Infectious Disease Book

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Infant BotulismAka: Infantile Botulism

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  1. See Also
    1. Botulism
  2. Epidemiology
    1. Incidence: Estimated at 250 cases in U.S. per year
      1. More cases than foodborne or wound Botulism
    2. States with highest rates
      1. California (50%)
      2. Utah
      3. Pennsylvania
    3. Age of Onset
      1. Age 6 weeks to 9 months
      2. Peaks at 2-3 months (90% are under 6 months of age)
  3. Pathophysiology
    1. Sources
      1. Contaminated soil
      2. Contaminated honey (10% of samples)
      3. Contaminated corn syrup (0.5% of samples)
    2. Other related factors
      1. Infants under 2 months living in rural farming area
      2. Infants over 2 months are typically breast fed
        1. Nursing infants account for 70-90% Infant Botulism
        2. Nursing may be protective and delay severity
        3. Non-nursing infants may have fatal undiagnosed case
  4. Symptoms and Signs
    1. See Botulism
    2. Early symptoms and Signs
      1. Constipation (65%)
        1. May precede weakness by weeks
      2. Cranial Nerve Dysfunction
        1. Weak cry and weak sucking
        2. Decreased oral intake (79%)
        3. Decreased Gag Reflex
        4. Cranial Nerve 6 palsy (unable to abduct eye)
        5. Mydriasis with sluggish pupil reaction
        6. Ptosis
      3. Autonomic changes
        1. Hypotension
        2. Neurogenic bladder
    3. Later Symptoms and Signs
      1. Weakness or hypotonia (88%)
      2. Decreased activity or lethargy (60%)
      3. Irritability
      4. Respiratory difficulties
  5. Differential Diagnosis
    1. See Hypotonia in Infants (Floppy Infant)
    2. See Pediatric Constipation Causes
  6. Labs
    1. See Botulism
    2. Serum sample for Botulinum toxin
    3. Stool for toxin and culture
      1. Passed stool is preferred
      2. Sample (25 g or 25 ml) via colonic irrigation
    4. Possible sources sent for Botulinum toxin
      1. Dust or soil from clothing
      2. Honey, Corn syrup and other foods
  7. Diagnostic Testing
    1. See Botulism
    2. Electromyogram (EMG)
  8. Management
    1. Supportive care with close supervision
      1. Anticipate Mechanical Ventilation
    2. Avoid Aminoglycosides (may increase toxin levels)
    3. Consider Botulinum Immune globulin
      1. Efficacy
        1. Reduces hospitalization duration
        2. Reduces Mechanical Ventilation duration
      2. Source: California Department of Health Services
        1. Phone (24 hours): 510-540-2646
    4. Botulinum antitoxin
      1. Botulinum Immune Globulin is preferred over antitoxin
      2. Controversial in infant Botulism
        1. May not be beneficial in infant Botulism
      3. Anaphylaxis rate is high (9 to 20%)
        1. Test for Horse Serum Sensitivity prior to use
  9. Prognosis
    1. Case fatality rate of treated patients: <2%
    2. Excellent long-term prognosis without residual changes
  10. Course
    1. Mechanical Ventilation: 23 days
    2. Hospital stay on average: 44 days
    3. Relapses, if they occur, usually do so within 13 days
  11. References
    1. (2000) AAP Red Book, 25th edition, p. 212-13
    2. Schechter in Behrman (2000) Nelson Pediatrics, p. 875-8
    3. Cox (2002) Am Fam Physician 65(7):1388
    4. Muensterer (2000) Pediatr Rev 21(12):427

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