PAEDIATRICS AND

PAEDIATRIC NURSING
UNIT: 3.2.10 NEONATAL TETANUS

NEONATAL TETANUS
 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

NEONATAL TETANUS
 INTRODUCTION
• 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.

NEONATAL TETANUS
 LEARNING OBJECTIVES

• By the end of the lesson the student should be able to:

• Define Tetanus
• Describe the etiology/predisposing factors
• Describe the pathophysiology

NEONATAL TETANUS
 LEARNING OBJECTIVES

• State the signs and symptom

• Describe the treatment/management
• Describe the prevention of Neonatal Tetanus
• State the complications of Neonatal Tetanus

NEONATAL TETANUS
 DEFINITION
• Tetanus is an acute notifiable condition characterized by
general increased rigidity and convulsive spasms of the
voluntary muscles
• Tetanus is a disease of the neonate which affects the
nervous system caused by clostridium tetani and is
characterized by generalized body rigidity

NEONATAL TETANUS
 ETIOLOGY

• Clostridium tetani: anaerobic gram positive bacillus

• Incubation period : is between 3 to 21 days with an
average of 8 days
• Port of entry : through the umbilical stamp

NEONATAL TETANUS
 CHARACTERISTICS OF C. TETANI
• It’s a gram-positive
• Non-encapsulated
• Motile
• Obligatively anaerobic bacillus.
• Its spores are highly resistant to disinfectants and a number
of antibiotics.
 CHARACTERISTICS OF C. TETANI
• It produces neurotoxins: tetanospasmin and tetanolysin
• It exist in vegetative and sporulated forms.
• Its found in soil and intestine and faeces of horses, sheep, cattle,
dogs, rats and manure treated soil contains large numbers of
spores.
 PREDISPOSING FACTORS

• Lack of maternal vaccination, during pregnancy as this

allows them not to protect their new-borns by passing the
antibody through the placenta
• Contamination of the stump by application of non-sterile
clay cow dung, soil or herbs on the umbilical stump
harboring the bacterium
NEONATAL TETANUS
 PREDISPOSING FACTORS

• Anaerobic condition of the umbilical stump.

• Use of contaminated razor blade to cut the umbilical cord.
• Contamination at delivery as a result of use of
contaminated environment.
• Application of Poor hygiene of the umbilical cord
NEONATAL TETANUS
 PATHOPHYSIOLOGY

• Tetanus occurs after spores or vegetative bacteria gain

access to body tissues through the umbilucus, pucture
wound and produce toxins locally.
• In neonates tetanus usually follows infection of the
umbilical stump. When the bacteria enter the body, they
remain at the site of entry..
NEONATAL TETANUS
 PATHOPHYSIOLOGY
• In the presence of anaerobic conditions, spores starts to
germinate and transform into rod shaped bacteria which
produces potent neurotoxins called tetanospasmin and
tetanolysin which cause body tissue effects of the disease.
• Tetanolysin causes lysis of RBC and tetanospasmin has affinity
for nerves or is neurotoxic affects anterior horn and brain stem.

NEONATAL TETANUS
 PATHOPHYSIOLOGY Contd....
• The toxin tetanospasmin remains inactive inside the
bacterium and only became active when it dies. The toxin
disseminate through the blood stream and lymphatic
system, however it does not enter the central nervous
system through this route as it does not cross the blood
brain barrier except at the fourth ventricle. The toxin is
taken up by the neuromuscular junction
NEONATAL TETANUS
 PATHOPHYSIOLOGY Contd....

• The neuro toxin will then attach to the ‘ganglia cells of

the anterior horn of the spinal cord, affecting the motor
neurones and eventually cranial nerves resulting into
stimulation of reflex convulsive activities and body
rigidity. The first muscles to be affected are those of the
jaws (trismus) resulting in ‘Lock jaw’ which eventually
leads to a facial expression called ‘sardonic smile’ or ‘
NEONATAL TETANUS
 PATHOPHYSIOLOGY Contd....

• ’ or ‘risus sardonicus’. This is followed by the muscles

of respiration resulting into difficulties in breathing
(dyspnoea). Eventually, all the muscles of the body are
affected leading to generalized body rigidity.

NEONATAL TETANUS
 PATHOPHYSIOLOGY

• Generalised convulsions may occur due to action of

toxins on brain
• Because of effect of toxins on SNS-hypertension,
tachycardia, bradycardia, hypotension and diaphoresis
• Urinary retention due to spasms
NEONATAL TETANUS
NEONATAL TETANUS
 SIGNS AND SYMPTOMS

• Irritability and restlessness due to the effect of toxins on

the nervous system(early signs)
• Trismus- failure to open the mouth due to spasm of
muscles of the jaw. (locked jaw)
• There is stiffness of the neck due to muscle spasms
(Tetany). This is a symptom of diagnostic importance.
NEONATAL TETANUS
 SIGNS AND SYMPTOMS

• Painful muscle contractions or convulsions seen

periodically induced by external stimuli(auditory or
tactile)
• Opisthotonous- the head, neck and spine are arched
backwards due to contractions of strong muscles of the
body, back and spine.
NEONATAL TETANUS
 MUSCLE RIGIDITY

NEONATAL TETANUS
 SIGNS AND SYMPTOMS
• Risus sardonicus- a fixed expression due to spasms of facial
muscles giving an appearance of an expression of a smile and
a cry at the same time (Devil’s smile).
• Labour respirations due to laryngospasm resulting in
cyanosis.
• Raised temperature up to 40 degrees Celsius since it is a
bacterial infection
NEONATAL TETANUS
 SIGNS AND SYMPTOMS
• Failure to suck due to spasms of the jaw.
• Retention of urine due to spasms of the bladder
• Convulsion which are usually triggered by a stimulus such as
touch, light or moving object
• Photophobia
• Local signs of umbilical infection
NEONATAL TETANUS
 MEDICAL MANAGMENT
Objectives
• To control the spasms
• To promote quick recovery
• To prevent complications
• To prevent spread of infection
• To help the patient return to his normal state as quickly as possible

NEONATAL TETANUS
 MEDICAL MANAGMENT

INVESTIGATIONS
• History taking & clinical features: The diagnosis is
based on the presentation of tetanus symptoms. For
example, history of application of cow dung on the
babies umbilical cord by the mother to promote stump
healing.
•.
NEONATAL TETANUS
 MEDICAL MANAGMENT

• Physical examination: The presence of ‘lockjaw’, risus

sadornicus’ and ‘opisthotonos’ suggests the existence of
neonatal tetanus.
• Wound swab for microscopic culture & sensitivity: In
only about 30% of cases the Clostridium tetani can be
isolated. May also be isolated from patients without tetanus.
NEONATAL TETANUS
 MEDICAL MANAGMENT

• Laboratory identification of C. tetani can also be

demonstrated by production of tetanospasmin.
• Diagnosis does not only depend on isolation of the bacteria.
• The "spatula test" is a clinical test for tetanus that involves
touching the posterior pharyngeal wall with a sterile, soft-
tipped instrument, and observing the effect.
NEONATAL TETANUS
 MEDICAL MANAGMENT

• A positive test result is the involuntary contraction of the

jaw (biting down on the "spatula"), and a negative test
result would normally be a gag reflex attempting to expel
the foreign object.
• The spatula test had a high specificity (zero false-positive
test results.
NEONATAL TETANUS
 MANAGEMENT
• Treatment ( mild cases)
- Anti tetanus immunoglobulin 250iu start, (250iu stat +500iu=750 iu)
1st day then 500 unit IM the next 2 days to neutralize the toxins so
that there is less harm done to the motor neuron (increase clinical
improvement from 4%-35%)
- Anti convulsants such as valium 2mg/kg until convulsions and
spasms are controlled Or chlorpromazine 1- 2mg/kg 4-6 hourly
 MANAGEMENT
• Metronidazole 7.5mg/kg bwt iv for 10 days
• Severe cases
 Admission to intensive care
 Diazepam as a continuous IV infusion
 Magnesium as a continuous IV infusion to prevent muscle spasms
 Remove tetanospasmin by debriding the wound
 MANAGEMENT
• Antibiotics may also be given such as benzyl penicillin
50,000iu/kgbwt QID or erythromycin 62.5 or 125mg QID
with amoxyl
• In case of respiratory imbalance, artificial ventilation can be
initiated.
• Tracheostomy and mechanical ventilation for 3 to 4 weeks
• Oxygen therapy to prevent hypoxia
 NURSING CARE

• Aims
• To maintain and sustain the airway.
• To maintain a clear and patent airway.
• To prevent infection.
• To reassure the mother.
NEONATAL TETANUS
 ENVIRONMENT

• Baby will be nursed in special baby care unit if possible

in an incubator or a crib to prevent falls
• The environment should be quiet to minimise stimulation
which can lead to convulsions
• The room should be semi darkened to prevent
photophobia
NEONATAL TETANUS
 ENVIRONMENT

• 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.
• Oxygen therapy equipment should be at hand in case the
child experiences respiratory failure
NEONATAL TETANUS
 ENVIRONMENT

• Suctioning apparatus should also be at ready in order to

ensure that the airway is kept patent and free of
secretions

NEONATAL TETANUS
 MAINTENANCE OF PATENT AIRWAY
AND ADEQUATE BREATHING
• Keep airway patent by correct positioning and suctioning of
oral secretions.
• If laryngospasms persist inform pediatrician who may order
endotracheal intubation
• Use mechanical ventilation as ordered to increase
oxygenation
NEONATAL TETANUS
 MAINTENANCE OF PATENT AIRWAY
AND ADEQUATE BREATHING
• Administer supplemental oxygen if oxygen saturation is
below 90% to improve tissue oxygenation

NEONATAL TETANUS
 PSYCHOLOGICAL CARE

• Mother will be distressed psychologically because of the

condition of the child so 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
NEONATAL TETANUS
 OBSERVATIONS

• Observe the general condition of the child in order to

determine whether the child is responding to medical care
or not.
• Vital signs such as temperature pulse and respirations are
taken to monitor onset of complications and detect
further deviations.
NEONATAL TETANUS
 OBSERVATIONS

• 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

NEONATAL TETANUS
 OBSERVATIONS

• Observe for cyanosis, dyspnea and respiratory distress

and administer oxygen if these signs are present.
• Observe signs of dehydration such as sunken fontanel,
concentrated urine, skin turgor

NEONATAL TETANUS
 REST

• Minimise interference during the nursing care

• Plan the care around times when treatment is given to
avoid frequent handling of the child.
• Observe the child all the time in case of convulsions so
that emergency care is initiated.

NEONATAL TETANUS
 NUTRITION

• The intial phase the child is unable to feed by mouth due

to lock jaw, NGT will be inserted and expressed breast
milk will be given.
• Give 3500-4000 calories and 150g of proteins daily in
liquid form direct to the stomach (gastrostomy)

NEONATAL TETANUS
 NUTRITION

• A high caloric diet should be maintained as there is

muscle increased activity.
• 5% dextrose is also give parentally for energy and
prevention of dehydration
• As condition improves oral feeding will be initiated
NEONATAL TETANUS
INFECTION PREVENTION/ HYGIENE

• Daily eye swabbing with normal saline to prevent eye damage.

• Cord care with cooled boiled water especially in newborn to
minimise or prevent infection
• Oral care when necessary to keep to clean and prevent oral sepsis as
the mouth may be open due to contraction of the muscles of the
face.
NEONATAL TETANUS
INFECTION PREVENTION/ HYGIENE

• Daily top and tail is done to reomove dirty and promote

patients comfort
• Use aseptic technique for all invasive procedures to
prevent introduction of micro-organisms

NEONATAL TETANUS
 PREVENTION

• Immunisation of child bearing women at first contact,

second dose after 4 weeks, 3 rd dose after 6 months, then
after 1 year and 5 dose after another year.
• Educate mothers on how to clean the umbilical cord
using cooled boiled water and not to be applying anything
on the stump to dry it.
NEONATAL TETANUS
 PREVENTION

• Teach the mother that children are given 3 doses of

DPT,HEP, HIB at 6 weeks, 10 weeks and 14 weeks to give
them immunity against tetanus.
• Use sterilised equipment when conducting deliveries to kill
clostridium tetani.

NEONATAL TETANUS
 PREVENTION
• Involve TBAs, update them on new trends in midwifery; how to
conduct deliveries.
• Strengthen infection prevention practices in the curriculum of TBAs
especially hand washing.
• Strengthening Domiciliary visits to check on the environment and
how mother is caring for the newborn, to identify problems early and
treat them.
NEONATAL TETANUS
 PREVENTION

• Provide well equipped delivery kits to TBAs so that they

do not use things/equipment that are not sterile or
proper for delivery.
• Ensure a clean environment by antenatal mothers- i.e
ensure their room is clean, prepare a clean tent, sack or
chitenge on which to deliver
NEONATAL TETANUS
 PREVENTION

• Using of sterile scissors or blade when cutting the

umbilical cord
• Incomplete immunised children with wound should be
given tetanus toxoid that is;

NEONATAL TETANUS
 PREVENTION

• Tetanus prophylaxisis (active immunisation)

• Vaccination with tetanus toxiod
• Booster every ten years
• Booster dose with each puncture wound

NEONATAL TETANUS
 COMPLICATIONS
• Broken bones/ fractures: The severity of spasms may cause the
spine and other bones to break.
• Disability: Treatment for tetanus typically involves the use of
powerful sedatives to control muscle spasms. Prolonged
immobility due to the use of these drugs can lead to permanent
disability. In infants, tetanus infections may cause lasting brain
damage, ranging from minor mental deficits to cerebral palsy.
NEONATAL TETANUS
 COMPLICATIONS
• Aspiration pneumonia - if secretions or contents of the
stomach are inhaled, which may sometimes happen in patients
with tetanus, a lower respiratory tract infection can develop,
leading to pneumonia.
• Laryngospasm - the larynx (voice box) goes into a spasm
which can last up to a minute and cause breathing difficulties.
In severe cases the patient can suffocate.
NEONATAL TETANUS
 COMPLICATIONS

• Pulmonary embolism - a blood vessel in the lung can

become blocked and affect breathing and circulation. The
patient will urgently need oxygen therapy
• Tetanic seizures - if infection spreads to the brain the
patient can have epileptic-like fits (seizures).

NEONATAL TETANUS
 COMPLICATIONS

• Severe kidney failure (acute renal failure) - severe muscle

spasms can result in the destruction of skeletal muscle
which can cause myoblobin - a muscle protein - leaking
into the urine, thereby, causing acute renal failure (severe
kidney failure).

NEONATAL TETANUS
 SUMMARY OF COMPLICATIONS
• Fractures due to intense muscle spasms
• Disability due to prolonged use of strong sedatives
• Brain damage due to spasms leading to inadequate oxygen
• Cerebral palsy
• Cardiac arrest
• pneumonia

NEONATAL TETANUS