Honey-borne infant botulism in tahnik practice: an explanation of the risk and its solutions

Harun, M.A.W., Abdullah, A., Mohamad, A.M. and *Baharuddin, A.S. School of Humanities, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia. Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, Jalan Tun Hamdan Sheikh Tahir, 13200 Kepala Batas, Pulau Pinang, Malaysia. Faculty of Syariah and Law Universiti Sains Islam Malaysia, Bandar Baru Nilai, 71800 Nilai, Negeri Sembilan, Malaysia. Centre of Research for Fiqh Forensics and Judiciary, Institut Sains Islam, Universiti Sains Islam Malaysia, Bandar Baru Nilai, 71800 Nilai, Negeri Sembilan, Malaysia.


Introduction
The Arabic term for feeding sweets to a newborn baby is 'tahnik,' which is a familiar practice in Islam. In the Malay custom, it is also referred to as 'belah mulut' which literally 'mouth splitting' (Ahmad, 1993). Usually, tahnik is performed using dates that will be masticated (to soften it) by religious figures or pious people and then be daubed on the palate of a newborn infant. Dates are preferred over other substances in the tahnik because of the sweetness of the fruit and its health benefits, 100 g of dates contain around 314 kcal, are high in fibre (8.0 g/100 g) and a good source of antioxidants, and provide approximately 15% of the recommended daily allowance of several key minerals (Al-Farsi and Lee (2008). However, when dates are not available, honey has been proposed as a substitute (al- 'Asqolani, 2017;Mualifa, 2017). Feeding dates to newborns does not present any issues, but a replacement with honeyespecially for those less than twelve months of age-has been associated with numerous cases of infant botulism infection. This is a serious health condition that can lead to death (Midura et al., 1979;Tanzi and Gabay, 2002;Nevas et al., 2005;Wikström, 2017). The danger arises because honey possesses the risk of being contaminated with Clostridium botulinum spores (Grabowski and Klein, 2017;Bittmann et al., 2019;Mohd Tamrin, 2020). Infant botulism occurs due to the release of botulinum neurotoxin (BoNT) during the C. botulinum reproduction process after it invades the baby's stomach Panditrao et al., 2020). In babies under the age of one year, the microflora of their still-immature intestine allows C. botulinum bacteria to germinate and colonise the stomach. This results in the absorption of BoNT by the intestine (Schocken-Iturrino et al., 1999). Sudden infant death syndrome has also been associated with the symptoms of this infection (Thompson et al., 1980). Originally these toxins were considered to be found in soil and air, but studies have also found these toxins to be present in honey (Sugiyama et al., 1978;Palmer et al., 2019). On average, around 0.5% -8.5% of honey available in the market are contaminated with the toxin as shown in Table 1. Analysis by Tanzi and Gabay (2002) also found that the consumption of contaminated honey-evidenced by honey samples testing positive for the presence of C. botulinum toxin-is associated with infant botulism throughout the United States of America. It is of particular concern that the honey contaminated with C. botulinum did not differ in smell, colour, or taste from pure honey, thus making it very difficult to identify Grenda et al., 2018). As a result, it is recommended that infant consumption of honey be avoided if at all possible.

Muslims believe that every
Scientists and doctors have implemented this same concept (and one similar to tahnik) as an alternative form of pain relief for preterm infants, such as giving them sucrose before and after injections. Typically, pain relief would be provided by administering paracetamol, but this is very restrictive in the case of preterm infants (Swapnil et al., 2017;Valeri et al., 2018). The aforementioned medical practice has obvious similarities to the practice of tahnik, a procedure proposed by the Prophet Muhammad (p.b.u.h). In essence, administering sucrose to a premature infant can have a pain-relieving effect. It can calm the baby, normalise its breathing, and stabilise its blood oxygen levels (Valeri et al., 2018). A study carried out by Beuno (2013) concluded that sucrose sweetmeat found in fruit nectar can be used for pain relief (as an analgesic) for babies. Therefore, other painkiller drugs-like paracetamol-can be avoided in the early treatment of infants. Additionally, research carried out by the Royal Children's Hospital in Melbourne, Australia, determined that oral sucrose is safe and effective for reducing procedural pain from a single event. This proves that the tahnik practice by Prophet Mohammed (p.b.u.h.) of feeding small amounts of date flesh to newborns is not only significant and effective but also consistent with the evidence of modern science.

Materials and methods
This study combined a semi-structured interview and armchair research methods to attain more comprehensive findings. The objectives of the study were to investigate: a reliable method of performing tahnik; the original proposition of using honey in tahnik; and the efficacy of using ingredients other than dates in tahnik. We interviewed three Islamic scholars, including two members of the State Fatwa Council, along with a Syariah academic. The study ended at the third respondent due to the data saturation achieved based on the similarity of answers given by the respondents. For the last objective, i.e., to find suitable substitutes for dates in tahnik, we performed a descriptive analysis of the USDA Food Composition Databases (2021). Finally, all data were analysed and discussed, together with the support of Islamic manuscript literature, to strengthen the main findings and to provide more comprehensive final research findings.

The correct method of tahnik is using dates, not honey
The proper method of performing tahnik is to feed newborns dates, not honey, as explained by all three respondents (Syariah scholars) and three literature sources of tahnik. Further, there is no single referenceeither from the Holy Quran or hadiths (prophet sayings) -to the use of honey in tahnik. The only substance ever used by the Prophet (p.b.u.h.) in tahnik is dates. The findings are shown in Table 2.
Based on these quotations, the Prophet (p.b.u.h.) used only dates in all tahnik practices. Therefore, the encouraged way of tahnik practice is with dates, and the use of honey does not coincide with the Prophet's Sunnah. After determining that the use of honey does not derive from the original tahnik practice and was never recommended by the Prophet (p.b.u.h.), we explored how the recommendation emerged in the practice. Respondents said that the recommendation came from local custom when the sweetness of honey was seen as comparable to that of dates. However, a study of the Islamic manuscript literature found that the recommendation of using honey in tahnik specifically came from some previous Muslim scholars, such as al-Asqalani (2017), al-Kaurani (2008), and al-Muzhiri (2012). Those findings are shown in Table 3.
These findings show that the use of honey should not be associated with tahnik practice as originating from the Prophet Muhammad (p.b.u.h.), but rather, it is an opinion of some Islamic scholars based on their ijtihad (analytical view). However, this opinion does not impair the credibility of their judgment as it was based on the medical technology/research at that time, i.e., al-Asqalani in the fourteenth century. At that time, the effects of giving honey to infants were still unknown. It was not until around the nineteenth century that Clostridium botulinum was discovered (Smith et al., 2018), which is 400 years after al-Asqalani's view. No doubt, the reason for the scholars' recommendation was the similar sweetness of the honey as with the dates, as mentioned by the third respondent.
In addition, there is a possibility that these scholars' views have been assimilated into tahnik practice with the Malay local customs referred as 'belah mulut' (translation: mouth splitting). This can be seen in a variety of Malay manuscripts that listed honey as one of the ingredients for the practice.
The method of belah mulut (mouth splitting) is described in Ensiklopedia Perbidanan Melayu: Sebuah Perbendaharaan Ilmu Perubatan dan Penjagaan Kesihatan (translation: the Encyclopedia of The Malay's Midwifery: A Treasury of Medical Science and Health Care) (Barakbah, 2007, p. 234), as follows: "Mother will prepare the zamzam water and honey to be dropped into baby's mouth using gold ring. Another discussion of mouth splitting is found in a book entitled Bicara Tentang Adat dan Tradisi (translation: A Talk of Custom and Tradition) (Mas, 1993, p. 62). It also mentions the use of honey as a main substance in the practice: 'After finished azan dan iqamah, then the boy's mouth will be split with sweets [honey, dates, or anything else].' In addition, the practice of mouth splitting using honey is also mentioned in Malay novels which is consistent with the practice of the Malay community. Among them, a novel titled Mat Kilau by Abdul Latip (2009, p. 20) explores the history of Mat Kilau's life from birth: "A woman hand over a bowl of salt to Imam Rasu. For mouth splitting ceremonies, usually, a pinch of salt is put into the baby's mouth. The purpose is to make it the first taste he experienced after birth into the world. We have honey and zamzam water, so that is what we will daub on his mouth (Mat Kilau), said Imam Rasu. He believed in the benefits of honey and zamzam water. These are what should be given to a newborn baby." Mouth splitting as Malay custom is not limited to dates and honey, as they have also used the combination of sweet (date, honey, and sugar), salty (salt), and sour (raisin and acidic) substances. This combination is used to give the baby a taste of things to come in his/her life; the baby will taste the sweetness, saltiness, and sourness of life (Rozninah, 2012). Thus, in a philosophical way, all these tastes will prepare the infant for challenging life experiences that he/she will face in the future.

When dates are not available, other sweet substances can be substituted
The practice of tahnik is generally done with dates. However, when dates cannot be found, the first and third respondents and Islamic literature reported that they can be replaced with other sweet substances. The second respondent does not suggest a replacement other than zamzam water. Overall findings indicate that the use of dates is not a fixture in tahnik practice. In fact, it can be changed if/as needed due to lack of availability. These findings are shown in Table 4.
The approval can be viewed through the first and third respondents who suggest substituting the dates with sweet and unheated fruits because that is what the previous scholars had suggested. The second respondent allows using only zamzam water after dates because al-Ato' has narrated that zamzam was used by the Prophet (p.b.u.h.)-along with Ajwa dates, known to Muslims as 'the holy date'-when performing tahnik on his grandsons, al-Hassan and al-Hussain (al-Fakihi, 2018). The second expert also disagreed with substituting dates with anything other than zamzam water because from his point of view, tahnik is a worship practice that must be followed exactly as the Prophet (p.b.u.h.) has done. If dates are replaced with other ingredients, the meaning of tahnik will not be achieved, just as the Prophet's practice of breaking fast with dates cannot be replaced with something else.

What are suitable substitutes for dates in tahnik?
"Honey is the most preferred than the other. Then if not found, replaced with something that never been touched by fire" (Al-'Asqalani 2017, p. 588). Yes, honey is very akin to dates in terms of nature and privilege; both are sweet, and both are mentioned in the Quran (Holy Quran,[11]:68-69)). However, from the standpoint of food group analysis, honey is a processed sweet produced by honeybees that decompose nectar into simple sugars in the honeycomb (Sammataro and Avitabile, 1998;Adriane et al., 2018).
By comparison, dates are naturally sweet and transformed into fruit without any external intervention. Therefore, the best substitutes for dates in tahnik practice should also come from this fruit group. Searching on the USDA Food Composition Databases (2021) has found fruits that have the same characteristics as dates in terms of sweetness and privilege, as well as the equation of nutrients and glucose that is closest to dates. These findings are shown in Table 5 . Therefore, when dates are not available, raisins are preferred first, then figs or pomegranates, followed by grapes, and then other sweet fruits.

Conclusion
The method of Sunnah in performing tahnik uses only dates. The recommendation of substituting dates with honey derives solely from some Islamic scholars. This view is based on their judgement (Ijtihad) and should not be attributed to the Sunnah of the Prophet (p.b.u.h.). When dates are not available, they can be substituted with raisins, figs, pomegranates, grapes, and/ or other sweet fruits.    (2021)