Approach to the Critical Patient

Immediate airway management

Airway threats in neonatal tetanus

Resuscitation priorities

Minimal stimulation protocol — immediately upon recognition

Hemodynamic monitoring and autonomic targets

Consultation and escalation triggers

Immediate consultation requirements

History

Onset and presenting complaint

Age at symptom onset

Progression of symptoms

Delivery and cord history

Delivery circumstances

Maternal immunization history

Maternal risk modifiers

Conditions reducing transplacental antibody transfer

Obstetric and social context

Additional risk factors

Neonatal characteristics

Geographic context

Physical Exam

Vital signs and general appearance

Vital sign abnormalities

Preserved consciousness

Neuromotor findings

Trismus

Axial rigidity

Stimulus-provoked spasms

Umbilical and local examination

Umbilical stump inspection

Respiratory assessment

Differential Diagnosis

Life-threatening mimics

Neonatal meningitis or encephalitis

Hypoxic-ischemic encephalopathy (HIE)

Neonatal sepsis

Metabolic and toxic mimics

Hypocalcemic tetany

Hypoglycemia

Strychnine poisoning

Other neonatal spasm causes

Neonatal seizures (non-metabolic)

Neonatal abstinence syndrome

Kernicterus

Laboratory Tests

Microbiological and confirmatory testing

No confirmatory laboratory test for neonatal tetanus exists

Blood culture

Metabolic and electrolyte panel

Point-of-care glucose

Serum calcium

Comprehensive metabolic panel

Hematological assessment

Complete blood count

C-reactive protein or procalcitonin

CSF analysis

Lumbar puncture when meningitis cannot be excluded

Diagnostic Tests

Scoring Systems

Ablett classification of tetanus severity

Neonatal Tetanus Severity Score (NTSS)

MRI

Brain MRI not routinely indicated for neonatal tetanus

Spinal MRI considerations

CT

Head CT not the primary diagnostic tool for neonatal tetanus

Chest CT

Ultrasound

Point-of-care ultrasound for respiratory assessment

Cranial ultrasound

Disposition

Admission criteria

All suspected neonatal tetanus cases require ICU admission — no exceptions

ICU level care requirements

Monitoring requirements

Duration of ICU stay

Discharge criteria

Resolution of spasms without pharmacological spasm control

Neurodevelopmental assessment arranged

Transfer considerations

Transfer indications from lower-level facilities

Public health reporting

Treatment

Immediate spasm control

Benzodiazepines — first-line spasm control

Adjunctive sedation agents

Antitoxin therapy

Human tetanus immunoglobulin (hTIG) — preferred antitoxin

Equine tetanus antitoxin (eAT) — if hTIG unavailable

Antibiotic therapy

Metronidazole IV — preferred antibiotic

Penicillin G alternative if metronidazole unavailable

Wound management

Umbilical stump debridement and cleaning

Autonomic dysfunction management

Magnesium sulfate infusion

Beta-blockade for refractory tachycardia

Neuromuscular blockade and mechanical ventilation

Indications for neuromuscular blockade

Ventilation strategy

Nutrition and supportive care

Nutritional support

Immunization

Special Populations

Pregnancy

Maternal tetanus — distinct from neonatal tetanus but shares prevention strategy

Geriatric

Geriatric considerations not directly applicable to neonatal tetanus

Pediatrics

Neonatal tetanus (birth to 28 days) — primary focus of this document

Pediatric tetanus (beyond neonatal period)

Immunization schedule for recovered neonates

Background

Epidemiology

Global burden of neonatal tetanus

Risk factor prevalence

Pathophysiology

Causative organism

Mechanism of tetanospasmin

Toxin irreversibility

Therapeutic Considerations

Evidence basis for treatment strategies

Barriers to treatment in resource-limited settings

Prevention as primary therapeutic strategy

Patient Discharge Instructions

copy discharge instructions

Discharge instructions for Neonatal Tetanus

References

Guidelines and key sources

Sudarshan R, Sayo AR, Renner DR, et al. Tetanus: Recognition and Management. Lancet Infectious Diseases. 2025.

Thwaites CL, Beeching NJ, Newton CR. Maternal and Neonatal Tetanus. Lancet. 2015.

Ergonul O, Kolsuz S, Figueroa JP. Tetanus. Lancet. 2026.

Yen LM, Thwaites CL. Tetanus. Lancet. 2019.

Kanu FA, Yusuf N, Kassogue M, Ahmed B, Tohme RA. Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination - Worldwide, 2000-2020. MMWR. 2022.

Supporting references

Onyeje CK, Onyeje BT. Successful Management of Neonatal Tetanus With Autonomic Manifestations. BMC Pediatrics. 2025.

Roper MH, Vandelaer JH, Gasse FL. Maternal and Neonatal Tetanus. Lancet. 2007.

Zhou S, Malani P. What Is Tetanus? JAMA. 2026.

Yozawitz E. Neonatal Seizures. NEJM. 2023.

WHO. Maternal and Neonatal Tetanus Elimination Initiative. World Health Organization.