Neonatal tetanus is an acute infectious disease caused by the tetanus bacillus, commonly known as "tetanus on the 4th-to-6th day after birth (neonatal tetanus)" or "seventh-day convulsion (neonatal tetanus)," also referred to as "neonatal tetanus" or "locked-jaw wind." Since the founding of the People's Republic of China, the widespread promotion of sterile delivery methods has significantly reduced the incidence of this disease, but it has not yet been eradicated.

bubble_chart Etiology

Tetanus bacillus is a Gram-positive anaerobic bacterium with highly resistant spores. Boiling for 1 hour or autoclaving at 120°C for 10 minutes is required to kill them, while a phenol solution takes 10–12 hours. Iodine-containing disinfectants or ethylene oxide can also eliminate them, whereas ordinary disinfectants are ineffective. Tetanus bacilli are widely present in soil, dust, and feces, particularly in cultivated soil. When scissors, strings, or gauze contaminated with tetanus bacilli are used to cut, ligate, or dress the umbilical cord, the bacteria can enter the umbilical area. The hypoxic environment created by bandaging favors the proliferation of tetanus bacilli. The spastic toxin produced by tetanus bacilli travels along nerve trunks and lymphatics to the spinal cord and brainstem, binding to gangliosides in central nervous tissue (this seasonal toxin cannot be neutralized by antitoxin), leading to intense muscle contractions throughout the body.

bubble_chart Clinical Manifestations

The incubation period is 3 to 14 days, mostly 4 to 8 days. The shorter this period, the more severe the condition and the higher the fatality rate. The time from symptom onset to the first spasm is the pre-spasm phase. The initial symptoms include difficulty opening the mouth wide, trouble inserting the nipple, and crying. This is followed by trismus, facial muscle tension, upturned corners of the mouth, resulting in a sardonic grin. The upper limbs flex, the lower limbs extend, and opisthotonos occurs. Persistent muscle contractions are accompanied by paroxysmal tonic spasms, but consciousness remains clear. Spasms of the laryngeal and respiratory muscles can cause asphyxia and cyanosis. Spasms of the bladder and rectal sphincters may lead to urinary retention and constipation. Muscle rigidity can cause elevated body temperature. This phase is also often complicated by pneumonia and sepsis. With proper treatment, those who survive the spasm phase will see spasms gradually lessen and intervals lengthen over 1 to 4 weeks, allowing for breastfeeding. Full recovery takes 2 to 3 months.

Based on a history of unsterile delivery, onset of symptoms 3 to 14 days after birth, and the presence of typical trismus and risus sardonicus, the diagnosis can be made. In the early stages, when only irritability and difficulty feeding are present, a tongue depressor can be used to examine the oral cavity. The harder the tongue depressor is pressed, the smaller the mouth opens, which also confirms the diagnosis.

bubble_chart Treatment Measures

1. Nursing and Nutrition (1) Place the child in a quiet, dimly lit environment, avoiding unnecessary stimulation. All necessary nursing and treatments should be performed at the same time whenever possible, and intravenous medication is preferred. (2) During the initial stage with frequent spasms, fasting is temporarily required. After symptoms ease, tube feeding can be administered, but sedation should be applied before inserting the tube. Avoid excessive feeding volume to prevent vomiting, which may lead to tracheal aspiration and suffocation.
2. Antitoxin can neutralize free toxins, and the earlier it is administered, the better. Tetanus Antitoxin (TAT) 10,000–20,000 units intramuscularly; for severe cases, half the dose can be given intravenously and the other half intramuscularly. Alternatively, Tetanus Immunoglobulin (TIG) 500–3000 units intramuscularly may be used. TIG has a longer half-life than TAT and does not cause allergic reactions such as serum sickness, eliminating the need for allergy testing.
3. Common antispasmodic medications include the following:
   1. Diazepam is the first-line medication. Administer 0.3–0.5 mg/kg intravenously every 4–8 hours. It is potent and fast-acting but has a short half-life.
   2. Chlorpromazine 1–2 mg/kg intravenously, repeated every 4–8 hours.
   3. Phenobarbital sodium 5 mg/kg intramuscularly or intravenously, every 4–8 hours.
   4. Chloral hydrate 10% solution, 0.5 ml/kg via gastric tube or rectal administration, used as a temporary measure during spasms.
   5. Meprobamate, a central skeletal muscle relaxant with sedative effects. Administer 50–100 mg intramuscularly every 4–8 hours.
   Common regimen: Alternate diazepam with chlorpromazine or diazepam with phenobarbital every 4–6 hours, supplemented with phenobarbital or chloral hydrate as needed. Intravenous administration is preferred in the early stages. The goal of antispasmodic therapy is to achieve no spasms at rest and only increased muscle tone upon stimulation. As spasms lessen, extend intervals between doses or reduce dosage gradually before discontinuing.
4. Antibiotics: Penicillin 100,000–200,000 units/kg/day or cephalosporins for 7–10 days to eliminate Clostridium tetani.
5. Chinese medicinals commonly include Jade-like Vitality Powder and Five Tigers Wind-Chasing Powder with modifications, which have antispasmodic, sedative, and detoxifying effects.
6. Umbilical care: Clean with 3% hydrogen peroxide or 1:4000 potassium permanganate, apply iodine tincture followed by alcohol essence for iodine removal, and inject 3000 units of TAT around the umbilical area.

bubble_chart Prevention

1. Strictly adhere to aseptic techniques during delivery. In emergency situations, the umbilical cord scissors can be sterilized by applying 2.5% iodine tincture and allowing it to dry before use, and the ligature can also be soaked in iodine tincture before use.
2. If the umbilical cord is improperly handled, within 24 hours, the remaining umbilical cord should be cut off a section, re-ligated, rinsed with 3% hydrogen peroxide or 1:4000 potassium permanganate solution, and then coated with iodine tincture. Additionally, administer intramuscular tetanus antitoxin (TAT) 1500–3000U, or human immunoglobulin (TIG) 75–250U.