Which food should not be given to infants due to the possibility of botulism?

On 2 June 2010 , the Food Standards Agency of the United Kingdom (UK) issued a press release for reminding parents not to feed honey to babies who are under a year old. This follows a case of rare but serious illness, called infant botulism.

Botulism is caused by a neurotoxin (destroyed if heated at 80 °C for 10 minutes or longer) produced by the bacterium Clostridium botulinum , which is anaerobic, gram-positive, spore-forming rod that commonly found in the soil. Although the toxin is destroyed by boiling for 10 minutes or longer; inactivation of spores requires much higher temperature. Three forms of botulism namely, food-borne, wound and intestinal (infant and adult) botulism are recognised, which differs in the site of neurotoxin production. The intestinal botulism was previously known as infant botulism.

Foodborne Botulism

1. Human cases are often linked to the consumption of home-canned foods. Clostridium botulinum needs no oxygen to multiply . Canned, bottled or vacuum-packed foods, which are improperly processed, or only lightly processed and then stored in air tight containers at room temperature, will provide suitable environment for the bacterium to grow and produce toxin in these products. In addition, some strains of Clostridium botulinum can grow at refrigeration temperature; and foodborne botulism cases associated with refrigerated food stored in vacuum packaging or modified atmosphere packaging have been reported.

2. Most foodborne botulism cases are caused by the ingestion of pre-formed toxin that is already present in food which was consumed without further cooking or reheating. Symptoms of foodborne botulism include marked fatigue, weakness, and vertigo often followed by blurred vision, dry mouth and difficulty in swallowing and speaking. Vomiting, diarrhoea or constipation may also occur. The toxin may also paralyse the breathing muscles and cause death if breathing assistance is not provided.

Infant botulism

1. Infant botulism, first recognised in 1976, is caused by the ingestion of the Clostridium botulinum spores that germinate and grow in the intestine of infants and release toxin.

2. Honey, which may be contaminated with the spores, is implicated in some cases. It is not known how honey becomes contaminated with Clostridium Botulinum. Spores of Clostridium Botulinum, which are commonly found in environment, may be picked up by bees and brought to the hive.

3. Infant botulism rarely happens to persons over one year old as the better developed natural microbiological flora in their intestines do not favour the germination of the spores. Early symptom of infant botulism is constipation, followed by lethargy, difficulties in feeding, generalised muscle weakness and weak cry.  While most cases require hospitalisation, fatal cases are rare.

Local Case

Botulism was added to the list of statutory notifiable diseases in Hong Kong since 14 July 2008. There had been no confirmed case of botulism reported to Department of Health since it became a statutory notifiable disease.

Advice to the Trade

1. ensure food products are properly processed to ensure safety, such as by following strict thermal processes, attaining appropriate pH values in the final products, and prudent use of preservatives.

2. handle food products appropriately during transportation and storage to prevent the growth of the bacteria and the formation of toxin.

Advice to the Consumers

1. Avoid feeding honey to infants less than one year old.

2. Honey should not be added to baby food or used on a soother to quiet a fussy or colicky baby.

3. For those individuals who do home-canning, follow proper canning requirements and hygienic procedures

4. Boil home-canned food for at least ten minutes before eating as botulism toxin can be destroyed by high temperatures.

5. Follow the handling and storage instructions given by manufacturers of canned, bottled and vacuum packed foods.

6. Avoid consumption of food from containers (e.g. canned food) that appear to be damaged, bulged or spoilt.

   Infant botulism is a rare but serious form of food poisoning that can affect babies up to a year old.

   In Canada, honey is the only food that has been linked to infant botulism.

   You can help reduce the risk of this disease by only feeding honey to healthy children over one year of age.

   Infant botulism is caused by Clostridium botulinum spores, which are sometimes found in both pasteurized and unpasteurized honey. When an infant ingests honey, bacteria from these spores can grow and produce toxins that could lead to paralysis.

   Frequently Asked Questions (FAQs)
   about Infant Botulism
   
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   What is infant botulism?
   
   Infant botulism is the infectious (intestinal) form of botulism, which results when swallowed spores of a particular bacterium (Clostridium botulinum) colonize the baby's large intestine and produce botulinum toxin in it. Botulinum toxin causes weakness and loss of muscle tone because it blocks the nerve ending's ability to signal the linked muscle to contract. The illness often begins with constipation but is usually first noticed as difficulty feeding (sucking and swallowing), a weak and altered cry and diminished facial expression.
   How does infant botulism differ from foodborne botulism?
   In infant botulism the swallowed botulism spores activate and produce botulinum toxin inside the baby's large intestine. In foodborne botulism the botulism spores activate and produce botulinum toxin in the food. Children and adults get foodborne botulism by eating the food in which the botulism bacteria have produced botulinum toxin.
   How does a baby get infant botulism?
   A baby contracts ("gets") infant botulism by swallowing the botulism spores at a moment in time when the baby's large intestine is vulnerable to spore germination and toxin production. Medical science does not yet understand all the factors that make a baby susceptible to botulism spore germination. Honey is the one identified and avoidable source of botulinum spores. By a process of exclusion (testing over the years of hundreds of foods, beverages and other items placed in infants' mouths with negative results), it was concluded that most infant botulism patients acquired their spores by swallowing microscopic dust particles that carry the spores.
   My infant was fed a commercial product containing honey (e.g. cereal with honey baked in), should I be worried about infant botulism?
   Please refer to the American Academy of Pediatrics best practice guidelines regarding feeding solids to infants (click here).
   
   Many foods and commercial products contain honey, and the honey is included in a variety of ways. Because the details of each manufacturing process vary, CDPH is unable to comment on the likelihood that the honey-containing food product may contain viable C. botulinum spores.
   My infant was fed honey. What should I do?
   Please refer to the American Academy of Pediatrics best practice guidelines regarding feeding solids to infants (click here).
   
   Although honey is a known food vehicle for the bacteria that causes infant botulism, we typically don’t consider an individual honey exposure to be overly risky for acquiring the bacteria that causes infant botulism. Honey is the one dietary reservoir of C. botulinum spores thus far definitively linked to infant botulism by both laboratory and epidemiologic evidence. However, that said, not every jar of honey has botulinum spores in it. To date, avoiding feeding honey to infants 12 months of age or less is the only known prevention measure for infant botulism.
   
   If, in the next few weeks you believe your infant is exhibiting the signs and symptoms of infant botulism, please reach out to your pediatrician.
   I know that honey is not a safe food for babies. Is it okay for a breastfeeding mother to eat honey? Can botulism be transmitted in my breast milk? Should I continue to breastfeed my infant through his/her illness with infant botulism?
   Yes, it is ok for a breastfeeding mother to eat honey. Botulism is not transmitted by breast milk. The Infant Botulism Treatment and Prevention Program recommends continuing breast feeding or the feeding of expressed breast milk during the illness and recovery from infant botulism.
   
   As always, thorough hand washing practices should be strictly adhered to, especially in households where honey is regularly consumed by family members and other caregivers. Doing so will help prevent having honey on surfaces that may come into contact with the infant's mouth.
   
   Although the bacterial spores that cause infant botulism are known to occasionally be present in honey, even if a mother was to eat botulism spores in honey, the spores are far too large to pass through her body and into breast milk. Also, botulinum toxin does not pass into breast milk. For this and other reasons, breast milk is not a source of the bacterial spores or the toxin that cause infant botulism.
   
   As stated in the patient management section of our website, breast milk constitutes optimal nutrition for infants, and mothers should be encouraged and supported in their efforts to continue breastfeeding through their infant's illness and recovery.
   
   For a more thorough discussion of breastfeeding and infant botulism, please refer to the Prevention section below.
   How is infant botulism treated?
   Infant botulism is treated with meticulous supportive care with special attention to feeding and breathing needs. In the United States the orphan drug BabyBIG® is also used to shorten hospital stay and reduce complications.
   What is BabyBIG®?
   The orphan drug BabyBIG® is human-derived botulism antitoxin that was approved (licensed) by the U.S. Food and Drug Administration (FDA) for the treatment of infant botulism on October 23, 2003. Use of BabyBIG® significantly reduces the length of hospital stay and associated hospital costs in patients with infant botulism.
   How soon after BabyBIG® treatment can my child be immunized?
   The infant should have good to full recovery of muscle strength and tone before immunizations resume. In addition, most live-virus vaccines (i.e., measles, mumps, rubella and varicella) will need to be delayed until 6 months after BabyBIG® treatment because the antibodies in BabyBIG® may interfere with the effectiveness of the vaccine.
   
   The live-virus vaccines for rotavirus, RotaTeq® and Rotatrix® should also be delayed until sustained return of normal bowel function after BabyBIG® treatment. Although current data suggest that administration of intravenous immunoglobulin products such as BabyBIG® will not interfere with the efficacy of oral rotavirus vaccines, patients with infant botulism should not receive the rotavirus vaccine because of the slowed intestinal motility that results from infant botulism.
   
   Accordingly, any of the recommended doses of the rotavirus vaccine (RotaTeq® or Rotarix®) that were not given to the infant before treatment with BabyBIG® should be delayed. Because the other live-virus vaccines (i.e., measles, mumps, rubella and varicella) are normally first given at one year of age, only those infant botulism patients who were 6 months of age or older when they were treated with BabyBIG® will need delayed immunization with these vaccines.
   Are there any long-term consequences of infant botulism?
   In the absence of serious hospital-acquired complications, no. The prognosis for infant botulism patients is excellent with anticipated full and complete recovery. Recovery results from regrowth of the nerve endings that then are able to signal the muscles to contract. Botulinum toxin does not penetrate into the brain, and so infant botulism patients retain all the intelligence, athletic ability, musical ability, sense of humor and orneriness with which they were born.
   Can my baby get infant botulism again?
   No. Infants treated with BabyBIG® will have a protective level of toxin-neutralizing antibody for at least six months following administration of the medicine. This feature allows sufficient time for elimination of C. botulinum, which has temporarily colonized the infant's intestine causing disease.
   
   Since the disease of infant botulism was first recognized more than 40 years ago, there have been no instances of an infant acquiring the disease more than once. During this time more than 4450 cases of infant botulism are known to have occurred worldwide.
   
   However, a few reports of "relapsing" infant botulism have been published during this time. Careful review of these case reports by our program's physicians indicates that these were cases in which the infant was discharged prematurely, before they had adequate recovery of strength needed to sustain feeding and breathing. For a further discussion of this topic please see the patient management section of our website under the For Physicians tab.
   Will my next child be at increased risk for infant botulism?
   No.
   How should I handle my baby's diapers as he/she recovers from botulism?
   It is known that patients with infant botulism excrete both C. botulinum toxin and organism in their feces for periods ranging from weeks to months after symptom onset. Consequently, scrupulous handwashing should be practiced after each diaper change. Soiled diapers should be quickly disposed of in an area where no other person or animal can come into contact with them. Persons with open cuts or wounds on their hands should wear gloves when changing diapers.
   
   Because the patient may be excreting the toxin and organism for weeks to months, it is advisable to limit close contact with other infants and children during this time. This is to ensure that other children do not come into contact with fecal material from a leaky diaper. Any contact the patient has with other infants and children during this time should be supervised by an adult.
   
   C. botulinum is not part of the patient's normal flora (normal, healthy bacteria that live in our bodies) and will eventually stop being excreted in the infant's feces.
   How can infant botulism be prevented?
   The only known prevention measure for infant botulism is to avoid feeding honey to infants 12 months of age or less. Breastfeeding may slow the onset of illness if it develops.
   How do I contact other families in my area whose children also had infant botulism?
   There are two ways to do this: 1) call the IBTPP collect and ask for assistance or 2) visit Infant Botulism Family Network Facebook page by searching infant botulism on Facebook or clicking here
   
   Click here for in depth information on infant botulism.
   
   
   Printable Version of this Page

   Which food should not be given to infants because of the possibility of botulism?

   The only known prevention measure for infant botulism is to avoid feeding honey to infants 12 months of age or less.

   What foods are at risk for botulism?

   Low-acid foods are the most common sources of botulism linked to home canning. These foods have a pH level greater than 4.6. Low-acid foods include most vegetables (including asparagus, green beans, beets, corn, and potatoes), some fruits (including some tomatoes and figs), milk, all meats, fish, and other seafood.

   What foods cause botulism in infants?

   The typical source of foodborne botulism is homemade food that is improperly canned or preserved. These foods are typically fruits, vegetables, and fish. Other foods, such as spicy peppers (chiles), foil-wrapped baked potatoes and oil infused with garlic, may also be sources of botulism.