Neonatal Tetanus

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A  neuromuscular  toxin-mediated  illness  caused  by  the  anaerobic  spore-forming  soil  bacterium  Clostridium tetani. The disease is transmitted when spores enter open wounds (injections, cutting  the umbilical cord) or breaks in the skin. While tetanus may occur in adults, infection primarily affects  newborns.  Neonatal  tetanus  has  decreased  dramatically  in  countries  with  improved  maternal  tetanus immunization rates. Maternal and neonatal tetanus is targeted for elimination in the WHO  African Region, aiming to achieve neonatal tetanus incidence rates of less than 1 case per 1000 live  births. Incubation period is 3 to 21 days, with an average of approximately 6 days. Usually occurs  through introduction of tetanus spores via the umbilical cord during delivery through the use of an unclean  instrument  to  cut  the  cord,  or  after  delivery  by  “dressing”  the  umbilical  stump  with  substances heavily contaminated with tetanus spores.   

Clinical Diagnostic Criteria 

  • Sudden inability of a newborn to suck/feed between 2nd and 28th day after birth
  • Generalized stiffness
  • Convulsions

Laboratory Investigation 

  • Diagnosis is mainly clinical as there are no reliable laboratory tests for confirming tetanus
  • Blood counts and blood chemical findings are unremarkable.
  • Peripheral leukocytosis may be suggestive

Prevention 

  • Immunize women of reproductive age with TTCV, either during pregnancy or outside of pregnancy. This protects the mother and also her baby through the transfer of tetanus  antibodies to the fetus. 
  • Good hygienic practices when the mother is delivering a child are also important to prevent neonatal and maternal tetanus. 

To  be  protected  throughout  life,  WHO  recommends  that  an  individual  receives  6  doses  (3  primary plus 3 booster doses) of TTCV through routine immunization. 

Non-pharmacological Treatment 

  • Rigorously cleanse the umbilical stump to stop the production of toxin at the site of infection 

Pharmacological Treatment 

A:  For  children  amoxycillin-clavulanate (PO)  via  Nasal  Gastric  Tube  20–30  mg/kg/day divided 8 hourly for 7 days 

For Adults amoxycillin-clavulanate (PO) via Nasal Gastric Tube 500mg 8 hourly for 7days 

AND 

A:  metronidazole  (PO)  7.5mg/kg  for  postnatal  age  ≤7days:  Weighing  1200–2000g:  7.5  mg/kg/day(PO) given every 24 hours >2000g: 15 mg/kg/day (PO) in divided doses every 12 hours. Postnatal age >7days: 1200-2000g: 15 mg/kg/day (PO) in divided doses every  12 hours >2000g: 30 mg/kg/day (PO) in divided doses every 12 hours for 7 days 

For Adults Metronidazole 400mg (PO) 8hourly for 7days 

OR 

C:  ceftriaxone (IV)  2g  (50  mg/kg  in  pediatric  patients  older  than  1  month)  12hourly  for  7days 

For Adults ceftriaxone(IV) 2g once or in 2 divided doses for 7days 

OR  

C: cefotaxime) (IV) 2g (50 mg/kg) in pediatric patients older than 1 month 6hourly for 5days. 

For Adults Cefotaxime 2g (IV) 24hourly or 1g 12hourly for 7days 

OR  

Immunotherapy to neutralise circulating toxin  

B:  Administer  human  antitetanus  immunoglobulin  TIG,  (IM)  100–300IU/kg  stat,  with  the dose  divided  into  two  different  muscle  masses  to  the  confirmed  infected  patients  (Don’t  give vaccine to the confirmed infected patients) 

AND         

A: diazepam (PO) 0.5mg/kg 8hourly as the effective management of muscle spasm, give a sedative cocktail of ALL the following via NGT:  

AND  

A: chlorpromazine (PO) 2mg/kg 8 hourly 

AND  

B: phenobarbitone (PO) 6mg/kg 12 hourly 

Table 4.2: Guidelines for Dosage Administration** 

Time (hours)   

0 

3 

6 

9 

12 

15 

18 

21 

24 

Diazepam  

* 

* 

 

* 

 

* 

 

* 

* 

Chlorpromazine  

  

* 

  

* 

  

* 

      

Phenobarbitone  

* 

  

* 

        

* 

  

** These are general guidelines. Frequency of drug administration should be titrated vs clinical  condition 

  • Airway / respiratory control 
    • Provide mechanical ventilation
  • Provide  adequate  fluids  and  nutrition,  as  tetanus  spasms  result  in  high  metabolic demands and a catabolic state.   

Public Health Control Measures 

The WHO global target for neonatal tetanus elimination is to reduce the incidence of neonatal  tetanus to less than 1 case of neonatal tetanus (NT) per 1000 live births in every district of every  country.  To meet the target 

  • Immunize the mother and other pregnant women in the same locality as the case with at least 2 doses of tetanus toxoid. 
  • Conduct  a  supplemental  immunization  activity  for  women  of  childbearing  age  in  the locality. 
  • Improve  routine  vaccine  coverage  through  IVD  and  maternal  immunization  program activities. 
  • Educate birth attendants and women of childbearing age on the need for clean cord cutting and care. Increase the number of trained birth attendants.