Tetanus in children - Classification, Epidemiology, Etiology, Clinical Features, Complications, Management, Prognosis and Prevention

1. Childhood Tetanus
Types, Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
And give to your relatives their due right, and to the poor and the
traveler; and do not squander in waste
Quran surah Bani-Israeel 17:26
Al- Quran

3. Case scenario
• A newborn baby 6 days of age presents with inability to feed and fits
for the last one day.
• Baby is unable to open his mouth
• Abdominal examination reveals rigidity of abdominal muscles.
• On touching the abdomen, fits are stimulated in which arms are
flexed and legs are extended with arching of back and jerky
movements of body
1. What is your most likely diagnosis ?
2. What other diseases can be suspected ?

4. Common causes of Fits in Newborn baby
• Hypoxic ischemic Encephalopathy / Birth Asphyxia
• Neonatal Meningitis
• Hypoglycemia / Hypocalcemia
• Bilirubin encephalopathy / Kernicterus
• Brain malformations / Metabolic disorder
• Tetanus neonatorum (spasms not seizures)

5. Tetanus neonatorum

6. Case scenario
• A 6 years old child from a rural area presents with fits for
the last 3 days.
• On examination, child is noticed to have frequent fits in
which trunk and legs are extended and become stiff.
• Child clenches his jaw and remains conscious during
these fits.
• He is unable to take solid food and takes liquids with
difficulty.
• What is your most likely diagnosis ?
• What other diseases can be suspected ?

7. Differential diagnosis of Fits in a Child
• Meningitis (Pyogenic Meningitis / TBM)
• Cerebral Malaria
• Febrile seizures (6 months to 5 years of age)
• Epilepsy
• Encephalopathy
• Tetanus

8. Tetanus
A bacterial disease
caused by
Clostridium tetani
and characterized by
Lockjaw, Rigidity and Muscle Spasms

9. Causative agent
Clostridium tetani
(Gram +ve anaerobic spore forming bacilli)

10. Entry of Clostridium tetani in Human body
• Source - soil, animal feces (animals are carriers)
• Transmission – Direct contact / Contaminated objects
• Route of entry –
• Newborn – Umbilicus of newborn
• Children - roadside / playground / crop-field accidents
- unclean surgical procedures
- circumcision
- ear piercing
- tooth extraction
- thorn pricks

11. Tetanus – Epidemiology and Transmission
• Usual age = Newborn, Children, Adults
• Common in unvaccinated children
• Transmission of bacteria – Clostridium tetani present in soil / on dirty
objects contaminating the Wounds / Broken skin
• Host – Newborns (if their mothers are unvaccinated)
-- Children and adults (not vaccinated against tetanus)
• INCUBATION PERIOD – 3 - 14 days

12. Pathogenesis of Tetanus
• Clostridium tetani enters the body
• Spores germinate and Clostridia produce Exotoxin
(tetanospasmin) in the wound
• Exotoxin fixes to local motor end plates and climbs
axons of motor neurons
• Exotoxin reaches anterior horn cells
• Exotoxin suppresses release of inhibitory transmitters
(GABA)
• Spasm of skeletal muscles

13. Pathogenesis of Tetanus

14. Clinical Features

15. Tetanus neonatorum
• Unable to feed
• Lockjaw
• Fever
• Stiffness of abdominal muscles
• Spasms – flexion of arms and extension of legs with
arching of back - stimulated by touch or spontaneously

16. Tetanus childhood
(any one of the following signs may be present)
• Trismus (lock jaw)
• Stiffness of abdominal muscles
• Spasms - flexion of arms and extension of legs with
arching of back - stimulated by touch, noise or sight

17. DIAGNOSIS
• DIAGNOSIS of tetanus is clinical diagnosis
• Lockjaw
• Abdominal / muscular rigidity
• Spasms stimulated by touch
• History of injury / surgical procedure / septic focus /
umbilical infection in newborn usually present

18. DIFFERENTIAL DIAGNOSIS
• Depends on clinical presentation
• Lockjaw – local inflammatory causes, gingivitis
• Abdominal rigidity – Peritonitis, appendicitis
• Limbs muscular stiffness – hypo-calcemic tetany
• Fits / Spasms – meningitis, intracranial hemorrhage

19. COMPLICATIONS
• Fever (due to increased muscle activity)
• Tongue- bite (during spasms)
• Aspiration pneumonia (inability to swallow / aspiration of
secretions)
• Apnea and hypoxia due to laryngeal spasm (can cause
death)
• Autonomic nervous system disturbances
• Muscle Rhabdomyolysis (due to sustained contractions)
• Bone Fracture (due to muscle spasms)
• Malnutrition (prolonged illness)

20. MANAGEMENT
• Tetanus antitoxin (human) – TIG – 500 units IM
• Tetanus toxoid – IM (given at a different site)
• Wound toilet – clean the source of infection
• Antibiotics – Benzyl penicillin / Metronidazole
• Sedation – Benzodiazepines / Chlorpromazine
• Muscle relaxants – Baclofen
• Nursing care – Dark room, Quiet environment, suction of airways
• Hydration and Nutrition – IV / NG fluids and feeds
• Complete muscular paralysis with artificial ventilation may be
needed in severe cases

21. Prognosis
• Tetanus Toxin already fixed to nerves is not neutralized
by anti-toxin
• Treatment is continued till spontaneous recovery occurs
in 2 – 6 weeks
• Mortality is high
• Recovered newborns may show permanent neurological
sequalae (cerebral palsy / mental handicap)

22. PREVENTION
• Tetanus toxoid (modified non-toxic tetanus toxin)
• Safe delivery – umbilical cord cut with sterile blade
-- chlorhexidine applied to umbilicus
• Appropriate wound care after injuries
• Clean surgical procedures

23. Tetanus immunization (Active immunization)
• Routine EPI doses – 6, 10 and 14 weeks (as Penta
vaccine)
• Booster doses – at 1.5 and 5 years of age
• Further doses – one dose every ten years
• Missed Immunization (Un-immunized older child)
• First dose of Tetanus toxoid (TT) – at first contact
• Second dose – 1 month after First dose
• Third dose – 6 month after Second dose

24. Tetanus prophylaxis for Newborn babies
• Tetanus toxoid – 2 doses – to pregnant mother one
month apart during pregnancy will protect the newborn
• Tetanus toxoid – 5 doses – during childbearing age will
protect all the newborns of a mother
• TT1 – at 15 years or in first pregnancy
• TT2 – one month after TT1
• TT3 – six months after TT2
• TT4 – one year after TT3
• TT5 – one year after TT4

25. Tetanus Prophylaxis after Injury or Accidents
• Wash and clean the wound, remove necrotic tissues
• Apply anti-septic medicines (Povidone-iodine)
• Active immunization – TT (Tetanus toxoid) Booster dose
(if immunized previously but no booster dose given in
last five years)
• TIG 250 IU and TT (Tetanus toxoid) – if child is un-
immunized with Tetanus toxoid before

26. Vaccination is Protection