On this page
Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL/ADMISSION to Hospital (H/RR with neonatal care) for ALL suspected cases of neonatal tetanus.
Red flags
- Neonate unable to suck after feeding normally for first few days.
- Generalized stiffness or spasms.
- History of unclean cord care or unimmunized mother.
Signs and symptoms
- Onset typically 3-14 days after birth.
- History of normal behaviour for first few days of life, followed by:
- - Irritability.
- - Difficulty sucking and feeding (due to trismus/jaw stiffness).
- - Excessive crying.
- - Generalized muscle rigidity.
- - Spasms (often triggered by handling, noise).
- - Opisthotonus (arching of back).
- - Risus sardonicus (grimace).
- - Apnea / Respiratory distress during spasms.
Risk factors
- Unimmunized or inadequately immunized mother (lack of passive immunity transfer).
- Unclean delivery practices.
- Cutting umbilical cord with unsterile instruments.
- Application of non-sterile substances (e.g., cow dung, mud, herbs) to the umbilical stump.
- Home delivery without skilled attendant.
Diagnosis
Clinical assessment
Diagnosis based on characteristic clinical presentation in a neonate (difficulty feeding, rigidity, spasms) typically starting after day 3 of life, often with history of unhygienic cord care.
Differential diagnosis
- Neonatal sepsis/meningitis.
- Hypocalcemia.
- Hypoglycemia.
- Birth asphyxia / Hypoxic-ischemic encephalopathy.
- Kernicterus.
- Strychnine poisoning (rare).
Investigations
- Clinical diagnosis primary.
- Investigations often aimed at ruling out other causes (e.g., blood glucose, calcium, sepsis workup including LP if meningitis suspected).
Diagnostic criteria
Clinical diagnosis: An infant who was normal at birth, fed normally for >=2 days, then between day 3-28 develops inability to suck AND becomes stiff/has spasms.
Management
Non-pharmacological management
- Urgent Hospital Admission (Neonatal Unit/H/RR).
- Minimize Stimulation: Nurse in quiet, dark, warm environment.
- Airway Management: Careful positioning, suctioning PRN. Be prepared for respiratory support (oxygen, BVM, intubation if needed - difficult).
- Umbilical Cord Care: Clean and debride infected umbilicus.
- Hydration & Nutrition: IV fluids initially (e.g., D5% in 0.225% Saline). Start feeding via NGT with expressed breast milk once stable and spasms controlled.
- Temperature Control: Maintain normal body temperature.
- Intensive Nursing Care: Monitor vital signs, spasms, respiratory status, feeding tolerance.
Pharmacological treatment
- Neutralize Unbound Toxin:
- - Human Tetanus Immunoglobulin (TIG): 500 IU IM single dose (split into >=2 sites, away from DPT site). (LOC: H)
- Eliminate Bacteria:
- - Metronidazole: IV/PO. Loading dose 15mg/kg, then Maintenance: <4wks: 7.5mg/kg Q12H; >4wks: 7.5mg/kg Q8H, for 10-14 days. (LOC: H)
- - Alternative: Benzylpenicillin 100,000 IU/kg IV Q12H for 10-14 days.
- Control Muscle Spasms (Sedation):
- - Diazepam: 0.2mg/kg slow IV OR 0.5mg/kg rectal Q1-4H PRN, titrated to control spasms. Monitor closely for respiratory depression. (LOC: H)
- - Chlorpromazine 1mg/kg PO/NGT Q8H may be added/alternative (UCG).
- - Phenobarbital sometimes used as second line for refractory spasms (specialist).
- Active Immunization: Give first dose of DPT-HepB-Hib (Pentavalent) vaccine.
Monitoring
Continuous close monitoring of vital signs, respiratory effort, frequency/severity of spasms, feeding tolerance, hydration, temperature.
Complications
- Respiratory failure / Apnea.
- Aspiration pneumonia.
- Laryngospasm.
- Sepsis.
- Umbilical infection.
- Fractures (rare).
- Long-term neurological sequelae (in survivors).
- High mortality rate.
Prevention
- Maternal Tetanus Toxoid Immunization: Ensure all pregnant women receive adequate TT doses during ANC.
- Clean Delivery Practices: Skilled birth attendance, clean environment.
- Clean Cord Care: Use sterile instrument to cut cord, keep stump clean and dry (WHO recommends dry cord care or topical Chlorhexidine in some settings). Avoid applying harmful substances.
- Routine infant immunization (DPT/Pentavalent).
Patient education
- (To Mother/Family):
- Explanation of serious infection, cause (cord contamination).
- Need for urgent hospitalization and intensive care.
- Explanation of treatments (TIG, antibiotics, sedation).
- Poor prognosis but potential for recovery with intensive care.
- Importance of maternal TT vaccination in future pregnancies.
- Importance of clean delivery and cord care practices.
Uganda-specific notes
Still a significant cause of neonatal mortality, linked to maternal immunization status and delivery/cord care practices. Prevention through maternal TT and clean cord care is paramount. Management requires intensive neonatal care.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.1.8.1
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15 (Neonatal Care)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 18 (Immunization - Maternal TT)