Pediatric emergency medicine trisk 2644 2644
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and if the diagnosis is unclear, the patient should be withdrawn from all
anticholinesterases and, if necessary, maintained on mechanical ventilation for 48
to 72 hours.
Myasthenic crises respond variably to additional anticholinesterases, and
plasmapheresis or steroid therapy may be particularly useful in this situation.
Cholinergic crises require the immediate withdrawal of all anticholinesterases.
Both myasthenic and cholinergic crises mandate admission to the hospital.
Botulism (See Also Chapter 132 Biological and Chemical Terrorism )
Infantile botulism is a cause of acute weakness in previously well infants younger
than 6 months. The illness is caused by intestinal colonization by Clostridium
botulinum, which produces a neurotoxin that impairs acetylcholine release from
the nerve terminal. Spores of C. botulinum are of ubiquitous origin, found in soil
and agricultural products. Honey has been found to be a particularly significant
reservoir. Although infant botulism occurs throughout the United States, the
incidence is highest in certain areas; approximately half the cases reported have
been from California, Utah, and Pennsylvania. The various host factors that
predispose certain infants to intestinal colonization are poorly understood.
The initial symptom of infantile botulism is usually constipation, followed
insidiously by lethargy and feeding difficulties. Physical findings at the time of
presentation are hypoactive deep tendon reflexes, decreased suck and gag, poorly
reactive pupils, bilateral ptosis, oculomotor palsies, and facial weakness.
Differential diagnosis is broad, and infants are often misdiagnosed initially. The
diagnosis is confirmed by identification of C. botulinum toxin (usually type A or
B) in the feces or isolation of the organism in stool culture, which is less
sensitive. EMG may supply more immediate information.
Affected infants require hospitalization to observe for respiratory compromise.
In one large series of 57 patients, 77% required endotracheal intubation because
of loss of protective airway reflexes, and 68% received mechanical ventilation for
some period. Nasogastric or nasojejunal feedings are usually needed as well.
Human botulism immunoglobulin, with activity against type A and B toxins, is
approved for use in infant botulism (often referred to as BabyBIG). Trials have
shown decreases in disease duration and hospital length of stay in treated infants.
Equine botulinum antitoxin has a high rate of anaphylactic reaction in infants and
is not recommended. The use of cathartics or other laxatives to reduce the amount
of C. botulinum present in the intestine has not proven beneficial. Antibiotics
such as penicillin, although widely used, have not been shown to eradicate the
