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Infant Botulism -- Massachusetts

A previously healthy 5-month-old male infant was admitted to a Massachusetts hospital in November 1983 with progressive lethargy and loss of developmental milestones over 3 weeks, constipation for 12 days, and poor suck and feeding. He had been breast-fed, and bottled foods were added at the age of 3 months. On examination, the child was generally hypotonic with flaccid extremities, no head control, and no suck or Moro reflexes. He was alert, able to smile, and had no oculomotor weakness. An electromyogram revealed a post-tetanic facilitation pattern after stimulation at 50 Hz, compatible with infant botulism. He was initially treated with intravenous hydration and saline enemas. Naso-gastric feedings were begun on the fourth hospital day, and he improved gradually thereafter. Type B botulinal toxin and Clostridium botulinum were identified in a stool specimen by the Massachusetts State Laboratory. Reported by DG Sidebottom, MD, Children's Hospital, Boston, JP Reardon, MD, MB Holmes, NJ Fiumara, MD, State Epidemiologist, Massachusetts Dept of Public Health; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Infant botulism, in contrast to foodborne botulism resulting from ingestion of preformed toxin, is caused by C. botulinum toxin produced in and absorbed from the gastrointestinal tract, leading to neurologic manifestations. This report represents the first case of infant botulism identified in Massachusetts and the second from the New England states; the first reported case occurred in 1983 in Connecticut. Infant botulism was first identified in 1976; four states--California, Texas, Pennsylvania, and Tennessee--reported cases that year. To date, 36 states in all geographic regions, including Alaska and Hawaii, have identified cases. Between 1976 and 1983, 395 cases were reported to CDC. Patients' ages ranged from 2 to 38 weeks, and 204 (52%) were male; most were hospitalized, and 11 died. Type A botulinal toxin was identified in 50% of the cases; type B, in 49%; and types F and B/F, in one case each.

A case-control study performed by the California Department of Health Services in 1976-1978 showed that infants with type B botulism were more likely than controls to have been fed honey, and type B spores were identified in implicated honey samples (1). This is the only exposure that is a clearly defined risk factor for cases of infant botulism, and CDC has recommended that honey not be fed to infants under 1 year of age (2). In a 1976-1980 epidemiologic study of infant botulism cases reported through CDC's surveillance system from states other than California, 96 infant botulism patients were compared with infants in the general population; infant botulism patients tended to have higher birth weights, and their mothers tended to be older and better educated (3). Seventy percent of the botulism patients were predominantly breast-fed.

For patients in whom the diagnosis of infant botulism is considered, physicians should collect stool specimens for toxin testing and culture and should contact their state health departments for processing specimens. Treatment is mainly supportive, with gradual recovery in most cases. Enemas may be given to help eliminate toxin from the gastrointestinal tract. The roles of botulinal antitoxin and antimicrobials in treatment are unclear.


  1. Arnon SS, Midura TF, Damus K, Thompson B, Wood RM, Chin J. Honey and other environmental risk factors for infant botulism. J Pediatr 1979;94:331-6.

  2. CDC. Honey exposure and infant botulism. MMWR 1978;27:249-50, 255.

  3. Morris JG, Snyder JD, Wilson R, Feldman RA. Infant botulism in the United States: an epidemiologic study of cases occurring outside of California. Am J Public Health 1983;73:1385-8.

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