Neonatal tetanus is a form of tetanus that occurs only in infants born to unvaccinated mothers. It enters the body of the newborn through infection of unhealed umbilical cords which can result from poor delivery operations, unsterilized instruments, delivery outside a proper healthcare facility, inadequate postnatal care, or certain cultural practices such as application of cow faeces or soil to the umbilical cord.

It can be viewed as the inability of a newborn to suck at birth and for the first few days of life, followed by the inability to suck starting between 3 and 10 days of age, spasms, stiffness, convulsions, and death.

It is one of the leading causes of death relating to newborns in developing countries because the onset and progression in neonatal cases are faster than in non-neonatal cases.

However, neonatal tetanus is a completely preventable disease. It can be prevented by immunizing the mother before or during pregnancy or by ensuring a clean delivery, clean cutting, and proper care of the umbilical cord days after delivery. Clean delivery practices have additional benefits including the prevention of other maternal and neonatal infections in addition to tetanus.

Also, immunization of adolescent girls and women of childbearing age, appropriate training of midwives, and the proper use of antibiotics can reduce the risk of neonatal tetanus. Immunization of women with at least three doses of tetanus toxoid vaccine provides complete prevention against maternal and neonatal tetanus.

This can help prevent deaths from neonatal infections in more than 3 million infants annually.

How Does Neonatal Tetanus Manifest

Neonatal infection occurs through the umbilical cord, which can become contaminated while cutting with unsterile instruments at birth or through substances applied to the cord.

The incubation period is synonymous with the time and age at which the symptoms develop. Its symptoms in newborns start about 8 days after birth, with common signs such as:

• Irritability or continuous crying
• Poor feeding/suckling ability with difficulty in opening the mouth
• Facial muscle spasms and restlessness
• The rigidity of muscles with spasms

Neonatal tetanus generally has a poor outlook, but once these signs are noticed, it is recommended to seek medical attention.

Causes and Risk Factors Associated with Neonatal Tetanus

Neonatal tetanus is caused by the bacterium Clostridium tetani infection, but its typical risk factors include the following:

• Unvaccinated pregnant mother
• Unhygienic conditions during childbirth
• Use of unclean hands during childbirth
• Use of unsterilized instruments during childbirth
• Use of traditional methods for umbilical cord care (ash, herbs, faeces, etc.)
• Exposing newborns exposure to soil/dust
• Animals/livestock kept around the home
• Lack of access to primary healthcare
• Lack of awareness of neonatal tetanus symptoms
• Traditional practices such as circumcision

How is Neonatal Tetanus Diagnosed

Tetanus can be quite difficult to diagnose or detect so diagnosis is usually based on clinical evaluation. Most cultures obtained from tetanus patients oftentimes fail to show the presence of the bacterium.

How to Treat Neonatal Tetanus

The best form of treating neonatal tetanus is prevention rather than cure. The effective approach to tetanus treatment is to stop the toxin from reproducing at the infection site along with wound care.

Antibiotics such as Amoxicillin or metronidazole are usually given. Tetanus human immunoglobins can help to stop the circulation of toxins by neutralizing the toxins. Management of muscular spasms can be done with tranquilizers such as diazepam.

How To Prevent Neonatal Tetanus

Over the years globally, immunization against tetanus has proven to have an impact on preventing neonatal tetanus. To prevent neonatal tetanus, maternal immunization is recommended with two doses of tetanus toxoid 4 weeks apart during pregnancy for women who have never been vaccinated or have been vaccinated. The vaccination with tetanus toxoid is considered highly safe, stable, effective, and relatively inexpensive. It can be administered during pregnancy, and with safe handling, provide protective and long-lasting immunity against tetanus. The antibody response is quite slow during the first dose but improves rapidly with multiple doses. It is recommended that a third booster shot is also administered to ensure longer protection.

Also, instead of traditional substances for umbilical cord care, the use of topical anti-microbial solutions/creams leads to a dramatic improvement in reducing infections and mortality. Additionally, it also helps in controlling sepsis and other bacterial pathogens during the cord-cutting procedure.

Epidemiology of Neonatal Tetanus and Prevention

Neonatal Tetanus (NNT) is a vaccine-preventable disease of public health importance. It is still being encountered in developing countries including Nigeria. Although there are still a vast number of tetanus cases in the developed world, they are quite rare. It is a toxin-mediated disease that usually presents with the inability to suck as a newborn who has been sucking before, excessive crying or irritability, with or without fever, generalized body stiffness or rigidity, and painful muscle spasms. For most cases of neonatal tetanus, the umbilical cord is the main part where the disease enters the body. Infected circumcision and ear piercing are other known sources of infection.

Neonatal tetanus happens from unhygienic delivery practices and some harmful traditional cord care practices which include cutting the cord with unsterilized instruments such as a razor blade, shea butter application, methanol-containing balms, and animal faeces to the umbilical cord. A hot compress is also used on the umbilical cord in some cases.

Most births in developing countries occur outside proper health facilities. The majority of the affected babies in Nigeria are delivered either at home or in faith (mission) based homes, with untrained or poorly trained traditional birth attendants as only 43% of deliveries are attended by skilled birth attendants. The case-fatality rate from tetanus in poor statistics areas can be close to 100% but can be reduced to 50% if access to basic medical care with experienced staff and appropriate facilities is available.

In 1988, the World Health Assembly passed a resolution to eliminate neonatal tetanus by the year 2000 (a disease that killed an estimated 800,000 neonates per year, causing 6 – 7 deaths per 1000 live births. By the end of 1999, 57 countries (mainly in Asia and Africa) were still underachieving the desired target. Then, the Maternal and Neonatal Tetanus Elimination Initiative was launched by The World Health Organization and its partners; United Nations Children’s Fund (UNICEF) and the UN Population Fund.

Globally, neonatal tetanus now accounts for about 1% of neonatal deaths, a decline from 14% in 1993 while in Nigeria, it accounts for about 20% of neonatal death. Efforts aimed at worldwide neonatal tetanus elimination have not yielded the desired result. One major strategy developed by the World Health Organization (WHO) and its partners aimed at achieving this goal is to improve vaccination among females before or during pregnancy and promote clean delivery using the Maternal and Neonatal Tetanus Elimination (MNTE) initiative. This has led to the vaccination of more than 900 million women of childbearing against tetanus.

Only 12 countries have not yet attained the Maternal and Neonatal Tetanus Elimination (MNTE) status as of July 2019, with Nigeria being one of these twelve countries because neonatal tetanus cases are still seen in our health facilities, though the numbers have reduced, possibly from under-reporting. Nigeria under-reports neonatal cases with only about 5% of its cases reported to the appropriate health bodies.

Although the incidence of tetanus is declining globally, Neonatal Tetanus is still a major public health problem in developing countries like Nigeria, and cases are still being encountered in newborns of an unvaccinated mothers. Thus, it is important for all women who are of childbearing age to get vaccinated against tetanus.