Infant Botulism: A-to-Z Guide from Diagnosis to Treatment to Prevention

The safety concern about honey arose because honey often contains spores that, under the right circumstances, can cause infant botulism.

Sometimes constipation and slow feeding are the only symptoms of infant botulism, a disease that is sometimes caused by honey.

What is infant botulism?

The honey story is fascinating. The safety concern about honey arose because honey often contains spores that, under the right circumstances, can cause a disease discovered in 1976, called infant botulism. Infant botulism is spread by these spores, not by pre-formed botulinum toxin.
Botulism spores are found throughout nature – in soil, in dust, and on the unwashed surfaces of unpeeled fruits and vegetables. The spores are present in about 10 percent of the samples of honey tested. These spores are tough to kill. They are quite heat-resistant; some can survive boiling for several hours.

Babies’ intestines are an ideal environment for the spores. When babies swallow them, the spores can turn into growing, multiplying bacteria that pump out a poison called botulinus toxin (or botulinum toxin). This toxin is absorbed through their immature intestines and causes infant botulism. Some cases of infant botulism are mild, but some are fatal.

Who gets infant botulism?

The peak age at which babies are susceptible is when they are 2 to 4 months old. However, they may be at risk until 9 to 11 months. This is the reason babies under one year old should not be fed honey. Because the spores are so heat-resistant, there is a theoretical risk for babies eating even processed foods containing honey. Commercial canning, however, usually destroys the spores. While honey is the most common single food associated with infant botulism, in most cases of infant botulism, the source is not identified.

Normally, swallowing spores is not a problem for healthy adults or older children. The spores usually remain spores. The bacteria do not grow well in mature intestines teeming with beneficial bacteria. Pregnant women, other adults, and older children are routinely exposed to spores without being affected.

Adults can get botulism from other sources, including getting the toxin directly through food or into wounds. The pre-formed toxin can be found in improperly canned or processed foods. The botulinum toxin is among the most lethal of all naturally occurring substances. Ingesting a trace amount can be deadly. Thankfully, toxin production can be prevented with proper refrigeration, freezing, drying, or adding the correct amounts of salt, sugar, or sodium nitrate. The toxin can be destroyed by heat (20 minutes at 176 degrees or 10 minutes at 196 degrees). It can even be harnessed — BOTOX is in vogue to reduce wrinkles.

What are the symptoms?

Usually infant botulism begins with a slowing down of the intestines, which results in constipation. This can progress to include slow feeding. Breastfeeding mothers often report feeling engorged.

Other classic symptoms include listlessness, weakness, and floppiness. The legs may flop open in a frog-leg position. Sometimes babies look so weak and lethargic that infant botulism is mistaken for meningitis.

The disease is a temporary partial paralysis that moves down the body. On closer examination early in the course of the disease, babies often have decreased facial expressions, “heavy” eyelids, poor head control, and a weak cry. Suck, swallow, and gag reflexes are decreased.

The disease can be very mild, with few symptoms, or rapidly progressive, causing respiratory distress or sudden infant death.

Is it contagious?

Botulism is not transmitted from person to person.

How long does infant botulism last?

Infant botulism begins 3 to 30 days after the spores are consumed. The illness usually lasts a number of weeks.

How is it diagnosed?

The diagnosis can be confirmed by laboratory analysis of the blood and stool.

How is infant botulism treated?

Botulism can be treated effectively with botulinum antitoxin. Often additional supportive measures are needed while the person is recovering.

How can infant botulism be prevented?

The CDC recommends that children younger than 1 year of age should not be given honey unless the product has been certified free of spores.

Sometimes honey is pasteurized – usually it is not. Pasteurizing does not reliably destroy botulism spores. Some honey is filtered; some is not. Filtering does not reliably remove botulism spores.

The safety of honey as a food for healthy adults and older children is unquestioned.


Last medical review on: February 18, 2012
About the Author
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Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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