Causes and risk factors
Tetanus neonatorum is caused by exposure of newborn baby to infected person, i.e., unvaccinated mother who is infected or unsterile obstetric instruments. It enters the body through open or unhealed wounds such as umbilical stump in case of newborn. A poison known as tetanospasmin is released by the bacteria. This poison is responsible for blocking nerve signals from brain to muscles thus resulting in muscle spasms, sometimes so severe that they can even tear the muscles. The risk factors for neonatal tetanus are home delivered babies, lack of sterile and antiseptic precautions at the time of delivery, inadequately vaccinated or nonimmunised mother during pregnancy.
Clinical presentation
The newborn infant presents with high fever. Tetanus neonatorum shows signs and symptoms like mild spasm affecting jaw muscles called as lockjaw. This leads to failure of newborn to suck milk from breast. The baby is unable to open his mouth. This is followed by chest, neck, back, and abdominal muscles spasms and muscle rigidity. Severe spasms can involve back causing arching of back and called as opisthotonos. When spasms affect the muscles of respiration, it leads to dyspnea [difficulty in breathing]. Prolonged muscle spasms with sudden severe painful contractions is called as tetani. This condition is so severe that it can lead to fracture and muscle tears. Additional symptoms include excessive drooling of saliva, irritability, crying, and difficulty in swallowing [dysphagia].
Investigation
Medical history by the patient and clinical examination by the doctor helps in diagnosis. Routine blood examination is done. Urine analysis is recommended.
Treatment
Treatment involves administration of antibiotics. Tetanus antitoxin [TT] is administered along with tetanus immune globulin [TIG]. Muscle relaxants and sedatives to reduce spasms may be given. Breathing is supported with oxygen and breathing machine. Recent management includes neuromuscular blockade and positive pressure ventilation with tracheotomy. Prevention is necessary which is possible by immunization. It includes active immunization of mother which includes 2 monthly injections of tetanus toxoid [TT] and aseptic cord care at birth and subsequently. If mother has not received tetanus toxoid during pregnancy, a dose of human tetanus immunoglobulin [TIG] will prevent TNN. Supportive care is given to prevent further infection such as the newborn should be provided with soothing dim light, reduced noise, and stable temperature. There must be minimum handling of the newborn; it should be kept in thermoneutral environment. Intramuscular injections should be avoided. Frequent suction of oral secretions should be done. Use of soft, nonirritant clothes is necessary. Feeding should be stopped for first 2-4 days during spasms. Gradually feeding must be started with nasogastric tube. IV fluid administration for nutrition is required. Care of umbilical stump, local wounds with debridement is necessary. The care should be taken in tertiary NICU setup.
Other Modes of treatment
The other modes of treatment can also be effective in treating Tetanus neonatorum. Homoeopathy is a science which deals with individualization and considers a person in a holistic way. This science can be helpful in combating the symptoms. Similarly, the Ayurvedic system of medicine which uses herbal medicines and synthetic derivates are also found to be effective in treating Tetanus neonatorum.
Facts and figures
There has been a significant drop in mortality rates from 80% to 36 % in past 10 years due to use of TIG.
