Pediatric emergency medicine trisk 1462 1462

An unusual process that produces a sepsis-like picture is infant botulism (see
Chapter 94 Infectious Disease Emergencies ). The symptoms of this illness are
caused by neurotoxins elaborated by Clostridium botulinum. An infant with
botulism is afebrile with lethargy, a weak cry, and possibly dehydration. The
parents may note a gradual progression with this illness that is preceded by
constipation. The disease is associated with the ingestion of honey, breastfeeding,
a recent change in feeding practices, a rural environment, and/or nearby
construction. Infants are generally well perfused with normal cardiovascular
parameters (unlike sepsis), but notably hypotonic and hyporeflexic, and may have
increased secretions caused by bulbar muscle weakness. The presence of a facial
droop, ophthalmoplegia, and decreased gag reflex are consistent with botulism,
and are rare findings with sepsis. The diagnosis of infant botulism is usually made
clinically. A stool specimen that identifies toxins of C. botulinum is diagnostic,
but requires considerable time for identification. Electromyography will show
decreased muscle action potential with the “staircase” phenomenon in this
disease, but this is rarely performed.
A young baby with a ventriculoperitoneal shunt in place because of
hydrocephalus can develop serious complications that cause the baby to appear
extremely ill (see Chapter 122 Neurosurgical Emergencies ). Shunt infection
could present with fever and irritability. Abdominal tenderness may be found on
examination, as well as erythema or pus around the shunt itself. The definitive
diagnosis is made by shunt aspiration or lumbar puncture. Shunt obstruction may
result in increased intracranial pressure that causes a young infant to present with
lethargy or poor feeding. On examination, the baby may have bradycardia, apnea,
coma, opisthotonic posturing, bulging fontanel, or cranial nerve VI palsy. A CT
scan or fast MRI will demonstrate ventricle size and indicate the adequacy of
shunt function.

Child Abuse
Consider intracranial hemorrhage from child abuse in the very ill infant. (See
Chapter 87 Child Abuse/Assault and ED Clinical Pathway for

Evaluation/Treatment of Children with Physical Abuse Concerns;
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Vigorous shaking of an infant or throwing the baby against a soft surface such as
a mattress or sofa can produce subdural or subarachnoid hemorrhages that may of
sufficient volume to cause shock. The history may or may not be helpful. A report
that the infant was well and is now suddenly in critical condition raises suspicion
of abuse. The parents may note that the child had respiratory distress at home;
only a few admit to shaking the infant. On examination, the infant may appear