Exploring the “Why” Behind the “No Honey Under One” Rule

I learned something new this year. It’s something that I didn’t pay attention to (or even know about) with my oldest son. (Good thing kids are hardy!) I learned that honey, in any form, should be avoided under the age of one.

Sure, sure. I knew that I shouldn’t give my son honey. But I was imagining, like, a spoonful of honey just shoved in his mouth. Or spread over some toast. What I learned this year went beyond that and clarified it for me in new ways.

The “No Honey Under One” rule means NO honey…no honey baked into bread as an ingredient. No honey mixed into a drink. No honey cooked into a batter. No honey as medicine. No honey. None. Zip. Zero.

Why not? And why is it suddenly ok once a child is older than a year?

This question is answered wonderfully by Jennifer Anderson, MSPH, RDN in the following Instagram post.

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A post shared by Jennifer Anderson, MSPH, RDN (@kids.eat.in.color)

Jennifer gives such a lovely summary of the “No Honey Under One” rule. And for most of us, we can stop right there. That’s sufficient information to help us help our babies stay safe. For those you are looking for more, let’s dive into some of this info in further detail.

What is botulism? Where does it come from?

According to the Food and Drug Administration (FDA) “[b]otulism is a rare but serious illness caused by a toxin that attacks the body’s nerves and causes difficulty breathing, muscle paralysis, and even death. This toxin is made by Clostridium botulinum and sometimes Clostridium butyricum and Clostridium baratii bacteria” (Center for Food Safety and Applied Nutrition, 2018).

These bacteria make spores to surround themselves, which act as a protective coating. This coating allows the bacteria to live in otherwise inhospitable situations and extreme conditions. And these spores can be found practically everywhere. They’re in the microscopic dirt and dust all around us; they’re on fruits and vegetables; they can be found in wounds; and they are found in honey. For most of us, this isn’t a problem because the spores themselves do not (generally) make people sick, even if ingested. Botulism is the result of the toxins the Clostridium botulinum bacteria create under specific sets of circumstances. In those specific circumstances, “spores can grow and make one of the most lethal toxins known” (Centers for Disease Control and Prevention). The most common condition resulting in the bacteria releasing toxins is a low oxygen environment.

Infant botulism versus foodborne botulism

Infant botulism differs from other forms of botulism not just because it occurs in a specific subset of humanity (infants) but also because of the way in which the toxins enter the body.

“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 [already] produced botulinum toxin” (Division of Communicable Disease Control, 2010).

In other words, in infant botulism, the bacteria are first ingested and then the toxins form, whereas in foodborne botulism, the bacteria have already produced toxins, which are then ingested, generally via foods.

The process that produces infant botulism generally doesn’t occur in healthy older children and adults due to the “natural defences [sic] in intestines that develop over time [that] prevent germination and growth of the bacterium” (World Health Organization, 2018). The medical community is still not sure of all the factors that go into creating these natural defenses or what makes an infant extra susceptible to the germination of the botulism spores.

As mentioned above, botulism is found in many places but there have been direct correlations found between infant botulism and honey ingestion. For this reason, most major western health organizations, including the Food and Drug Administration, the World Health Organization, and the Centers for Disease Control and Prevention, all strongly recommend avoiding honey before the age of one. This allows plenty of time for a child’s gut to develop its defenses and be more prepared to fight against bacteria germination.

What does botulism do to our bodies?

All of the information in this section is taken from the Centers for Disease Control and Prevention‘s article “Botulism“, all punctuation and emphasis are original:

Signs and symptoms [of botulism] might include:

• Difficulty swallowing
• Muscle weakness
• Double vision
• Drooping eyelids
• Blurry vision
• Slurred speech
• Difficulty breathing
• Difficulty moving the eyes

Possible signs and symptoms in foodborne botulism might also include:

• Vomiting
• Nausea
• Stomach pain
• Diarrhea

Signs and symptoms in an infant might include:

• Constipation
• Poor feeding
• Drooping eyelids
• Pupils that are slow to react to light
• Face showing less expression than usual
• Weak cry that sounds different than usual
• Difficulty breathing

People with botulism might not have all of these symptoms at the same time.

The symptoms all result from muscle paralysis caused by the toxin. If untreated, the disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs, and trunk (part of the body from the neck to the pelvis area, also called the torso).

In foodborne botulism, symptoms generally begin 18 to 36 hours after eating a contaminated food.

If you or someone you know has symptoms of botulism, immediately see your doctor or go to the emergency room.

What’s the treatment for botulism? Is there a cure?

Since botulism is caused by toxin production, the treatment involves the administration of an antitoxin, which stops the toxin from continuing the spread of paralysis throughout the body. The sooner the antitoxin is administered, the better the prognosis (or outcome) will be for the patient.

However, it’s important to note that antitoxin, no matter how soon it is administered, does not reverse the damage already done to the body. “Depending on how severe your symptoms are, you may need to stay in the hospital for weeks or even months before you are well enough to go home”(Centers for Disease Control and Prevention). One common cause for the long hospitalization is that the toxins often paralyze lungs, making it difficult or impossible to breath. The use of a ventilator (breathing machine) is necessary at that point, until independent breathing is once again achieved. In general, most people who become sick from botulism are able to recover their mobility and the paralysis gradually lessens over time.

For infant botulism, specifically, the outcome post-treatment “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” (Division of Communicable Disease Control, 2010).

How reassuring is that!? Horray!

Why can’t my child eat honey in cooked foods? How is it killed if not via heat?

It seems as though it’s been drilled into our heads that cooking food helps to make it safe for ingestion and removes bacteria. So it’s an easy conclusion to come to that cooking honey would make it safe for our babies too. After all, washing, cooking and correctly processing foods are what prevent foodborne botulism. This exact line of thinking is what kept me from fully understanding the “No Honey Under One” rule previously. I didn’t even think that it could mean in cooked foods too because, in my mind, cooking food made it “safe”.

However, “[s]pores produced by the bacteria Clostridium botulinum are heat-resistant” and “[c]ommercial heat pasteurization…may not be sufficient to kill all spores”. Only “very high temperature treatments such as commercial canning” and boiling has been shown to consistently kill the spores, and that’s only after hours of boiling (World Health Organization, 2018). [Note: the honey is boiling. Adding honey to boiling water is not the same thing. For example, adding honey to boiling water to make honey tea will not kill the Clostridium botulinum bacteria].

Remember, the bacteria live in spores specifically designed to help them survive in extreme conditions. Let’s use an analogy to really bring this point home. In their protective spores, the bacteria safely pass through the cooking/heating process just like astronauts, in their protective capsules, safely pass through the extreme heat (1480°C/2700°F – !!!) of reentering the earth’s atmosphere. The capsule shields the astronauts from the heat that otherwise would obliterate them instantly. Once back on land, the astronauts emerge unharmed from their protective capsule and carry on their lives. So, too, with the bacteria. Once they reach a suitable anaerobic (oxygen free) environment, they emerge from their protective spores, unharmed, and multiply, producing their potent toxins. And it just so happens that your baby’s immature gut is the perfect minimally defended, anaerobic environment for the bacteria to do this.

For this reason, it is recommended that honey not be served to infants under the age of one, even in cooked foods.

But, if you do accidentally serve food with honey and the unthinkable happens, you can rest in the assurance that there is treatment and that there is a very high likelihood of full and complete recovery for your child.

Be aware. Be smart. Be safe. No honey (at all) under the age of one.

This is Part One in my three-part series on the “No Honey Under One” rule. Watch for my follow-up posts for a discussion of kid-friendly foods that honey surprisingly shows up in and how the “No Honey Under One” rule differs from the often misunderstood recommendation not to serve milk under one.

Hello! I’m Briana!