Infant botulism

Definition
This is a type of botulism in which bacteria, Clostridium botulinum, grow within an infant’s gastrointestinal tract and produce a toxin which can cause a potentially life-threatening disease.

Causes, incidence, and risk factors

Clostridium botulinum is a spore-forming organism that is common in nature. The spores may be found in soil, foods (such as honey and some corn syrups), and elsewhere.

This disease occurs mostly in young infants between 6 weeks and 6 months of age. Onsets as early as 6 days and as late as one year have been reported.

Risk factors include the ingestion of honey, young age, contact with soil, breast-feeding, and having less than one stool per day for a prolonged period (greater than 2 months).

Symptoms

     
  • incubation period unknown  
  • first and most frequent symptom is constipation  
  • “floppy infant” secondary to muscle weakness (hypotonia)  
  • tired all the time (lethargy)  
  • weak cry (due to muscle weakness)  
  • poor feeding and weak suck (due to muscle weakness)  
  • loss of head control  
  • infant doesn’t gag (absent or decreased gag reflex)  
  • respiratory distress (due to muscle weakness)  
  • eyelids sag or partially close - ptosis (due to muscle weakness)  
  • descending paralysis  
  • respiratory failure

Signs and tests

Physical examination shows the symptoms described above, such as decreased muscle tone (hypotonia), an absent or decreased gag reflex, absent or decreased deep tendon reflexes, and eyelid drooping (ptosis).

Laboratory testing consists of checking a stool sample to demonstrate the presence of botulinum toxin in the stool or demonstration of Clostridium botulinum in the stool.

A special muscle test known as electromyography (EMG) can help differentiate between muscle abnormalities and neurologic abnormalities.

Treatment

The mainstay of treatment is supportive and may include keeping the airway clear, observing for respiratory difficulty, and ensuring adequate nutrition. If respiratory distress develops, respiratory support including use of a ventilator may be indicated.

Botulism immune globulin (BIG) is a new form of treatment recently tested for infants with botulism. Although it is not a cure, studies have shown that BIG may reduce the duration and severity of infant botulism. You should discuss the risks and benefits of this treatment with your doctor.

Antibiotics do not appear to increase the rate of improvement. Antibiotics are not needed unless a secondary infection, such as pneumonia, develops.

The use of human-derived botulinum antitoxin may also be of benefit.

Expectations (prognosis)
Full recovery is expected with early recognition and supportive treatment. Death or permanent disability may result in complicated cases.

Complications
Respiratory insufficiency can develop, requiring assistance with breathing (mechanical ventilation).

Calling your health care provider
Since infant botulism can be life-threatening, go to the emergency room or call the local emergency number (such as 911) immediately if your infant has one or more of the symptoms of botulism.

Prevention

Theoretically, the disease might be avoided by preventing exposure to spores. Since honey and corn syrup are sources of Clostridium spores, they should not be fed to infants under 12 months of age.

Although breast-feeding appears to be a risk factor for infantile botulism, the overall risk is very low - for that reason, the benefits of breast-feeding still greatly outweigh the risks in nearly all cases.

Johns Hopkins patient information

Last revised: December 6, 2012
by Dave R. Roger, M.D.

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