Neonatal TETANUS (1).pptx

Neonatal TETANUS
5/10/2023 1
by Yonas

• It is an acute, spastic paralytic neurotoxin illness.
• Greek words -“tetanos and teinein”, meaning rigid and
stretched, which describe the condition of the muscles
affected by the toxin, tetano spasmin,
• Tetanus was first described in Egypt over 3000 years
ago(Edwin smith papyrus)
• causative agent: Clostridium tetani
• It produces a powerful toxin that affects the nervous
system
• Incubation period : Typically is 2–14 days, but it may be
as long as months after the injury
5/10/2023 2
by Yonas

Neonatal Tetanus
 Most infants with disease will die
 Improper umbilical cord care can lead to neonatal tetanus
 Caused by Clostridium tetani
 universally found in soil
 produces neurotoxin in dead tissue (e.g. umbilicus following non-
sterile delivery)
 disease characterized by muscle spasms (initially jaw
muscles) and generalized seizure-like activity
http://www.aap.org/en-us/about-the-aap/aap-press-room/aap-press-room-media-
center/Pages/AAP-Pressroom-Photos.aspx?nfstatus=401&nftoken=00000000-0000-0000-
0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
5/10/2023 3
by Yonas

Epidemiology
– Endemic in 90 developing countries
– Most common form – neonatal (umbilical) tetanus,
killing ~500,000 infants each year
– ~80% of deaths occur in just 12 tropical Asian &
African countries
– Additionally, 15,000 – 30,000 Unimmunized mothers
die each year from:
• maternal tetanus result from post-partum, post-abortal &
post-surgical wound infection
– Most non-neonatal cases associated with traumatic
injury by a dirty object
5/10/2023 4
by Yonas

Clinical Manifestation
– Neonatal tetanus (Tetanus Neonatrum):
• Infantile type of generalized tetanus
• Typically manifests with in 3 – 12 days of birth
• Difficulty in feeding, crying, paralysis, stiffness
to touch with or without opisthotonus are
characteristics
5/10/2023 5
by Yonas

Clinical feature
•
Opisthotonus
 is an equilibrium position that
results from unrelenting total
contraction of opposing
muscles, all of which display
the typical board like rigidity of
tetanus.
6
The smallest disturbance by sight, sound, or touch
may trigger a tetanic spasm
5/10/2023 by Yonas

Case definition
 Suspected case: Any neonatal death between
three and 28 days of age in which the cause of
death is unknown; any neonate reported as
having suffered from neonatal tetanus between
three and 28 days of age and not immunized
mother
 Confirmed case: Any neonate with normal ability
to suck and cry during the first 2 days of life and-
cannot suck normally between 3 and 28 days of
age, and becomes stiff and/ or has spasms (i.e.
jerking of the muscles)
5/10/2023 7
by Yonas

Ethiopia’s Success in Eliminating Maternal
Newborn Tetanus
5/10/2023 8
by Yonas

Umbilical Cord Care: Traditional Practices
 Ties
• Blades of grass, bark fibres, reeds or fine roots
• Problem: may be contaminated with tetanus
spores or other bacteria from soil
 Tools for cutting the cord
• Scissors, knives, broken glass, stones,
used razor blades
• Problem: transmit infection as may not be
cleaned or boiled before use
(WHO Care of Umbilical Cord 1999)
http://bushcraftoz.com/forums/showthread.
php?1467-Home-Spun-Bark-Fiber-Fishing-
Line
http://news.sky.com/home/world-news/article/15963716
5/10/2023 9
by Yonas

 Leaving the Cord Long
Reason: belief that short umbilical cords cause a small
uterus and narrow hips  difficulty with childbirth
Problem: more difficult to keep clean (contact feces and urine)
 Applying Substances to Cord
Reasons: prevent bleeding, promote separation, keep spirits away
Substances: ash, oil, butter, spice pastes,
herbs, mud, dung (cow, chicken, rat)
Problem: substances often contaminated with bacteria
***dung application very dangerous: high risk neonatal tetanus
http://www.cordbloodbankingcanada.ca/
http://www.cepolina.com/mud_argil_water.html
5/10/2023 10
by Yonas

Binding abdomen with cloth or bandages
Reasons: prevent bulging or protrusion of umbilicus
secure internal organs
protect stump from “bad air”
Problem: keeps stump moist, delays healing
increases infection risk (especially if unclean material used)
does not prevent umbilical hernias
5/10/2023 11
by Yonas

Cord Clamping: When and Why?
 Timing of cord clamping
when pulsations cease which is about 3 minutes after birth
 Why
↑ newborns red cell count and iron stores
 ↓ iron deficiency anemia (Hutton and Hassan 2007)
 early clamping traps neonatal blood in placenta
 early clamping required in emergencies (need for resuscitation)
Essential delivery care practices
for maternal and newborn
health and nutrition, 2007.
http://www.paho.org
5/10/2023 12
by Yonas

How to Cut the Umbilical Cord
 Wash hands with clean water and soap before cutting/tying cord
 Place baby on clean surface. Wear gloves if in hospital
 Use 2 ties at least 15 cm in length
Home: use clean string ties or threads Hospital: sterile ties or clamp
 Tightly apply one tie 2 cm (2 fingers) and another tie 5 cm (4 fingers)
from abdomen
Tie tightly to prevent bleeding
when the jelly shrinks and dries
(WHO Care of the Umbilical Cord 1999)
http://www.sciencephoto.com/media/290368/enlarge
5/10/2023 13
by Yonas

How to Cut the Umbilical Cord
 Cut between ties or clamps with sterile instrument
Home: sterile blade (razor blade in original packing considered sterile)
if unavailable, use knife or scissors boiled for 10 minutes
Hospital: sterile scissors or blade
 Observe for bleeding; apply additional tie between skin and tie if present
(WHO Care of the Umbilical Cord 1999)
http://collections.infocollections.org/ukedu/uk/d/Jh1436e/15.1.html
5/10/2023 14
by Yonas

http://www.operationalmedicine.org/ed2/images/Pregnancy/CordTie2.jpg
Clean ties tightly applied
Sharp knife boiled in
water x 10 minutes
Cut between ties
5/10/2023 15
by Yonas

Care of the Umbilical Cord
Wash hands before and after cord care
Leave stump uncovered
Fold diaper below stump
Put nothing on the stump
Do not bind or bandage stump
If soiled, wash with clean water and soap, dry thoroughly
5/10/2023 16
by Yonas

Does the Umbilical Cord Require
Antiseptics Applied Routinely?
No
• No difference in infection comparing topical antiseptics, dry cord care
and topical antibiotics (Zupan, 2004)
• Antiseptics delay cord separation; interrupt normal process (Novak,
1988)
Exceptions
• If harmful traditional practice used, antiseptic application required
• If infant separated from the mother in a nursery or intensive care:
antiseptic likely required (e.g. chlorhexidine, triple dye)
• Check each institutions specific policy and procedure
5/10/2023 17
by Yonas

Umbilical Cord: Normal Drying and Separation
http://newborns.stanford.edu/PhotoGallery/Cord1.html
http://newborns.stanford.edu/PhotoGallery/CordVessels1.html
Just after falling off
1 2
3 4
5/10/2023 18
by Yonas

Umbilical Cord Care: Maternal Education
 Cord will dry and shrink
 Usually falls off before the end of the second week of life
(Wilson, 1985)
 Never pull the cord or attempt to loosen it
 A small drop of blood may be present when the cord falls off
 Seek help if redness or drainage of blood or pus develops (risk
of infection and/or bleeding)
http://www.smartparentshealthykids.com/blog/?p=9
Omphalitis
5/10/2023 19
by Yonas

Five cleans to prevent infection
Clean hands of attendants
(washed with soap)
Clean surface for delivery Sterile cutting instrument
to cut cord(i.e. razor blade)
Clean string to tie cord
Cloth to wrap baby and mother
Clean cloth to wrap baby
5/10/2023 20
by Yonas

Management
 General measures: IV fluid, O2, quite dark room,
 Antibiotics: to eradicate the source of tetanus toxin
 Antitoxin (TIG or TAT): to neutralizes circulating
toxin
 Control of muscle spasms: Diazepam
 Respiratory care: gentle suctioning, tracheostomy
5/10/2023 21
by Yonas

Control of muscle spasms
 The patient should be admitted to a quiet,
darkened room where all possible auditory,
visual, tactile, or other stimuli are minimized.
 Diazepam controls spasms better and safer than
other options (The initial dose of 0.1–0.2mg/kg
every 3–6 hr given intravenously is subsequently
titrated to control the tetanic spasms);
5/10/2023 22
by Yonas

Control of muscle spasms
 Other drugs which can be used in combination
with diazepam include:
Chlorpromazine (1-5mg/kg/dose q8hr)
Phenobarbitone (loading dose 20mg/kg,
then 2.5mg/kg/dose q12hr, increased to max
5mg/kg/dose q12hr)
5/10/2023 23
by Yonas

Antitoxin therapy
 Tetanus immunoglobulin ( TIG)/human tetanus
immunoglobulin should be given intramuscularly in
a single dose (3,000 to 6,000 IU)
 If human serum immunoglobulin is unavailable,
tetanus antitoxin ( TAT) should be given,
assuming sensitivity reactions to horse serum are
negative
 The antitoxin is given intravenously and
intramuscularly (half of the dose via each route)
5/10/2023 24
by Yonas

Antimicrobial therapy
• Metronidazole (30 mg/kg/day, given at six hour
intervals; maximum 4 g/day) or
• Parenteral penicillin G (100,000 U/kg/day) is an
alternative. Treatment for 10 to 14 days is
recommended
5/10/2023 25
by Yonas

Supportive treatment
 Oxygen should be available. During early
stages, oral feeding should be avoided
because of the danger of aspiration
 A continuous intra- venous infusion can
provide fluid
5/10/2023 26
by Yonas

Respiratory care
 Meticulous nursing care is imperative
 Gentle suctioning of or pharyngeal suctions is
done although tracheotomy need not be
considered a routine procedure, it should be
done prior to the development of severe
asphyxia
5/10/2023 27
by Yonas

 Mortality is about 90%
 Bad prognostic signs include
I. Onset in the first week of life
II. Interval between lock jaw ( trismus) and onset
of muscle spasms less than 48 hrs
III. High fever
IV. Tachycardia
 Recovery is almost complete
 An attack of tetanus does not confer immunity
so active immunization following recovery is a
must
Prognosis
5/10/2023 28
by Yonas

Prevention
 Universal immunizations of pregnant
mothers between 16 and 36 weeks of
pregnancy with 2 doses of tetanus toxoid
can prevent neonatal tetanus
 The second dose should be given at least
4 weeks before the expected date of
delivery
5/10/2023 29
by Yonas

Global accelerated disease control issues
• 2005 target date for elimination of NNT.
• To reduce the incidence of case to <1: 1000 live
births per year in every district. (MNT elimination
definition)
– Increase TT coverage
– TT Campaign in high risk areas ( three rounds)
– Promote clean delivery
– Improve surveillance & reporting of neonatal
tetanus
• As the bacteria also survives in the environment,
eradication is not feasible and vaccination has to
continue after the goal.
 tetanus can not be eradicated but eliminated
30
by Yonas
5/10/2023

Neonatal TETANUS (1).pptx

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