Botulism has been associated with damaged food cans, honey, and botox injections — but what exactly is botulism? And how dangerous is it? 

Botulism is a rare but serious illness that results from toxins produced by the Clostridium botulinum bacteria. The illness attacks the nervous system and can cause paralysis and difficulty breathing.

A recent recall of a brand of infant formula due to more than 20 infants getting sick with botulism has put a spotlight on the illness.

“Infant botulism happens when a baby ingests Clostridium botulinum spores,” says Dr. Michael Alfonzo, a pediatric emergency medicine doctor at NewYork-Presbyterian Komansky Children’s Hospital of Children’s Hospital of New York. “Those spores can germinate and the resulting bacteria can thrive in the gut. The release of the toxin is a byproduct of the bacteria.”

Health Matters spoke with Dr. Alfonzo to learn more about the different kinds of botulism, symptoms to look out for, and available treatment options.

What is botulism? Are there different kinds?

Botulism is the illness caused by the toxin released from Clostridium botulinum bacteria. There are a few different kinds, but the source is the same toxin.

The current outbreak is in infant botulism, which occurs when infants ingest the spores; from these spores, the bacteria may grow in the GI tract and releases a toxin. The immaturity of the gut in infants makes them particularly vulnerable to this bacterial growth. The older we get, the less likely our GI tract is going to be the right environment for the process to happen. This is also the reason why we recommend avoiding honey under the age of 1 because honey can carry Clostridium botulinum spores.

While infant botulism is serious, it is not a common condition, affecting less than 200 infants in the U.S. per year.

Foodborne botulism occurs when you eat food that has been contaminated with the Clostridium botulinum bacteria itself. Many of us might associate this with canned food; if it’s improperly canned at home or damaged in grocery store, it can create an environment where the bacteria grows, and we get sick from ingesting the toxin.

Wound botulism occurs when a wound gets infected with the bacteria. This is rare but most commonly seen in IV drug users.

Iatrogenic botulism is also extremely rare, but can come from excessive botulism toxin type A injections. Botox is used for cosmetic purposes, but it’s also used for other conditions, such as migraine treatment. 

Where else might people be exposed to Clostridium botulinum spores?

While we classically link it to food, botulism can also develop from environmental exposure because Clostridium botulinum lives in our soil, dust, sediment, and the agricultural environment. During construction, it can be kicked up in the dust. Overall, environmental exposure carries very low risk in typical situations. For example, infants are not going to get botulism from being pushed past a construction site in a stroller.

If someone ingests spores, will they inevitably develop botulism?

Not everybody who is exposed to Clostridium botulinum spores is going to develop botulism. Infants under 12 months old are a more vulnerable population, so they are at higher risk. We’re seeing this outbreak in infant botulism because formula is the primary component of their diet, so they will have more exposures. If the formula is contaminated, and it’s their only nutrition source, they are at much higher risk for the bacteria to take hold. But not everybody who’s ever had this formula is going to have botulism, and theoretically, somebody could have been exposed to a contaminated batch and not go on to develop symptoms.

What are the symptoms of infant botulism?

Botulism progresses gradually, so it’s not a sudden onset of symptoms. This gradual pattern helps distinguish botulism from other emergencies. These symptoms include:

• Constipation
• Weak cry
• Poor suck resulting in poor feeding
• Decreased or flatter facial expressions because of muscle paralysis
• Drooling
• Generalized weak muscle tone/floppiness
• Difficulty breathing

The life-threatening concern is paralysis of your muscles for respiration, and so it can lead to breathing difficulty until the toxin is eliminated.

How do you diagnose it?

Doctors can diagnose botulism based on evaluation of the patient and the symptoms. We would send a stool sample as confirmatory testing, but it’s not a quick test result because only a few select labs do the testing. Since it can take between 7 to 21 days for the culture to come back, we don’t wait if we recognize the symptoms. We never hold off on supportive care, including intubating, and treatment if it meets the right criteria.

How do you treat it?

Botulism is treatable. We provide supportive care to address the symptoms and give a botulinum immunoglobulin intravenously. The medication gives the body the antibodies to fight off the botulinum toxin. It does not immediately reverse paralysis, but it halts the progression within 24 hours. Recovery is gradual, but patients should see signs of improvement within days and most infants will make an eventual full recovery.

Should concerned parents have their baby tested for botulism even if they don’t have symptoms?

No, we don’t typically test infants who don’t have symptoms. But if parents are concerned, it’s helpful for them to be aware of the signs. Because it takes time for the spores to grow, infant botulism doesn’t happen immediately. Symptoms can appear anywhere from three days to a month after exposure. While some symptoms, like constipation, could be due to a number of reasons, it’s rare for a parent not to recognize that something is off. That’s when you should bring them in for evaluation and testing. And when in doubt, contact your pediatrician for guidance.       

Are there signs that food might be contaminated with Clostridium botulinum bacteria?

No, there’s no taste, smell, or color. In damaged canned goods, you might see the bulge due to the gas expansion that occurs when the bacteria grows. But it’s not like mold, which you can see. It’s worth noting the difference between mold, which is a fungal-like growth, and Clostridium botulinum, which creates the toxin. Mold is not likely to be harmful in the same way if ingested.

What can people do to protect themselves and their families from botulism?

For adults, don’t eat expired food and don’t eat food that’s possibly contaminated, including improperly prepared or stored food. It can spread in items like minced garlic that lives in oil in a jar, so properly refrigerate and store food to avoid foodborne botulism.

In terms of infant botulism, don’t ingest the currently identified formula, but before discarding it, contact the manufacturer, and see if it should be tested.

Avoid honey in all kids under 1. And if you notice construction, dirt, and sediment being kicked up in your environment, try to avoid or limit exposure.

Botulism, in general, and infant botulism are rare, so there’s no major cause for alarm. The vast majority of exposed infants never become ill. In this instance of the outbreak, it seems like there’s been good investigation to figure out the culprit and hopefully the number of cases will halt.