Fussy 3-month old with feeding issues diagnosed with Botulism


Botulism acquired from excavation and landscaping around infant’s home.

This article describes the case of a 3-month old girl who presented to her primary care provider with her parents with complaints of a 48-hour history of decreased appetite and fussiness. The mother told the doctor that she had tried to feed her baby with both bottle and breast. However, every time she would make a gurgling sound and stop feeding. She further stated that the infant has been constipated for a “few days” and hasn’t had a wet diaper in 8 hours. In addition, her last bowel movement was 4 days ago. The child was tentatively diagnosed with botulism.

The baby girl was born full term via a cesarean delivery. Her post delivery course was unremarkable with an Apgar score of 9/9. In addition, all her screening tests after birth were negative. Well-child visits all the way till 2 months of age also showed a healthy, well-developed and normal newborn at the 70th and 30th percentile for length and weight. The baby had no issues with feeding before these complaints. She had no known allergies and was take no medications. Her patents’ medical history was also insignificant.

Physical examination showed that the baby girl was appropriately interacting with her parents. Her immunisations were up to date. Doctors attempted to bottle-feed the baby but she appeared uncomfortable and started making gurgling noises, ceasing feeding. Although, there was no vomiting or spitting after she was attempted to be fed. The absence of oral intake and dry diapers were a concern, despite. Doctors referred her to the regional medical centre for further evaluation and workup.

She presented to the emergency department shortly after leaving the primary care provider’s office.

She was initially evaluated by a paediatric resident in the emergency department. Tests showed a decrease in blood sugar levels of 49 mg/dL. The infant was able to tolerate an oral electrolyte replacement and apple juice which helped bring her glucose level up to 69 mg/dL. Routine laboratory tests including a urine test for culture and toxicology showed normal results. Lumbar spinal puncture was also normal. Doctors further advised a computed tomography of the head without contrast which also showed normal findings. Examination of the abdomen showed nonspecific bowel gas patterns and dilated loops of bowel, in addition to air in the rectum. Neurological examination was significant for minimal gag, hypotonia with poor sucking and mild head lag.

Based on the findings, doctors diagnosed the patient with botulism, admitting her to the regular paediatric floor. Neurology evaluated the patient shortly after admission. Doctors initiated tube feeding after inserting a nasogastric tube. The baby’s stool sample was obtained for and forwarded to the Centers for Disease Control and Prevention for testing. Similarly, infusion with BabyBIG was started on the 2nd day. On the 5th day, she was evaluated for speech therapy, occupational therapy and physical therapy. Doctors advised restarting oral intake with only occasional mild cough and choking noted.

The baby was discharged after 6 days with normal examinations. The patient’s tests came back negative for C Botulism but because the presentation, timing, and recovery process, she was diagnosed with Botulism. Doctors believed that she was exposed to Botulism because of excavation and landscaping around her home.


Clinical Challenge: Feeding Issues and Fussiness in a 3-Month-Old Infant https://www.clinicaladvisor.com/home/topics/pediatrics-information-center/feeding-issues-increased-fussiness-3-month-old/2/

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.


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