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2025 ICD-10-CM code A48.51

Infant botulism is a serious illness affecting infants, caused by Clostridium botulinum bacteria, often ingested through contaminated food or soil.

Use additional code to identify resistance to antimicrobial drugs (Z16.-).

Medical necessity for the diagnosis and treatment of infant botulism stems from the potentially life-threatening nature of the condition. Prompt diagnosis and treatment are essential to prevent respiratory failure, long-term disability, and death.

Physicians diagnosing and treating infant botulism may include pediatricians, neurologists, and infectious disease specialists. Clinical responsibilities include thorough patient history, physical examination, ordering appropriate diagnostic tests (stool culture, EMG, CSF analysis, imaging), administering botulism immune globulin, providing supportive care (respiratory support, nutritional management), and monitoring the patient's progress.Accurate documentation of symptoms, diagnostic findings, and treatment procedures is crucial for appropriate coding and billing.

In simple words: Infant botulism is a rare and serious illness that babies can get, usually from eating food or touching soil with the botulism germ. This germ makes a poison that can make babies weak and floppy, have trouble eating and breathing, and sometimes cause serious problems. Doctors can test for it and give special medicine to help babies get better.

Infant botulism is a rare but serious illness typically affecting infants between 6 weeks and 6 months of age. It is caused by the bacterium Clostridium botulinum, which is often found in soil and can contaminate food sources such as honey or corn syrup.Upon ingestion, the bacteria colonize the infant's gastrointestinal tract, producing toxins that affect neuromuscular function, leading to symptoms such as muscle weakness ("floppy baby syndrome"), weak cry, difficulty feeding, double vision, drooping eyelids, slow breathing, drooling, and potentially paralysis. Severe cases can result in respiratory failure, long-term disability, or even death. Diagnosis involves laboratory testing of stool samples to identify the bacteria and may include electromyography (EMG), cerebrospinal fluid (CSF) analysis, and brain scans. Treatment primarily involves administration of botulism immune globulin and supportive care to maintain nutrition and airway patency.

Example 1: A 3-month-old infant presents with constipation, poor feeding, and a weak cry. The infant appears floppy and has diminished gag reflex.Stool samples are positive for Clostridium botulinum, confirming infant botulism., A 5-month-old infant is brought to the ER with difficulty breathing and generalized weakness. The infant has a history of consuming honey. Diagnostic tests confirm infant botulism., A 2-month-old infant exhibits signs of lethargy, poor feeding, and weak muscle tone.After a thorough evaluation, including stool sample analysis, the diagnosis of infant botulism is made.The infant receives botulism immune globulin and supportive care.

Documentation should include the infant's symptoms (e.g., constipation, weak cry, poor feeding, muscle weakness), history of potential exposure (e.g., honey consumption, soil contact), laboratory results confirming the presence of Clostridium botulinum in stool samples, results of any additional diagnostic tests (e.g., EMG, CSF analysis, brain scans), treatment provided (e.g., botulism immune globulin administration), and the patient's response to treatment.

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