Case 1

A 6-month-old infant was admitted to the intensive care unit of our centre with a 2-day history of poor feeding, decreased movement of all limbs and respiratory distress. The patient was hypotonic and cold peripherally with a metabolic acidosis. Treatment for presumed sepsis was commenced. On day 4 of illness the child became unconscious and bradycardic, necessitating ventilation.

Cranial MRI was normal. Electromyography (EMG) was suggestive of Guillian–Barre syndrome but there was no improvement despite intravenous immunoglobulin therapy. Infantile botulism was queried, and a faecal sample sent for analysis to the regional Health Protection Laboratory confirmed the presence of toxin A producing Clostridium botulinum on PCR. Botulism immune globulin (BabyBIG) was given on day 16 of the illness. Improvement was notable but still slow, requiring continued ventilation for 6 weeks through a tracheostomy.

Case 2

A 2-month-old infant presented with a 5-day history of constipation, poor feeding, lethargy, poor respiratory effort and hypotonia. Within hours the child deteriorated, requiring intubation and ventilation and remained floppy, with dilated pupils despite minimal sedation. The infant was mixed breast and bottle fed and the parents reported giving a commercial brand of honey as a remedy for constipation. The cranial CT scan was normal. Clinical suspicion of botulism was raised and confirmed on day 4 of intensive care admission with faecal sample positive for C botulinum toxin type A. EMG was compatible with this clinical picture of botulism. BabyBIG was given on day 11 of illness, after which neurological and respiratory improvement was noted. …