer needs that tough layer, and can reactivate to form the botulinum toxin. The toxin then gets absorbed into your baby’s intestines, leading to a botulism infection. (more on what this means, below)

Clostridium and Bacillus groups of bacteria are spore-forming. Clostridium is the group of bacteria also responsible for the really bad infections in the hospital, if you’ve ever heard of c.diff (clostridium difficile). They’re spore-formers too, and require special disinfecting wipes and very specific “dwell times” on surface areas before those spores are killed and can be considered sanitized. It’s gross, results in very bad diarrhea that requires antibiotics and sometimes even surgery to remove a section of the affected colon if it becomes really bad. 

I will reiterate – Spore-forming bacteria are really resilient and can protect itself from heat, boiling and steaming, pasteurizing, harsh chemicals, by encapsulating itself. So without getting too microbiological…

What is Infant Botulism?

According to the CDC, of the 150 or so cases reported every year, 65% are infant botulism infections. Others include foodborne (15%) and wound (20%) sources of botulism.

Infant Botulism is the type of infection that occurs when an infant swallows the clostridium botulinum spores (from contaminated soil, dust, or ingested through raw honey or corn syrup) and it colonizes/grows in the baby’s intestine and produces neurotoxins (toxins that affect the tissues in the nervous system). These toxins are then absorbed directly through the gut tissue and bind to receptors on motor nerves (the nerves responsible for muscular movements), which is responsible for the muscle weakness that occurs with an infection. 

Infants six months and younger are at highest risk of botulism poisoning from spores found in honey, but the risk continues even up to 11 months in age. The American Academy of Pediatrics: Botulism recommends avoiding honey for the entire first 12 months. 

Swallowing botulinum bacteria spores aren’t a concern for adults and children older than 1 year old, since they remain in spore form in the gut. Meaning, the spores don’t change and reactivate to the botulinum toxin, since the matured gut contains healthy microflora (good bacteria) that fight against the botulinum spores. Even pregnant women and the elderly aren’t at risk of a botulinum infection. Adults and older children are still at-risk of a botulinum infection if the toxin is already present in contaminated/poorly canned food or it gets into wounds, but not by eating spores in foods like honey. 

Signs and Symptoms of Botulism Infection in an Infant (expected approx 12-48 hours after an exposure/swallowing of spores)

• Drooping/heavy eyelids 
• Difficulty breathing/irregular breathing (might be quick and/or shallow breaths, grunting, using the shoulder and chest muscles to take breaths, and of course if baby stops breathing or the breathing rate slows down)
• Constipation (since the toxin attacks the gut muscles, due to less gut motility)
• Muscle weakness/lethargy/paralysis. You may notice that your baby’s muscle tone is diminished and appears “floppy.” If they suddenly become weak in their arms or legs, if they are suddenly experiencing increased difficulty sitting up. 
• Weak cry (due to reduced muscle strength in the diaphragm)
• Poor feeding/diminished appetite
• Loss of head control
• Infant gagging (muscle tone affected in the throat) or difficulty swallowing

Diagnosing Infant Botulism

Since the symptoms of a botulism infection can sometimes appear vague and can present like other illnesses, multiple tests may be done to rule out other conditions, such as a stroke and muscular conditions (Guillain-Barré syndrome, myasthenia gravis), etc. after the patient history (recent exposures and foods eaten) and physical are not enough to suggest botulism.

The physical examination would include the doctor checking for your baby’s gag reflex, assessing muscle tone, missing or diminished deep tendon reflexes (like when they tap baby’s knee, wrist, elbow with the little rubber hammer), and eyelid drooping. A stool sample and blood test will also be done to identify the presence of the bacteria. Further testing includes an EMG (electromyography) test is performed to check for muscle nerve conduction. 

Treatment

Almost all children with a botulism infection will need to be hospitalized.

The effect of the toxins on the motor system eventually progresses to other muscles, including those in the respiratory tract (diaphragm), so immediate treatment once an infection is suspected, is very important. 

Treatment for a botulism infection requires supportive measures, which means keeping their airway open (possibly needing a mechanical ventilator with a breathing tube) if their breathing muscles have become too weak to take in enough oxygen, tube feedings to provide nutrition and calories since the slower-moving gut will have difficulty in processing whole food due to the absorption of toxins, and medications like botulinum immune-globulin or antitoxin to provide baby with immunity against it. 

Hospitalization can range anywhere from several weeks to several months, depending on the severity.  However, as published in an American Family Physician article by Cox and Hinkle, the good news is the low risk of death (2%) when treated quickly. 

Prevention

Since it’s hard to know where exactly where clostridium botulinum-contaminated soil is found (largely in California, Pennsylvania, and Utah), the easiest and most effective way to prevent exposure to these spores is to completely avoid feeding honey, honey products, and corn syrup to your infant 0-12 months old, as these foods have a much higher risk of containing these particular spores.

As for preventing food-borne botulism (food contaminated with botulinum toxin), the AAP recommends to:

• boil foods for at least 10 minutes (which can destroy the TOXINS)
• do not feed your child spoiled foods
• discard food containers that are bulging – the toxins from the botulinum bacteria produce gas responsible for the bulging

Remember, gut infection/colonization in adults, children, and toddlers older than 1 year, is uncommon. 

For non-infant botulism (food borne and wound) prevention, please refer to the CDC’s botulism guide for further reference. 

Sources:

HealthyChildren.org – Botulism. https://www.healthychildren.org/English/health-issues/conditions/infections/Pages/Botulism.aspx

CDC: Botulism, General Information http://www.cdc.gov/nczved/divisions/dfbmd/diseases/botulism/

National Institutes of Health, MedlinePlus – Infant Botulism: https://www.nlm.nih.gov/medlineplus/ency/article/001384.htm

Mayo Clinic, Infant Botulism: How can I prevent my baby from infant botulism? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/infant-botulism/faq-20058477

San Francisco Department of Public Health, Communicable Disease Control and Prevention: http://www.sfcdcp.org/botulism.html

American Family Physician: Infant Botulism http://www.aafp.org/afp/2002/0401/p1388.html#afp20020401p1388-b11

Dr. Greene – Infant Botulism: A-to-Z Guide from Diagnosis to Treatment to Prevention http://www.drgreene.com/articles/infant-botulism/