Snapshot A 4-month-old infant is brought to the ER by his mother who reports that he has been experiencing poor feeding, lethargy, constipation,reduced muscle tone and weakness, and eye paralysis. The child is afebrile. According to the mother, the infant refused to eat his formular without her sweetening it. Introduction Life-threatening paralysis caused by Clostridium botulinum neurotoxin irreversibly blocks acetylcholine release from peripheral neurons Results when infants ingest spores that grow in the intestine and produce the toxins not caused from ingesting toxins, as in food-borne botulism Epidemiology most common in infants form 2-6 months always <1 year old not in newborns Risk factors include honey ingestion corn syrup ingestion house dust and aerosolized soil exposure constipation Presentation Symptoms constipation weak cry loss of head control "floppy baby" facial paralysis secretion-pooling in cheeks decreased gag reflex sagging eyelids Physical exam ptosis descending paralysis respiratory arrest Evaluation Diagnosis is based primarily on clinical observation and patient history based on acute onset of flaccid descending paralysis with clear sensorium without fever or paresthesias Stool sample for botulinum toxin EMG may differentiate between muscular and neurologic paralysis Differential Traumatic paralysis Treatment Medical management botulism immune globulin indicated in all cases decreases length of hospital stay and severity of illness avoid horse serum antitoxin or antibiotics in infants hospitalization and mechanical ventilation may be indicated in severe disease includes proper nutrition workup and supplementation if necessary Prognosis, Prevention, and Complications Prognosis very good to excellent with early diagnosis and treatment most children recovery completely Prevention avoid feeding infants honey and corn syrup until 1 year of age Complications severe cases can result in permanent paralysis and/or death respiratory insufficiency/failure can result requiring mechanical ventilation pneumonia can develop secondary to respiratory failure