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Pediatric Botulism Treatment & Management

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

Medical Care

In patients with botulism, supportive care, especially ventilatory support, is essential.[33]

  • Promptly initiate ventilatory support, because respiratory muscle weakness rapidly progresses and the gag reflex is frequently impaired, which predisposes patients to respiratory failure and/or aspiration. Patients need continued suctioning and may require intubation or tracheostomy.

Antitoxin (see Medication) dramatically alters the course of the disease, especially if administered within the first 24 hours.

  • As of 2010, Heptavalent antitoxin active against all 7 types of botulism toxin (A-G) has been available from the CDC for treatment for food borne and wound botulism. It is very effective and safe, and should be started as soon as possible, as longer periods of ventilation were needed if the antitoxin was started more than 12 hours after hospitalization.[14]
  • Human Botulism Immune Globulin Intravenous (BabyBig) should be administered for infant botulism. It is effective if given within 7 days of onset of symptoms. It can only be obtained from the California Department of Public Health by calling the Infant Botulism Treatment and Prevention Program (IBTPP) (Telephone #510-231-7600). It is given as an IV drip of 50 mg / kg over 1 hour and has to be reconstituted 2 hours before use in 5% sucrose and 1% albumin solutions. It is very safe and not associated with the anaphylactic reactions that were previously seen with antitoxins derived from horse serum. Without treatment with BabyBig, infants have prolonged symptoms and an increased number of complications, including longer hospitalizations, longer ICU stays and higher overall costs. Although the cost of BabyBig is $45,300 per infant, this cost is more than made up by decreased hospital costs when BabyBig is used.[12]
  • In general, antibiotic therapy to clear clostridial GI infection in infant botulism is contraindicated, because the treatment increases toxin release and worsens the condition. Antibiotics may be used to treat secondary bacterial infections, but if possible this should be done after BabyBig has been given.[13]
  • Aminoglycosides, such as gentamicin or tobramycin, may potentiate the neuromuscular blockade caused by the botulinum toxin, and therefore are contraindicated. It is recommended that aminoglycosides not be administered for the next 6 months.[13]
  • Many experts recommend antibiotic therapy after antitoxin administration in wound botulism. Penicillin G and Metronidazole are most commonly used, but Clindamycin has also been shown to be effective. Aminoglycosides, Nalidixic acid and Trimethoprim-sulfamethoxazole have not been shown to be effective against C. botulinum, and should not be used.[14]
  • Cathartics containing Magnesium should not be used.[14]

Surgical Care

In patients with wound botulism, surgical debridement of the wound is indicated to remove the source of toxin production.



Consultations with an infectious diseases specialist and a neurologist are frequently beneficial.

Consultations with the local public health and state health departments are very useful, and will often facilitate obtaining antitoxin and getting confirmatory testing done. Also, the CDC may be called directly at 770-488-7100 to obtain management advice and antitoxin. For management advice for infant botulism and for obtaining BabyBig, the IBTPP should be called at 501-231-7600.



Tube feeding may be useful if GI tract motility is intact. If motility is not intact, consider parenteral feeding.

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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