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• NEONATAL TETANUS


  Caused by a spore forming obligate, gram positive anaerobe which is present in the soil, dust,& alimentary tracts of many animals
• In developing countries approximately 1,000,000 cases of tetanus are estimated to occur worldwide each year
• Neonatal tetanus, which the WHO originally targeted for elimination by 1995, accounted for 200,000 deaths in the year 2000 (200,000-500,000 deaths /year)
• In Ethiopia ,a community based study conducted in Southern Ethiopia(1989) ,estimated MR of neonatal tetanus 6.7deaths /1000 live births ; or 40% of all neonatal deaths
• Pathogenesis


  1. In a newborn, the portal of entry of the bacilli is almost always the site at which the umbilical cord is cut

  2. After inoculation C. tetani can then transform into a vegetative rod-shaped bacterium and produces toxins called tetanospasmin & tetanolysin

  3. Through retrograde axonal transport ,it reaches the SC & brainstem where it binds tightly and irreversibly to receptors (inhibitory interneurons) & thus blocks neurotransmission by its cleaving action on membrane proteins involved in neuroexocytosis (i.e. prevents release of GABA)

  4. Lack of neural control of adrenal release of catecholamines induced by tetanospasmin produces a hyper sympathetic state that manifests as sweating, tachycardia and hypertension

  5. Recovery requires the growth of new axonal nerve terminals, thus the usual duration of clinical tetanus is four to six weeks
• Transmission


  Occurs through infection during unhygienic cutting of the umbilical cord or improper handling of the cord stump<|>It's the only vaccine preventable Ds that's not communicable
• Clinical features


  • Different types: Generalized (the most common), Localized, Cephalic (in older children)
  • Incubation Period: The time between the start of infection and the occurrence of the first symptom, usually trismus (lockjaw), ranges from 3-28 days; but usually lasts 2-14 days
  • Period of Onset: Time from 1st symptom to occurrence of spasms; important for prognosis
  • As a rule, neonatal tetanus follows a descending pattern of nerve involvement
  • Failure to suckle is often the first sign of infection , followed by difficulty swallowing, stiffness in the neck, rigidity of abdominal muscles, and a temperature rise of 2ºC – 4ºC above normal
• Management


  1. Goals: Halting the toxin production, Neutralization of the unbound toxin, Control of muscle spasms, General supportive management, Prevention

  2. A. Halting Toxin Production: Wound debridement, Antimicrobial therapy - Penicillin G (100,000IU/kg/day) for 10-14 days OR Metronidazole (30 mg/kg/day, given at six hour intervals; maximum 4 g/day)

  3. B. Neutralization of the unbound toxin: TIG- Doses as small as 500IU is sufficient, TAT- 10,000IU ,Given as ½ IM & ½ IV

  4. C. Control of Muscle Spasms: Admit to a quiet, darkened room, Sedatives- Diazepam, CPZ, Dantrolene, Neuromuscular Blocking Agents – Pancuronium, Vecuronium

  5. D. General supportive care: Use of High Calorie diet, TPN if possible or vigourous support through NGT, Frequent change of position esp. after spasms have decreased, Preparation for possible tracheostomy, Frequent Cardio respiratory monitoring, continuous suctioning, Use of antacids or H2 blockers to prevent GI hemorrhage, Nursing care to the mouth ,skin, bladder
• Complications include Aspiration pneumonia, Pneumothorax & pneumomediastinum if pt was intubated, Cardiac arrythmias, Asystole, Tongue bite, fractures, bleeding into muscles & myoglobinuria leading to Renal failure, Venous trombosis, pulmonary embolism, gastric ulcer, Paralytic Ileus & Decubitous ulcers
• Prevention


  1. Infants born to immune mothers acquire temporary immunity for about five month, if mother had completed before 2wks of delivery

  2. Vaccintion of ALL women in child bearing age is recommended

  3. Use of safe delivery practices

  4. Female education

  5. Generally, TT vaccine given will produce protective antibodies in 80-90% of the cases after the second dose,95-98% after the 3rd dose

  6. Fourth & fifth doses given will give protection for 10 & 20yrs respectively
• Prognosis: MR <10% with ICU Rx & > 75% without it
• Poor prognosis is associated with

  • IP < 7 DAYS, Period of onset < 3 days, Presence of autonomic dysfunction, Fever & frequent spasms
• Good Prognosis is associated with

  • IP>7Days ,& period of onset >3days, Localized form, Occasional spasms, absence of fever
• Mother didn't receive any vaccination, home & risky delivery, No adequate treatment given; TAT, Muscle relaxants, Dose of Crystalline should have been 400,000IU/kg/d ; use of Gentamycin good choice, Follow up should have included use of charts with V/S sheet, type of resp., frequency of contraction, urine output, if possible BP monitoring help us to guide management & peak complications early, Ideally management should be at NICU, Maternal education!!!