Neonatal tetanus

Paediatrics, Neonatal Sepsis

1. NEONATAL TETANUS Denice A. Benedict, MD 4

2. Introduction. Neonatal Tetanus is an acute spastic paralytic illness historically called LOCK JAW that is caused by the neurotoxin produced by Clostridium tetani which is a spore forming, anaerobic gram positive bacillus. It produces two exotoxins namely tetanoplasmin and tetanolysin . It is the tetanoplsmin which is neurotoxic while tetanolysin potentiate the effect of tetanus toxin

3. Epidemiology It is the major cause of mortality in unvaccinated person and newborns of unvaccinated mothers. About 1000000 million cases occur world wide with developing countries being he most affected regions In 2013 it caused 59,000 deaths

4. Etiology. Etiological agent is Clostridium tetani a motile gram +ve spore forming bacteria found in soil, dust and animal feces. It causes tetanus in both man and animals

5. Pathogenesis C. tetani usually enters the body through a wound Stays in sporuted form until anaerobic conditions are present Germinates under anaerobic conditions and begins to multiply and produce tetanospasmin Tetanospasmin spreads via blood and lymphatic system and binds to motor neurons Travels along the axons to the spinal cord Binds to sites responsible for inhibiting skeletal muscle contraction Blocks the release of inhibitory neurotransmitters (glycine and gamma-amino butyric acid across the synaptic cleft which is required to check the nerve impulses If nerve impulses cant be checked it leads to unopposed muscular contraction and spasms that are characteristic typical features of tetanus

6. Routes of entry Umbilical stump Contaminated wounds Traumatic injury from unsterilized objects Animal bite and frostbite Abscess and chronic ulceration

7. Risk factors. Puncture wounds e.g. body piercing, tattoos drug injections Compound fractures Crash injuries Burns Surgical wounds Animal bites Infected foot ulcer Inadequately immunized mothers.

8. Types 1. LOCAL TETANUS Persistent spasm of musculature at a site of primary infection (injured site) Contractions persist for weeks before subsiding its milder but can progress to generalized tetanus Affects most the cranial nerves and facial nerves 2.CEPHALIC TETANUS Primary site of infection is head injury or otitis media Associated with injury of 1 cranial nerve most common the facial nerve with features of retracted eyelid

9. 3. GENERALISED TETANUS Most Common Form (80% of cases) 1 st sign is trismus (lockjaw) due to spasm of masseter muscle and hence the common name Followed by stiffness of the neck, difficulty in swallowing, rigidity of abdominal muscles. 4. TETANUS NEONATORUM Is the form of generalized tetanus that occur in newborn infants Occurs in infants of non-immunized mothers Mostly is due to infection of un-healed umbilical stump particularly when the stump is cut with non sterile instrument Very Poor prognosis

10. Cont.…. This has faster acting progression with the incubation period normally only four days A rare condition in developed countries but elsewhere accounts for15% neonatal deaths If the mother is immunized against tetanus this can help to give the child passive immunity

11. Clinical features. Febrile, Irritability Heavy sweating Trismus or lockjaw Neck muscle spasm and buccal followed by generalized spasm Dysphagia Apnea, Asphyxia, Cyanosis Risus sardonicus Tachycardia Opisthotonus, the spasm of extensor of the neck, back and legs forming a backward curvature Arrhythmia Poor sucking

12. Investigations The dx of tetanus is basically clinical with proper hx taking and examinations. There are no specific confirmatory tests Others Lumbar puncture. FBP Blood culture RBG

13. Management. There is no cure for tetanus. Rx focuses on managing complications until the effects of tetanus toxin resolve. Cleaning of the wound is essential to prevent growth of tetanus spores Give Tetanus immunoglobulin (TIG) as soon as possible even if he/she has been vaccinated. TIG contains antibodies which kill C. tetani, if injected provide immediate short term protection against tetanus.

14. Cont . Control of spasm and rigidity Eradication of residual clostridia infection Optimal nursing and supportive care Immunizing survivors prior to discharge

15. C ont . Give Diazepam 0.1-0.2mg/kg 4hrly or give Phenobarbitone (1mg/kg)+ diazepam (0.5mg/kg) 6hrly Neuromuscular blocking agents; Vecuronium, Pancuronium + Mechanical ventilation Thoroughly debridement Antibiotics; Give Penicillin, Metronidazole OR if allergic to Penicillin switch to Tetracycline NG Tube for neonates and encourage Expressed Breast Feeding.

16. Complications. Laryngospasm Fracture of spine and long bones Nosocomial Infections eg septicemia Aspiration pneumonia Disability Pulmonary embolism Tetanic seizures Acute renal failure

17. Ddx Meningitis Encephalitis Pharyngitis Rabies

18. Prognosis Poor Prognostic factors Inadequate nursing care Short incubation period Short time of onset Asphyxia Good Prognostic factors Neonate able to feed Response to the Rx and medication given Close monitoring with nursing staff

19. Prevention TT= 2 Doses for pregnant women DPT at 6, 10 or 14 weeks after birth DPT booster after 18 months DT at 5 yrs. TT boosters at every 10 yrs. Prompt cleaning of wounds with hydrogen peroxide Tetanus is completely preventable by active tetanus immunization Cutting of umbilical stump with sterile instrument Observing simple cleanliness at birth and hygienic handling and care of umbilical cord

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