What is the diagnosis and treatment for infantile botulism (Clostridium botulinum infection)?

From the Guidelines

Infantile botulism should be treated with human-origin anti-A, anti-B botulinum antitoxin (BabyBIG) as soon as possible after diagnosis, in addition to supportive care, to reduce morbidity and mortality. The treatment of infantile botulism involves administration of BabyBIG, which is available after consultation from the California Department of Public Health Infant Botulism Treatment and Prevention Program 1. Supportive care includes respiratory support if needed, careful monitoring of feeding and hydration, and management of constipation.

Key Considerations

• The disease occurs when infants ingest bacterial spores that colonize the intestine and produce botulinum toxin, which blocks neuromuscular transmission by preventing acetylcholine release, resulting in the characteristic descending flaccid paralysis.
• Parents should seek immediate medical attention if their infant shows symptoms such as constipation, weak cry, poor feeding, decreased facial expression, generalized weakness, or respiratory difficulties.
• Prevention involves avoiding honey in infants under 12 months (as it can contain botulinum spores) and proper food preparation and storage.
• Most infants recover completely with prompt treatment, though recovery may take weeks to months.

Treatment Approach

• The primary treatment is supportive care and administration of BabyBIG, which should be given as soon as possible after diagnosis.
• The standard dose and administration of BabyBIG should be followed as recommended by the California Department of Public Health Infant Botulism Treatment and Prevention Program.
• Supportive care includes respiratory support if needed, careful monitoring of feeding and hydration, and management of constipation, as well as intensive care including intubation and mechanical ventilation when necessary 1.

From the FDA Drug Label

BabyBIG®, Botulism Immune Globulin Intravenous (Human), is indicated for the treatment of infant botulism caused by toxin type A or B in patients below one year of age. The recommended total dosage of BabyBIG is 1.0 mL/kg (50 mg/kg), given as a single intravenous infusion as soon as the clinical diagnosis of infant botulism is made.

• Key Points:
  • The treatment is for patients below one year of age.
  • The dosage is 1.0 mL/kg (50 mg/kg) as a single intravenous infusion.
  • The treatment should be administered as soon as the clinical diagnosis of infant botulism is made.
  • Administration: The infusion should begin within 2 hours of reconstitution and conclude within 4 hours of reconstitution.
  • Monitoring: Monitor vital signs continuously during infusion.
  • Precautions: Use with caution in patients with pre-existing renal insufficiency and in patients judged to be at increased risk of developing renal insufficiency 2 2 2

From the Research

Definition and Causes of Infantile Botulism

• Infantile botulism is a rare disease caused by the ingestion of Clostridium botulinum spores, which germinate in the large intestine and produce a neurotoxin that prevents the release of acetylcholine at the presynaptic membrane, resulting in flaccid paralysis 3, 4.
• The spores can be found in soil or honey products, and infants can acquire the disease by ingesting these spores 4.
• The toxin irreversibly binds to acetylcholine receptors on motor nerve terminals at neuromuscular junctions, causing progressive weakness, hypotonia, and hyporeflexia 4, 5.

Symptoms and Diagnosis of Infantile Botulism

• The symptoms of infantile botulism include constipation, lethargy, weak cry, poor feeding, and dehydration 4.
• The disease can quickly progress to respiratory failure, making prompt diagnosis and treatment crucial 4.
• Diagnosis is confirmed by isolating the organism or toxin in the stool and finding a classic electromyogram pattern 4.
• A high index of suspicion is important for the diagnosis of infantile botulism, as the disease can be easily mistaken for other conditions 4.

Treatment and Prognosis of Infantile Botulism

• Treatment consists of nutritional and respiratory support until new motor endplates are regenerated, which results in spontaneous recovery 4.
• Botulinum-specific antitoxin, such as Botulism Immune Globulin Intravenous (BIG-IV), can be administered to stop the progression of the disease 3, 6.
• With early recognition and implementation of treatment, most infants will make a full recovery within several months to a year 3, 6.
• Neurologic sequelae are seldom seen, but some children may require outpatient tube feeding and may have persistent hypotonia 4.