NEONATAL TETANUS_090903 ; STUDY GUIDE NOTES

STUDY NOTES

1. NEONATAL
TETANUS
CHIBA ALBERT (Snr)

2. GENERAL OBJECTIVE
At the end of disusion,students
will have a clear understanding
on neonatal tetanus.

3. SPECIFIC OBJECTIVES:
Define neonatal tetanus
Mention Aetiology
Mention Incubation period
Mention Epidemiology
State Risk factors

4. CONT…
Describe Pathophysiology
State Signs and symptoms
Discuss Management
State Complications and
preventive measures.

5. INTRODUCTION
Tetanus was derived from a Greek
word tetanos which means
“stretch”.
Common in many developing
countries.
Highest in unvaccinated children
and children born from
unvaccinated mothers

6. CONT…
It is responsible for about 14% of
neonatal deaths.
It occurs worldwide but more
common in hot, damp climate with
soil rich in organic matter.
This is particularly true with
manure treated soil, as spore are
widely distributed through faeces.

7. DEFINATION
It is an acute of the neonate
which affects the skeletal muscle
spasms and autonomic nervous
system disturbances caused by
Clostridium Tetani and is
characterized by generalized body
rigidity

8. ETIOLOGY
Caused by gram positive
anaerobic Clostridium tetani

9. INCUBATION
PERIOD
Between 3 to 21 days with an
average of 8 days
PORT OF ENTRY :- through
the umbilical stamp

10. EPIDEMEOLOGY
Developing countries

11. RISK FACTORS
Unvaccinated mother during
antenatal period.
Home delivery in unhygienic
delivery rooms.
Use of unsterile blades and cord
scissors when cutting of the
umbilical cord increase
susceptibility to tetanus

12. CONT….
Lack of aseptic techniques during
delivery of the baby.
Potentially infectious substances
applied to the umbilical stump (e.g
animal dung, mud)

13. CHARACTERISTICS OF C.
TETANI
It’s a gram-positive, non-motile and
anaerobic bacteria
It exist in vegetative and
sporulated forms.

14. CONT…
Its spores are highly resistant to
disinfectants and a number of
antibiotics.
Its found in soil and intestine and
faeces of horses, sheep, cattle, dogs,
rats and manure treated soil
contains large numbers of spores.

15. PATHOPHYSIOLOGY
Tetanus occurs after spores or
vegetative bacteria gain access to
tissues and produce toxins locally.
In neonatal tetanus usually follows
infection of the umbilical stump.

16. CONT…
In the presence of anaerobic
conditions, spores starts to
germinate.
Spores transform into rod shaped
bacteria and produces a potent
neurotoxin called Tetanospasmin
and Tetanolysin which potentiates
infections.

17. CONT….
The toxin is inactive inside the
bacteria but when it dies the toxin
become activated.

18. CONT….
The toxin disseminates through the
blood stream and lymphatic system,
however it does not enter the
central nervous system through
this route as it can not cross the
brain barrier except at the fourth
ventricle.

19. CONT…
It is taken up by the neuromuscular
junction.
The toxin cleaves membrane
protein which is involved in neuro-
exocytosis and in turns blocks
neurotransmission

20. CONT…
The toxin acts after the incubation
period of 3 to 14 days at several
sites within the central nervous
system, including motor end plate,
spinal cord and brain.

21. CONT…
The toxin interferes with release of
neurotransmitter and blocking
inhibitor impulses.
This leads to loss of reflex control
responses to afferent sensory
stimuli.
General muscle rigidity arises from
un inhibited afferent stimuli.

22. SIGNS AND SYMPTOMS
 Lock jaw :due to severe
muscular spasms which usually
starts from the jaw causing
difficulties in opening the mouth
Difficulties in feeding: due to
spasms of the muscles of the jaw
and failure of mouth to open (
Trismus)

23. CONT…
Risus sardonicus: The child
appears to have a devilish smile due
to spasms of the muscles of the
face

24. CONT…
High pitched: cry due to CNS
irritation
Episthotonus: There is aching of
the back with head retraction
Stiff neck: due to muscle spasms of
the neck and back.
Convulsion which are usually
triggered by a stimulus such as touch,
light or moving object

25. CONT….
Difficulties in breathing due to
spasms of muscles involved in
respiration.
Fever: due to antibodies reactions
Photophobia

30. MANAGEMENT
Physical examination
History taking
Blood for culture and sensitivity.
Full blood count
CSF

31. MANAGEMENT
TREATMENT ( MILD CASES)
Anti tetanus immunoglobulin 250IU
start given I.M to neutralize the
toxins.
Diazepam 1mg/kg until convulsions
and spasms are controlled
Or chlorpromazine 1- 2mg/kg

32. CONT…
X-pen 50,000 I.U IV
Gentamycin 7mg/kg IV
Metronidazole 10mg/kg IV for 10 days
Oxygen therapy
Tetanus vaccination

33. NURSING MANAGEMENT
ENVIRONMENT
Nurse the child in a quiet
environment to minimize
stimulation which can lead to
convulsions
Isolate the baby
The room should be semi darkened
to prevent photophobia

34. CONT…
Maintain a clean environment to
prevent nosocomial infection and a
dust free environment as dust can
harbour micro-organism and cause
irritation to the respiratory passage.
The child will be nursed in an
incubator or a crib to prevent falls

35. CONT…
Oxygen therapy equipment should
be at hand in case the child
experiences respiratory failure
Suctioning apparatus should also be
at ready in order to ensure that the
airway is kept patent and free of
secretions

36. OBSERVATIONS
Observe the general condition of
the child in order to determine
whether the child is responding to
medical care or not.
Vital signs are taken to monitor
onset of complications and detect
further deviations.

37. CONT…
Observe child’s tolerance of light in
order to detect presence of
photophobia
Observe the feeding pattern of the
child
Observe the frequency of
convulsions noting the time, its
duration and when it stops. Record
on the fits charts

38. CONT…
Observe for cyanosis, dyspnoea and
respiratory distress
REST
Minimize interference as you carry
out the nursing care
Plan the care around times when
treatment is given to avoid frequent
handling of the child.

39. CONT…
However I will be with the child
all the time in case of convulsions
so that I initiate emergence care.
NUTRITION
If the child is unable to feed by
mouth due to lock-jaw, NGT will
be inserted and expressed breast
milk will be given.

40. CONT…
As condition improves oral feeding
will be initiated
5% dextrose is also give parentally

41. HYGIENE
Do daily eye swabbing with normal
saline to prevent eye damage.
Cord care especially in newborn to
minimize or prevent infection.
Apply spirit and keep it dry.
Oral care when necessary to
prevent oral sepsis as the mouth
may be open due to contraction of
the muscles of the face.

42. PSYCHOLOGICAL
CARE :
Educate the parents on the
condition in order to allay anxiety
and gain their cooperation
Keep on reassuring them and allow
the mother to stay at the beside and
involve her in child care

43. COMPLICATIONS
Respiratory failure secondary to
muscle spasms, obstruction by
secretions, exhaustion and
pulmonary aspiration
Cardiac complication due to
hyperactivity of the sympathetic
nervous system with a heart rate of
over 180b/min

44. PREVENTION
Immunization with ATT to all
pregnant mothers during ANC
Immunization of all children with
DPT.
In neonates, avoid application of
non sterile soil

45. CONT…
Delivering in a clean environment.
Using of sterile scissors or blade
when cutting the umbilical cord
Incomplete immunized children
with wound should be given
tetanus toxoid