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Pediatric Botulism Clinical Presentation

  • Author: Muhammad Waseem, MD, MS; Chief Editor: Russell W Steele, MD  more...
Updated: Feb 23, 2015


Food-borne botulism

GI tract symptoms usually occur first, beginning 18-36 hours after ingestion (range, 2 h to 8 d) and consist of nausea, vomiting, and diarrhea followed by constipation.

Motor function symptoms follow, with the cranial nerves usually affected first. As a result, many patients present with diplopia (eg, impaired lateral gaze secondary to sixth cranial nerve involvement) and blurred vision secondary to loss of accommodation.

Many patients have dry mouth.

Finally, a rapidly progressive descending weakness or paralysis occurs. Respiratory muscle paralysis and subsequent death may occur.[8, 25] Autonomic dysfunction may lead to orthostatic hypotension, urinary retention, or constipation.

Because the toxin affects only motor and autonomic systems, sensation and mentation remain intact. Patients are usually afebrile.

Wound botulism

Except for the prerequisite history of a wound, this type of botulism presents in the same way as food-borne botulism. The diagnosis of wound botulism should be suspected in any patient with a contaminated wound that presents with neuro-muscular weakness, especially if there is bulbar involvement.[14] Also, wound botulism, as compared to the other types of botulism, is much more like to cause fever.[14]

Wound botulism is the least common type of botulism and may follow a penetrating or blunt injury. Recurrent wound botulism has been reported in injection drug users.[26]

The incubation period is 4-14 days.

Infant botulism

The incubation period is 2-4 weeks. The peak age of incidence is 2-4 months.

Constipation is the usual presenting symptom, often preceding motor function symptoms by several days or weeks.

Other signs of autonomic dysfunction usually present early as well, including those mentioned above. Gag reflexes are frequently impaired, which can lead to aspiration if the airway is unprotected.

Infants with botulism are afebrile, suck poorly, and are lethargic and listless. They often are described as being floppy.[9] Constipation is almost always the first sign of infant botulism.[27] Constipation, poor feeding, ptosis, facial and generalized weakness are considered to be the classical signs of infant botulism.[15] They develop the same descending weakness and paralysis that occurs in those with food-borne disease. About 25% of babies with infant botulism present with hypoventilation,[13] but 60% of patients with infant botulism may develop hypoventilation, and require ventilatory support as the disease progresses.[8] Awareness of the symptoms of botulism, and a high degree of clinical suspicion is needed to make a prompt diagnosis of infant botulism and prevent death.[25] Initially, infant botulism may be confused with an infection or may exist concomitantly with a respiratory infection, and if the potentially fatal diagnosis of infant botulism is not thought of, it willbemissed with dire consequences.[27] Breastfeeding may protect infants from lethal fulminant infant botulism, but exclusive breastfeeding is a risk factor for the disease, presumably because the relatively pristine bowel flora of the exclusively breastfed infant is more permissive for spore germination and toxin production.



Suspect botulism in patients with autonomic dysfunction (eg, dry mouth, blurred vision, orthostatic hypotension), cranial nerve involvement (eg, ptosis, mydriasis, decreased ocular motility, dysphagia, dysarthria),[28] and muscle weakness or flaccid paralysis.

Frequencies of the most common symptoms and signs of food-borne and wound botulism are as follows:

  • Dysphagia - 96%
  • Dry mouth - 93%
  • Diplopia - 91%
  • Dysarthria - 84%
  • Extremity weakness - 73%
  • Constipation - 73%
  • Blurred vision - 65%
  • Nausea - 64%
  • Dyspnea - 60%
  • Vomiting - 59%
  • Abdominal cramps - 42%
  • Diarrhea - 19%

Frequencies of the most common symptoms and signs of infant botulism are as follows:

  • Poor ability to suck - 96%
  • Poor head control - 96%
  • Hypotonia - 93%
  • Weak crying - 84%
  • Constipation - 83%
  • Lethargy - 71%
  • Facial weakness - 69%
  • Irritability - 61%
  • Hyporeflexia - 52%
  • Sluggish pupils - 50%
  • Respiratory difficulty - 43%

It is important to maintain a high degree of suspicion of the diagnosis of infant botulism, in any infant presenting with acute acquired hypotonia.[13] The history of constipation, hoarse cry, progressive weak suck, and symmetric descending weakness, and the physical exam findings of bilateral extremity weakness, truncal weakness, marked head lag and decreased gag reflex point very strongly to the diagnosis of infant botulism.[13] The combination of ptosis, bilateral facial weakness and poor respiratory effort should make the physician very suspicious of the diagnosis of infant botulism complicated by respiratory failure.[27]



See Pathophysiology.

Contributor Information and Disclosures

Muhammad Waseem, MD, MS Associate Professor of Emergency Medicine in Clinical Pediatrics, Associate Professor of Clinical Healthcare Policy and Research, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Muhammad Waseem, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, Society of Critical Care Medicine, Society for Simulation in Healthcare, American Medical Association

Disclosure: Nothing to disclose.


Joel R Gernsheimer, MD, FACEP Visiting Associate Professor, Department of Emergency Medicine, Attending Physician and Director of Geriatric Emergency Medicine, State University of New York Downstate Medical Center

Joel R Gernsheimer, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Geriatrics Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.


Nahed M Abdel-Haq, MD Assistant Professor, Department of Pediatrics, Wayne State University School of Medicine

Nahed M Abdel-Haq, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Daniel AC Frattarelli, MD, FAAP Senior Staff, Departments of Pediatrics and Emergency Medicine, Henry Ford Hospital

Daniel AC Frattarelli, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Clinical Pharmacology, and American Society for Clinical Pharmacology and Therapeutics

Disclosure: Nothing to disclose.

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This is a photomicrograph of Clostridium botulinum stained with Gentian violet. The bacterium, C botulinum, produces a neurotoxin which causes the rare, but serious, paralytic illness, botulism.
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