Dr. Arun Kr. Thakur*, Dr. Shailendra Kumar**, Dr. Binod Kumar Singh***
Associate Professor, Nalanda Medical collage hospital, Patna.*, Senior Resident, Nalanda Medical College hospital, Patna.**, Assistant Professor, Nalanda Medical College hospital, Patna.***
Tetanus Neonatorum is the only vaccine preventable illness in the neonates. It can be prevented by
  1. Active immunization of mother by giving two monthly injections of tetanus toxoid.
  2. Aseptic cord core at birth &subsequently.

If mother has not received TT during pregnancy, Human tetanus immunoglobulin in a dose of 250 IU IM will prevent TNN.
General Measures
The newborn should be cared in a quiet room. Handling of the baby should be minimum. Baby should be put in thermoneutral environment. Intramuscular injections should be avoided. Oral secretions should be sucked when required. Baby temperature should be recorded frequently and controlled. Clothes used in bed should be soft and less irritant. Care should be done at tertiary NICU settings.
Nutrition, Fluid & Electrolyte
IV canula should be put in place and feeding should be stopped for first 2 to 4 days till repeated spasms stop. After 2-4 days, nasogastric feeding should be started with milk. IV line is essential not only for medication but also for providing sufficient fluid, calories and electrolytes.
Human Tetanus Immunoglobulin (TIG)
It does not dislodge the tissue bound Tetanospasmin. It simply neutralizes the circulating toxin that diffuses from wound to the circulation, so it should be administered as early as possible. It does not cross the blood brain barrier also. The dose of human TIG-250 IU/kg IV slow as a single dose is sufficient. Different studies have shown no additional benefits of intrathecal administration of TIG in TNN.
Wound Care
Local wounds, discharging ears and umbilical cord should be cleaned and debrided if necessary.
Penicillin is the antibiotic of choice as it is bactericidal for Cl. tetani. Penicillin-G 50,000 to 200,000 units/kg IV 4 divided doses for 10 days is sufficient. Associated or intercurrent infection is common in TNN. Therefore Gentamicin or Amikacin and Cefotaxime should be given intravenously Sedatives:- Diazepam 2 to 5 mg (maximum 2 mg/kg/dose) iv slow and chlorpromazine 2 mg/kg/dose-iv slow 2 to 4 hourly alternating with each other so that sedative dose is being given at every 1 to 2 hours. In intractable patients, administration of paraldehyde in a dose of 0.2 mg/kg can be given IV.

The dosages and frequency of sedatives need to be titrated by clinical observation to attain maximum sedation with minimum side effects.
Muscle Relaxants
They have limited role in the management of TNN. Muscle relaxants which may be tried are Methocarbamol - 50-75 mg/kg/day in 2 divided doses intravenously or Mephenesen - 30-120 mg/kg/dose every one hourly orally.
Tracheostomy and Assisted Ventilations
Early assisted ventilation has improved the outcome in TNN. Indications of assisted ventilation are:
  1. Frequent episodes of laryngeal spasms
  2. Apneic attacks with cyanosis
  3. Central respiratory failure
Mortality is 50-75 percent and the survivors do not have mental sequelae unless apnea is prolonged and unattended. TNN does not offer immunity to the survivors, so babies recovering from TNN should receive standard tetanus immunization. Bad prognostic parameters in TNN are:
  1. Onset within first week
  2. Period between lockjaw and onset of spasms less then 48 hrs
  3. Presence of tachycardia
  4. Increased frequency and severity of spasm especially of larynx
  5. Frequent and prolonged apnoeic episodes
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Thakur K A D, Kumar S D, Singh K B D.. Available From : Conference_abstracts/report.aspx?reportid=119
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