Infant Botulism – Help From Dr. Fox of Pediatric EM Morsels

Parents want to give their coughing infants and children something for the cough. The big thing to tell parents, is Don’t Give “Honey For Cough” to infants less than one year of age because it can cause infantile botulism which is the most common type of botulism in the U.S.

Dr. Fox’s post, Honey For Cough, is an excellent review of infantile botulism. Go review the post now. It is just great. And online CME is available for this post from FOAMbase. Here is just a bit of his post:

[Although] Honey consumption is the classically associated with infantile botulism, but as with many cases of “classical” medical associations, this is not the full story.

  • 85% of cases have no known honey exposure.
  • Botulinum spores are ubiquitous.
  • Honey should still be avoiding in children < 1 year of age… and don’t overlook honey being used as oral pacifier. [Benjamins, 2013]

The following is an excerpt from Clinical Diagnosis:


Because infants are unable to describe their symptoms, the onset of infant botulism can only be detected by careful observation. Usually the first indication of illness is constipation (defined as decreased frequency in defecation), although this sign is frequently overlooked by parents and physicians. Generally, parents first notice that the baby feeds poorly. The breast-feeding mother may notice breast engorgement because the baby’s suck is weak. The infant has become lethargic and listless. Respiratory effort may become shallow and rapid, and the cry is feeble. Drooling may become more noticeable, which is sometimes attributed to teething rather than to dysphagia.

Clinical Presentation

A “catastrophic” presentation of infant botulism with a paucity of the usual clinical signs has also been recognized. See Nevas et al., Journal of Clinical Microbiology, 2005; Mitchell W, Tseng-Ong L, Pediatrics 2005; 116;436-438; and Hurst and Marsh, The Journal of Pediatrics, 122(6):909-911, 1993.

Because botulinum toxin binds at the neuromuscular junction, the toxin produces a flaccid motor paralysis that invariably begins in the bulbar musculature. Somatic musculature is affected next, and patients with rapidly evolving illness may have generalized weakness, hypotonia and respiratory difficulty when first seen.

On initial presentation, the typical patient has some or all of the following findings: ptosis (which may not be evident until the infant’s head is held erect), weak cry, diminished suck and gag, drooling and/or pooling of saliva, dilated and/or sluggishly reactive pupils, disconjugate gaze, blunted facial expression, poor head control, decreased anal sphincter tone, hypotonia and generalized weakness. Deep tendon reflexes may be either normal or decreased. Sensation remains intact, but this may be difficult to demonstrate because of the motor paralysis.

In mild cases or in the early stages of illness, the physical signs of infant botulism may be subtle and easily overlooked. Cranial nerve palsies and the fatigability of muscular function must be elicited by careful examination. Table 1 below describes physical examination techniques which have proved helpful in evaluating these infants. [Table 1 is in the link Clinical Diagnosis]

Dr. Fox’s post provides a link to the Infant Botulism Treatment And Prevention Plan from the Division of Communicable Disease Control, California Department of Health. The website has detailed information on the disease including:

And, as always, Dr. Fox’s brief introduction to the post contains much to think about. Because each of his posts are focused and brief, I like to go read all the links in his post. This really increases the study value for me. So here’s Dr. Fox’s intro:

Cough is a very common symptom in children. Certainly, we need to consider that an ominous cause may be lurking (AsthmaOccult Aspirated Foreign BodyCroupSinusitisPneumoniaAcute Chest Syndrome, etc.). Most often, though, the cough is due to a viral illness, but remember viral illnesses can become complicated (see, MyocarditisGuillaine-Barre). So, take care not to be dismissive. Additionally, while you are doing your best to avoid the phrase “just a virus,” prepare yourself to address the parent’s next question: “What can be used to make the cough better?”  Unfortunately, there are not many medications that are safe to use in young children… but this may be an opportunity to “prescribe” Winnie the Pooh’s favorite: Honey for Cough. [But remember that honey should never be given to those less than one year of age because of the risk of infant botulism]

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