Written by Hannah Harp
Spoon Feed
There have been a few cases of confirmed infantile botulism (IB) treated only on an outpatient basis in the United States in the past 50 years.
Summary
This study characterizes outpatient cases of IB in the U.S. between 1976 and 2021, revealing that outpatient cases are rare (0.4% of total IB cases) but under-recognized due to mild symptoms that do not necessitate hospitalization. Among 17 identified outpatient cases, the median age of onset was 20 weeks, with constipation as the most frequent symptom (94%) and cranial nerve palsy signs present in most patients. Diagnosis typically took longer than for hospitalized cases. This study emphasizes the importance of clinical vigilance for IB in infants presenting with constipation, weak suck, and poor feeding, even if symptoms appear mild. (AI generated)
You better believe it, honey
IB is rare enough that many of us never see a case during our careers. But did you know that there are cases of IB that are mild enough that they can be treated on an outpatient basis? In fact, there have been 17 such cases in the U.S. documented in the past 45 years. These babies presented with constipation (94%), decreased head control (81%), generalized weakness (75%), and a spate of other flaccid paralysis symptoms. Surprisingly, two of these babies had respiratory difficulties and weren’t hospitalized. Unsurprisingly, time to diagnosis was longer for the babies with milder disease (9.5 days vs. 3 days), and those with milder symptoms had a higher median age (20 weeks). Only one of the babies had been exposed to honey, a good reminder that most cases of IB come from ingestion of spores on dirt particles rather than honey exposure.
A successful outpatient case of IB would require an astute clinician, but it would also require:
- Speedy access to a laboratory that can test for botulinum neurotoxin.
- Urgent contact with the state health department,
- who could then relay the message to the IBTPP (IB Treatment and Prevention Program),
- who would need to approve and get BIG-IV…
- into the hands of an infusion center that would agree to treat an infant with confirmed IB as an outpatient.
- Oh…and insurance would have to cover it.
Phew! As for me, if IB ever starts creeping up my differential, I can’t imagine not sending the baby off for further evaluation and monitoring.
Another Spoonful
Don’t miss this recent review of botulism to dig deeper on diagnosis and treatment.
Editor’s note: To the few, the proud, the 17 audacious pediatricians who treated IB as an outpatient…wow, that is next level! Agree with Dr. Harp. I’m never mad when any child is referred to the PED – even the ones that don’t need to be there – but especially a baby with suspected IB! Who’s going to be cranky about seeing a once-in-a-lifetime patient like that? ~Clay Smith
Source
Outpatient Infant Botulism in the United States, 1976-2021. J Pediatr. 2024 Oct 18;276:114365. doi: 10.1016/j.jpeds.2024.114365. Epub ahead of print. PMID: 39428092
