Infant Botulism, Israel, 2007-2021

Infant Botulism: In Search of Clostridium botulinum Spores

Infant botulism is now the most common form of human botulism in Canada and the United States. Infant botulism is a severe neuroparalytic disease caused by ingestion of the spore-forming neurotoxic clostridia, including Clostridium botulinum that colonize the large intestine and subsequently produce botulinum neurotoxin in situ. It has been over a century since the first surveys documenting the ubiquitous prevalence of C. botulinum in soils around the world. Since then, honey has been identified as the only well-known risk factor for infant botulism despite a multitude of international environmental surveys isolating C. botulinum spores from ground soil, aquatic sediments, and commonly available infant foods. Associations of infant botulism cases with confirmed sources of C. botulinum exposure have primarily implicated outdoor soil and indoor dust, as well as commonly ingested foods including honey, dry cereals, and even powdered infant formula. Yet the origin of infection remains unknown for most infant botulism cases. This review summarizes the various surveys from around the world for C. botulinum in environmental soils and sediments, honey, and other infant foods, as well as laboratory-confirmed associations with documented infant botulism cases. Additional factors are also discussed, including the composition of infant gut microbiota and the practice of breastfeeding. We make several recommendations to better identify sources of exposure to C. botulinum spores that could lead to effective preventive measures and help reduce the incidence of this rare but life-threatening disease.

Fecal Microbiota Transplantation for Severe Infant Botulism, China

Infant botulism in a 4-month-old boy in China who continued to excrete toxins for over a month despite antitoxin therapy was further treated with fecal microbiota transplantation. After treatment, we noted increased gut microbial diversity and altered fecal metabolites, which may help reduce intestinal pH and enhance anti-inflammatory capabilities.

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal

OBJECTIVE

Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies.

METHODS

We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated.

RESULTS

Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%.

CONCLUSION

Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications.

LEVEL OF EVIDENCE

Level 3 Case-series Laryngoscope, 2024.

Dissecting and tracing the gut microbiota of infants with botulism: a cross sectional and longitudinal study

Background

Infant botulism is caused by botulinum neurotoxin (BoNT), which is mainly produced by Clostridium botulinum. However, there is a lack of longitudinal cohort studies on infant botulism. Herein, we have constructed a cross-sectional and longitudinal cohort of infants infected with C. botulinum. Our goal was to reveal the differences in the intestinal microbiota of botulism-infected and healthy infants as well as the dynamic changes over time through multi-omics analysis.

Methods

We performed 16S rRNA sequencing of 20 infants' stools over a period of 3 months and conducted whole genome sequencing of isolated C. botulinum strains from these laboratory-confirmed cases of infant botulism. Through bioinformatics analysis, we focused on the changes in the infants' intestinal microbiota as well as function over time series.

Results

We found that Enterococcus was significantly enriched in the infected group and declined over time, whereas Bifidobacterium was significantly enriched in the healthy group and gradually increased over time. 18/20 isolates carried the type B 2 botulinum toxin gene with identical sequences. In silico Multilocus sequence typing found that 20\u00B0C. botulinum isolates from the patients were typed into ST31 and ST32.

Conclusion

Differences in intestinal microbiota and functions in infants were found with botulism through cross-sectional and longitudinal studies and Bifidobacterium may play a role in the recovery of infected infants.

That head lag is impressive! Infantile botulism in the NICU: a case report

BACKGROUND

Infantile botulism (IB) is a devastating and potentially life-threatening neuromuscular disorder resulting from intestinal colonization by Clostridium botulinum and the resultant toxin production. It can present with constipation, descending paralysis, and, potentially, respiratory failure. Botulism is a diagnosis that is more commonly seen in the pediatric intensive care unit (PICU) or on the general pediatric wards and would not typically be managed in the neonatal intensive care unit (NICU), and therefore requires high clinical suspicion to ensure prompt diagnosis and treatment.

CASE PRESENTATION

We discuss a case where an infant from central Pennsylvania presented to a Level IV NICU rather than to the PICU for an evaluation for sepsis and was uniquely diagnosed with IB. The infant presented with poor oral feeding and reduced oral intake, hypothermia, and lethargy. His symptoms progressed into hypoxia and acute respiratory failure. Interestingly, this infant had no known exposure to honey or any other identifiable sources of botulism contact. The infant's twin brother and the other infants who attended the mother's in-home daycare remained asymptomatic. This infant was initially evaluated and managed for a potential infectious etiology. However, a diagnosis of IB was suspected, and was later confirmed through the detection of botulinum toxin in the infant's stools. A high level of suspicion allowed for timely treatment with Botulism Immune Globulin neutralizing antibodies (BabyBIG), even prior to confirmatory testing. We describe the process of obtaining BabyBIG, as well as the natural course of illness after treatment in our patient who ultimately made a complete recovery.

CONCLUSIONS

This case highlights the importance of considering infantile botulism as a diagnostic possibility even in the absence of risk factors, and the need for vigilance in diagnosing and treating this rare but potentially life-threatening condition. With timely recognition, subsequent treatment with BabyBIG, and supportive care, infants with infantile botulism can be expected to recover completely. This information is particularly important for neonatologists providing care for infants outside the neonatal period, especially during times of high patient census and resulting overflow of pediatric admissions in the NICU.

A Challenging Case: Botulism in a Toddler

Botulism is a life-threatening, rapidly progressive neuroparalytic disease caused by one of the most potent toxins known, botulinum toxin. It manifests as flaccid and symmetrical descending paralysis that can affect both cranial and peripheral nerves. The only specific treatment available is the administration of botulinum antitoxin. We present the case of a three-year-old boy who had gastrointestinal symptoms and had ingested garden soil/dust at a construction site before the onset of cranial nerve palsy, which manifested as dysphagia in swallowing liquid and solid food and bilateral progressive ptosis. Early suspicion of botulism and treatment with botulinum antitoxin resulted in complete neurologic recovery. This case highlights the importance of a careful history and neurologic examination to avoid misdiagnosis. Administration of botulinum antitoxin should not be delayed until the diagnosis is confirmed and clinicians should be aware that this approach can be life-saving.

Knowledge, attitude and practice among mothers on the relationship between honey and botulism in Saudi Arabian infants: a cross-section study

BACKGROUND

Botulism is a rare disease, and infant botulism (IB) even rarer, especially when steering the condition to honey consumption. IB is considered a life-threatening disease as it leads to severe neurological symptoms. Exploring the knowledge, attitude, and practice (KAP) among mothers on the relationship between honey and IB will help public health professionals implement appropriate maternal health education materials targeting infant health and increase the awareness of the paediatric primary care providers, physicians, and nurse practitioners about the risk of IB among their patients.

OBJECTIVES

To determine the knowledge of mothers from Hail city in Saudi Arabia (SA) regarding IB and assess their attitude and practice towards feeding honey to their infants before 12 months of age.

METHODS

Using a comparative cross-sectional study, in February 2022, we broadcasted an online questionnaire through social networking and evaluated the KAP of 385 mothers.

RESULTS

Less than half (48%) of the mothers have heard about IB, 40% of them knew the relation between honey ingestion and IB and only 6.5% acknowledged that they knew the causative agent for IB. The prevalence of feeding honey to infants before 12 months was 52%. Mothers from Hail city were less likely to provide honey to their infants (p = 0.002).

CONCLUSION

The study revealed that mothers from Hail city have relatively low knowledge of IB and that they hold favourable perceptions of using honey as a food supplement and feeding honey to their infants before 12 months. Considering the high prevalence of honey feeding with the known low incidence of IB in SA, Medical professionals should consider IB in their differential diagnosis particularly in the presence of neurological symptoms.