On 6th February 2011 at 9.00 am we have received a very sick child, one week old.
The infant was continuously shaken by convulsions and spasms.
We were not able to visit the child because any time we were touching even with the stethoscope convulsions were becoming stronger.
The child was in a position of forced extension of backbone, neck and legs (position known as opistotonus). There was high fever of 390 C and the child was not able to swallow or to breastfeed.
We have urgently performed a lumbar puncture, which was negative.
The umbilical stump was infected.
We have therefore put a provisional diagnosis of neonatal tetanus.
The infant has been born at home and the mother never attended any clinic during pregnancy: therefore she has never been given the booster dose of tetanus toxoid.
We believe that this fact, together with the unclean conditions of delivery at home, may have contributed to the neonatal tetanus.
The child is not able to cry and this makes us think of a severe disease because it means that there is involvement of the respiratory muscles and the vocal cords.
We have promptly got an IV line; then we have proceeded to thorough cleaning and dressing of the wound with a lot of hydrogen peroxide.
We have given benzhil-penicillin IV to try to kill the remaining bacteria in the body.
High fevers were tackled with per rectum paracetamol (but so far the fever remains 390 C in spite of our efforts).
Because of the continuous spasms we have tried with diazepam per rectum at the dose of 2.5 mg/kg but we have not got a satisfactory response.
Therefore we have switched to continuous IV fluids with 0.3 mg/kg diazepam in it.
We have also added a dose of phenobarbitone i.m. equal to 15mg/kg once daily.
The child is running hypoglycaemia due to impossibility to feed: we are therefore giving boluses of 50% dextrose, together with slow IV infusion with 10% dextrose.
We have also inserted NGT (nasal-gastric tube) and we feed the infant with expressed breast milk. The child is kept in a couch of the nursery where we try to keep a silent and calm environment in order to reduce the frequency of spasms.
We have also put darkening curtains at the windows for the same reason.
We know we have little chance of success because the rate of death for neonatal tetanus in our setting is close to 100%.
Tetanus occurs world wide and is endemic in 90 developing countries, but its incidence varies considerably.
The most common form, neonatal (umbilicus) tetanus, kills approximately 500 000 infants each year because the mother was not immunized.
In addition, an estimated 15 000-30 000 non- immunized women world-wide die each year from maternal tetanus that results from postpartum, postabortal or postsurgical wound infection with Clostridium tetani.
The World health organization is currently engaged in a global programme for the elimination of neonatal tetanus through maternal immunization with at least two doses of antenatal tetanus toxoid.
Bro Dr Giuseppe Gaido
Source
Manson’s. Tropical diseases
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