|Year : 2016 | Volume
| Issue : 2 | Page : 106-108
Neonatal tetanus: Case series
Dharti Rajesh Patel, Haresh S Sindhal, Dipen Vasudev Patel, Somashekhar Marutirao Nimbalkar
Department of Pediatrics, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India
|Date of Web Publication||8-Apr-2016|
Dipen Vasudev Patel
Department of Pediatrics, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad - 388 325, Anand, Gujarat
Source of Support: None, Conflict of Interest: None
Neonatal tetanus occurs in developing countries, particularly those with the least developed health infrastructure. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a nonsterile instrument. World Health Organization defines it as an illness in a child who has the normal ability to suck in the first 2 days of life, but who loses the ability between 3 and 28 days of life and becomes rigid and has spasms. The overall incidence of tetanus is reducing globally and is rare in developed nations. We describe four cases of neonatal tetanus with regard to demography, clinical profile, and outcome. From them, 3 newborns were delivered at home by untrained birth attendants. All the mothers were from lower socio-economic class, illiterate and were below 25 years of age. Common symptoms were unable to feed, difficulty in respiration, episodes of spasms, and convulsions. Mortality was 50%.
Keywords: Maternal factors, neonatal tetanus, outcome, untrained birth attendants
|How to cite this article:|
Patel DR, Sindhal HS, Patel DV, Nimbalkar SM. Neonatal tetanus: Case series. J Clin Neonatol 2016;5:106-8
| Introduction|| |
Neonatal tetanus is a form of generalized tetanus caused by a toxin of Clostridium tetani, Gram-positive spore-forming anaerobes. An infant who has not acquired passive immunity because the mother has never been immunized is at risk.  Neonatal tetanus is a medical emergency with high mortality (7% of total neonatal death).  A confirmed case of neonatal tetanus is defined by World Health Organization (WHO) as a child with a history of all three of the following: (1) Normal feeding and crying during the first 2 days of life; (2) onset of illness between age 3 and 28 days; and (3) inability to suckle (trismus), followed by stiffness (generalized muscle rigidity) and/or convulsions (muscle spasms).  It is a clinical diagnosis, and no laboratory investigation can confirm it. , Overall, there is more than 30% decline in tetanus related deaths from the years 2000 to 2013 in under five children, and now it contributes to around 1% of neonatal deaths.  Elimination (<1 case in 1000 live births in every district across the country) is achieved for maternal and neonatal tetanus in India by May 15, 2015. Only 500 cases/year were reported during 2013 and 2014 in India.  We summarize fours cases of neonatal tetanus as a result of the failure of the clean chain during delivery and/or no tetanus toxoid vaccination during pregnancy.
| Case Report|| |
All four neonatal cases were managed at a Tertiary Care Neonatal Intensive Care Unit of Shree Krishna Hospital attached to Pramukhswami Medical College of Karamsad, Gujarat in Western India between the years 2005 and 2013. Individual case files were retrieved and then studied. The case series received approval of the Institutional Human Research Ethics Committee of the HM Patel Center for Medical Care and Education. All the mothers were illiterate, aged <25 years and were from the poor socioeconomic background. Maternal and neonatal characteristics are given in [Table 1].
Initial symptoms were unable to feed, difficulty in respiration, episodes of convulsions and spasms. Only 1 (Case 4) had a history of fever. The diagnosis was made by the clinical presentation of the cases using WHO definition criteria. 
Case 3 was initially treated at a private hospital for 6 days, but when spasms were not controlled, was referred to this hospital. She had laryngospasms leading to respiratory acidosis (arterial blood gas on admission: pH - 7.11, PCO 2 - 122.8 mmHg, PO 2 - 77.7 mmHg, HCO 3 act - 38.3 mEq/L) requiring continuous muscle relaxation and mechanical ventilation. Case 1 and Case 2 had refractory spasms with autonomic dysfunction (episodes of bradycardia and tachycardia). Case 4 had occasional spasms. Other complications such as fractures, renal failure, sepsis, aspiration pneumonia were not seen in these cases.  Wound or infected lesions were not found over the umbilicus or skin. A tracheotomy was not required.
| Discussion|| |
Poorly served rural populations and the urban poor areas having low immunization coverage, inappropriate cord care, delivery by untrained traditional birth attendants as seen in this case series are considered the high risk for neonatal tetanus.  Due to the poor socioeconomic status, maternal illiteracy, and low community awareness, the mothers in this study failed to take complete antenatal care, and/or the tetanus toxoid injections. Nonsterile delivery practices by local "dai" (the traditional birth attendant) are major contributing factors in developing country like India. Since, last few years Accredited Social Health Activists (grass root health workers) employed across all villages in India to promote home-visits, antenatal counseling, delivery escort services, breastfeeding advice, and immunization advice have been found effective.  In addition to this incentive programs for institutional delivery, providing safe delivery kit have paved the way for maternal and neonatal tetanus elimination in India. 
Mother of Case 2 had regular antenatal care and had taken two doses of tetanus toxoid but still her baby developed tetanus. Ibinda et al. also reported cases of neonatal tetanus who had detectable levels of anti-tetanus antibodies and their mothers were immunized and were delivered in a hospital.  Multiple factors for this could be ineffective vaccine, nonresponder, failure of aseptic techniques at either delivery or postdelivery. ,
The conditions that can mimic the clinical picture of neonatal tetanus are congenital (cerebral anomalies); perinatal (complicated delivery, perinatal trauma and anoxia, or intracranial hemorrhage); and postnatal (infections and metabolic disorders).  All the cases did not have any significant clinical event until after few days of life, had normal ultrasonography of brain and lumbar puncture findings ruling out other possibilities except in Case 1 where diagnosis was only supported by clinical criteria.
Only Ablett classification of severity of tetanus predicted the outcome in this case series. Phillips and Dakar score were not able to predict the severity. These favor the findings from a study by Thwaites et al.  The in vitro susceptibilities of Clostridium tetani e metronidazole, penicillins, cephalosporins, imipenem, macrolides, and tetracycline. Use of penicillin has been recommended, but metronidazole use had been found to be associated with significantly low mortality.  This finding is similar to the current case series showing high mortality in the nonmetronidazole group. Standard therapy for autonomic dysfunction is controversial.  However, there is no apparent advantage of intrathecal immunoglobulin,  it was given in the current case series in association with an intramuscular route. Benzodiazepines (diazepam, lorazepam, and midazolam) of varying doses are the mainstay of treatment of controlling the spasms. Barbiturates and chlorpromazine are considered second line and if still spasms persist neuromuscular blocking agents (vecuronium or pancuronium), propofol infusion, and mechanical ventilation may be required.  In this case series in the two survived neonates, after achieving the control of spasms and when they started tolerating the gavage feeds, oral diazepam was started and was well tolerated. Overall control was achieved with a combination of benzodiazepines, barbiturate, fentanyl, and pancuronium in Case 3 and benzodiazepines with barbiturate were needed to control spasms of Case 4.
Although, it is very small sample size, mortality from neonatal tetanus was 50% in this study which corresponds to the average mortality from neonatal tetanus of 50%.  Even though neonatal tetanus is eliminating from developing countries, it still caused 58,000 deaths in 2010 globally.  We suggest the use of metronidazole and aggressive intensive care to combat autonomic dysfunction and spasms would increase the survival.
| Conclusion|| |
Neonatal tetanus is a rare disease, with the high mortality. As the incidence of tetanus drops, continuous emphasis on antenatal tetanus immunization and safe delivery practices should be maintained, lest there be a breach and reemergence of neonatal tetanus. Clinicians caring for neonates should be aware of the presentations of neonatal tetanus to allow them to diagnose these patients early and initiate appropriate lifesaving management.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Pan American Health Organization. Neonatal Tetanus Elimination Field Guide. 2 nd
ed. Washington, D.C. 2005.
Roper MH, Vandelaer JH, Gasse FL. Maternal and neonatal tetanus. Lancet 2007;370:1947-59.
Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al.
Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet 2015;385:430-40.
Cousins S. India is declared free of maternal and neonatal tetanus. BMJ 2015;350:h2975.
Fathima FN, Raju M, Varadharajan KS, Krishnamurthy A, Ananthkumar SR, Mony PK. Assessment of ′accredited social health activists′-a national community health volunteer scheme in Karnataka State, India. J Health Popul Nutr 2015;33:137-45.
Ibinda F, Bauni E, Kariuki SM, Fegan G, Lewa J, Mwikamba M, et al.
Incidence and risk factors for neonatal tetanus in admissions to Kilifi County Hospital, Kenya. PLoS One 2015;10:e0122606.
Thwaites CL, Yen LM, Glover C, Tuan PQ, Nga NT, Parry J, et al.
Predicting the clinical outcome of tetanus: The tetanus severity score. Trop Med Int Health 2006;11:279-87.
Ogunrin OA. Tetanus - A review of current concepts in management. Benin J Postgrad Med 2009;11:46-61.
Owusu-Darko S, Diouf K, Nour NM. Elimination of maternal and neonatal tetanus: A 21 st
-century challenge. Rev Obstet Gynecol 2012;5:e151-7.