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For several months, botulism has been making news, but not because someone bought from a fancy roadside stand or served at a church potluck. Or squirted on chips sold at a gas station mini-mart -- yes, this really happened.

Our struck 15 individuals from nine U.S. states who suffered neurologic scares after receiving counterfeit or mishandled botulinum toxin (Botox).

Fair enough. This modern fiasco is a reminder of the high price people sometimes pay when seeking beauty from a sketchy source. For example, take last year's roughly in Turkey who suffered neurologic harm after receiving intra-gastric botulinum toxin meant to shrink their stomachs. Is anyone surprised that dubious providers and counterfeit Botox might also hurt folks here in the U.S.? Not me.

But here's what does surprise me: just how little we talk about botulism in infants. This is the innocent subgroup who -- for at least two decades -- have comprised of all domestic cases due to the world's most dangerous bacterial toxin. Once Clostridium botulinum spores enter infants' immature guts and produce their pre-synaptic poison in vivo, the babies' best hope is for someone to do two things: 1) quickly consider the diagnosis; and 2) obtain life-saving treatment that can prevent weeks to months on a ventilator or even death.

Soon I'll share recent stories of hypotonic infants , the FDA-approved, intravenously-administered immune globulin that counters infant botulism types A and B. But first let's review key facts about botulism spores. They could be closer than you think.

Spores in the Wind

Pop quiz: what exactly are C. botulinum spores? And why should no one ever give a child under 12 months of age even a tiny dab of raw honey that might contain them? Technically speaking, are bulging, intracellular structures with protective, shell-like coats that develop within C. botulinum after the bacilli are shed in animal feces. Once that happens, the transformed microbes can withstand harsh conditions, disperse, and reside in soil, dust, and vegetation -- and survive for years.

Which leads us to honey, a product easily contaminated by these tiny, airborne warheads. Before infant botulism (IB) was and increasingly , the thought that spores in the sweet sticky stuff could actually germinate inside a human intestine and cause neuromuscular blockade was antithetical to many families' time-honored practices around honey.

A few chilling thoughts: Over time, who can say how many undiagnosed, ailing babies fed honey have suffered IB? And how many babies worldwide are still dying due to spores in this long-revered remedy for everything from a cough to constipation to colic?

Even today, honey still sporadically causes botulism in the U.S., as shown by a recounted in a New England Journal of Medicine article titled, "An 8-Week-Old Male Infant with Inconsolable Crying and Weakness."

Two months later, when news emerged about a arising from the same west Texas neighborhood, I felt more chills down my spine. The presumed route of transmission in this instance? Instead of swallowing honey, the likeliest explanation is that the three children simply swallowed spores blowing in the wind -- a conclusion that ranging from other geo-temporal IB clusters in windy areas to reports connected to rural residence, local perturbation of soil, home renovation, and even C. botulinum spore-laden that killed an 11-week old infant in Finland who presented with sudden infant death syndrome.

Fortunately, after each of the Texas patients was rescued by a ventilator and BabyBIG at a hospital in Lubbock, their families banded together and went public. "This isn't a one-off, this isn't the flu," one of the moms told a Houston television station. "Families need to know what it looks like so another baby [doesn't sit at home] for 8 hours when they could have been getting care."

Amen to that.

Modern Challenges and our "Moral Obligation"

Sarah Rubin, MD, is a pediatric critical care specialist in Pittsburgh who studies children's long-term outcomes following extended stays in pediatric intensive care. But her larger academic focus is all about preventing bad outcomes, period. So, while still a resident in Los Angeles, Rubin committed to a major project, analyzing reams of patient data, then co-authoring a seminal, that compared 15 IB sufferers who received BabyBIG with 52 sufferers who did not. In 2007, when the paper came out, Rubin told me, BabyBIG had only recently become available, and "we were still trying to figure out how we were going to recognize these kids" and differentiate them from "other neurologic disorders, metabolic disorders, genetic conditions that were still so muddled."

Today, Rubin is equally if not more concerned that families may not feel empowered by physicians, apps, or other contemporary sources of health information on how to differentiate "what's sick and what's not."

So, what might encourage families to seek care during IB's most treatable stage? "If they have a gut feeling that something's wrong, if their child is suddenly constipated and weak," she quickly replied. "Weakness is never okay. A hoarse cry is never okay."

Rubin also stressed the need for healthcare professionals to elicit other IB clues from patients' caregivers -- poor feeding or suck, fatigability when eating, an expressionless face, lethargy, and drooling, among others -- and to perform detailed neurologic exams. Then, she cut to the chase. When suspecting IB, the basic rule is this: treat first, confirm later. It was essentially the same message with which she and her co-authors concluded their seminal 2007 paper, writing: "Giving BIG-IV as soon as the diagnosis of infant botulism is suspected can decrease the morbidity and expense of this life-threatening disease."

In 2024, Rubin also described the need to treat IB as soon as possible as a "moral obligation." Today, more than ever, there's reason to heed her words. Although no one knows exactly why, the U.S. has witnessed a slow but steady increase in documented cases in recent years. According to California's Infant Botulism and Treatment Prevention Program, the recent estimated yearly average count of U.S. cases based on with BabyBIG is 150.

We can only hope that's not just the tip of the iceberg.

Note to clinicians: The California Department of Health for a no-cost clinical consult for all providers with patients 15 months of age and younger with suspected infant botulism.

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