Pediatric Tetanus 

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jan 9, 2012
 

Background

Tetanus is an intoxication characterized by increased muscle tone and spasms caused by the release of the neurotoxin tetanospasmin by Clostridium tetani following inoculation into a human host. Tetanus occurs in several clinical forms, including generalized, cephalic, localized, and neonatal disease.

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Pathophysiology

Most cases of tetanus are caused by direct contamination of wounds with clostridial spores. Wounds with low oxidation-reduction potential, such as those with dead or devitalized tissue, a foreign body, or active infection, are ideal for germination of the spores and release of toxin. Infection by C tetani results in a benign appearance at the portal of entry because of its inability to evoke an inflammatory reaction (unless co-infection with other organisms develops).

Tetanospasmin, a zinc metalloprotease, is released in the wound and binds to the peripheral motor neuron terminal, enters the axon, and, via retrograde intraneuronal transport, reaches the nerve cell body in the brainstem and spinal cord. The toxin migrates across the synapse to presynaptic terminals where it blocks the release of the inhibitory neurotransmitters glycine and gamma-aminobutyric acid (GABA) by cleaving proteins crucial for the proper functioning of the synaptic vesicle release apparatus. One of these important proteins is synaptobrevin. This diminished inhibition results in an increase in the resting firing rate of the motor neuron, which is responsible for the observed muscle rigidity.

The lessened activity of reflexes limits the polysynaptic spread of impulses (a glycinergic activity). Agonists and antagonists may be recruited rather than inhibited, with consequent production of spasms. Loss of inhibition may also affect preganglionic sympathetic neurons in the lateral gray matter of the spinal cord and produce sympathetic hyperactivity and high levels of circulating catecholamines. Finally, tetanospasmin can block neurotransmitter release at the neuromuscular junction, causing weakness and paralysis.

Localized tetanus develops when only the nerves supplying the affected muscle are involved. Generalized tetanus develops when the toxin released at the wound spreads through the lymphatics and blood to multiple nerve terminals. The blood-brain barrier prevents direct entry of toxin to the CNS.

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Epidemiology

Frequency

United States

Neonatal tetanus is rare. Tetanus affects nonimmunized persons, partially immunized persons, or fully immunized individuals who do not maintain adequate immunity with periodic booster doses. The risk for development of tetanus and for the most severe form of the disease is highest in the elderly population. Most cases follow an acute injury, such as a puncture wound, a laceration, or an abrasion.

Tetanus can be acquired outdoors as well as indoors. The injury is usually trivial, and, often, no initial medical treatment is sought. Tetanus can also develop as a complication of some chronic conditions, such as decubitus ulcers, abscesses, and gangrene. Finally, it may complicate burns, frostbite, middle ear infections, surgery, abortion, childbirth, and intravenous or subcutaneous drug use. Fewer than 50 cases of tetanus per year have been recorded since 1995.[1] The infection has not been transmitted from person to person.

International

C tetani is found worldwide in soil, on inanimate objects, in animal feces, and, occasionally, in human feces. The disease is common in areas where soil is cultivated, in rural areas, in warm climates, during summer months, and among males. In countries without a comprehensive immunization program, tetanus predominantly develops in neonates and young children.[2, 3]

Mortality/Morbidity

Tetanus causes approximately 60,000 deaths annually (almost all in newborns and infants).[4]

A rating scale for the severity and the prognosis of tetanus is described below.[5]

Score one point for each of the following:

  • Incubation period less than 7 days
  • Period of onset less than 48 hours
  • Acquired from burns, surgical wounds, compound fractures, septic abortion, umbilical stump, or intramuscular injection
  • Narcotic addiction
  • Generalized tetanus
  • Temperature greater than 104°F (40°C)
  • Tachycardia greater than 120 beats per minute (>150 beats per minute in neonates)

Total score indicates the severity and the prognosis as follows:

  • Score of 0-1 indicates mild severity with less than a 10% mortality rate.
  • Score of 2-3 indicates moderate severity with a 10-20% mortality rate.
  • Score of 4 indicates severe tetanus with a 20-40% mortality rate.
  • Score of 5-6 indicates very severe tetanus with greater than a 50% mortality rate.
  • Cephalic tetanus is always severe or very severe.
  • Neonatal tetanus is always very severe.

Race

No particular racial predilection has been reported.

Sex

No gender predilection has been reported, except to the extent that males may have more soil exposure in some cultures.

Age

Neonatal tetanus is most common in countries without comprehensive vaccination programs. Otherwise, most severe disease develops in elderly people. Age predilection is mostly governed by soil exposure patterns.

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Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Specialty Editor Board

Rosemary Johann-Liang, MD  Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sonali Ray, MD, to the development and writing of this article.

References

  1. Tetanus surveillance --- United States, 2001-2008. MMWR Morb Mortal Wkly Rep. Apr 1 2011;60(12):365-9. [Medline].

  2. Fetuga BM, Ogunlesi TA, Adekanmbi FA. Risk factors for mortality in neonatal tetanus: a 15-year experience in Sagamu, Nigeria. World J Pediatr. Feb 2010;6(1):71-5. [Medline].

  3. Basu S, Paul DK, Ganguly S, Chandra PK. Risk factors for mortality from neonatal tetanus: 7 years experience in North Bengal, India. Ann Trop Paediatr. Sep 2006;26(3):233-9. [Medline].

  4. Blencowe H, Cousens S, Mullany LC, Lee AC, Kerber K, Wall S, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health. Apr 13 2011;11 Suppl 3:S11. [Medline]. [Full Text].

  5. Bleck TP, Brauner JS. Tetanus. In: Scheld WM, Whitley RJ, Durack DT. Infections of the central nervous system. 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997:629-53.

  6. Ceneviva GD, Thomas NJ, Kees-Folts D. Magnesium sulfate for control of muscle rigidity and spasms and avoidance of mechanical ventilation in pediatric tetanus. Pediatr Crit Care Med. Oct 2003;4(4):480-4. [Medline].

  7. Petitjeans F, Turc J, Coulet O, Puidupin M, Eve O, Benois A. The use of boluses of propofol for the management of severe tetanus in a child. Trop Doct. Jan 2009;39(1):52-3. [Medline].

  8. Bunch TJ, Thalji MK, Pellikka PA, Aksamit TR. Respiratory failure in tetanus: case report and review of a 25-year experience. Chest. Oct 2002;122(4):1488-92. [Medline].

  9. Lin TS, Chen LK, Lin TY, Wen SH, Chen MC, Jan RH. Autonomic dysfunction because of severe tetanus in an unvaccinated child. Pediatr Neonatol. Jun 2011;52(3):169-71. [Medline].

  10. AAP. Tetanus (Lockjaw). In: Red Book: 2009 Report of the Committee on Infectious Diseases. 28th. Elk Grove Village, IL: American Academy of Pediatrics; 2009:655-60.

  11. Adeniyi OF, Mabogunje CA, Okoromah CN, Renner JK. Neonatal tetanus: the Massey Street Children's Hospital experience. Nig Q J Hosp Med. Oct-Dec 2010;20(4):147-52. [Medline].

  12. Tetanus. In: Spector JM, Gibson TE. Atlas of Pediatrics in the Tropics and Resource-Limited Settings. Elk Grove Village, IL: American Academy of Pediatrics; 2009:241-244.

  13. Attygalle D, Rodrigo N. New trends in the management of tetanus. Expert Rev Anti Infect Ther. Feb 2004;2(1):73-84. [Medline].

  14. Aydin-Teke T, Bayhan GI, Afsarlar CE, Oz FN, Akansel AR, Tanir G. A report of two pediatric tetanus cases. Turk J Pediatr. Jul-Aug 2011;53(4):437-40. [Medline].

  15. Beltran A, Go E, Haq M, Clarke HB, Zaman M, Recco RA. A case of clinical tetanus in a patient with protective antitetanus antibody level. South Med J. Jan 2007;100(1):83. [Medline].

  16. Brook I. Current concepts in the management of Clostridium tetani infection. Expert Rev Anti Infect Ther. Jun 2008;6(3):327-36. [Medline].

  17. Campbell JI, Lam TM, Huynh TL, To SD, Tran TT, Nguyen VM, et al. Microbiologic characterization and antimicrobial susceptibility of Clostridium tetani isolated from wounds of patients with clinically diagnosed tetanus. Am J Trop Med Hyg. May 2009;80(5):827-31. [Medline].

  18. Chang SC, Wang CL. Neonatal tetanus after home delivery: report of one case. Pediatr Neonatol. Jun 2010;51(3):182-5. [Medline].

  19. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth. Sep 2001;87(3):477-87. [Medline].

  20. Esslinger P, Kistler W, Berger TM. Severe autonomic dysfunction in an 11-year-old girl with generalised tetanus. Eur J Pediatr Surg. Jun 2003;13(3):209-12. [Medline].

  21. Evaluation of elimination of neonatal tetanus in Madagascar, 2009. Wkly Epidemiol Rec. Sep 10 2010;85(37):357-61. [Medline].

  22. Farrar JJ, Yen LM, Cook T, et al. Tetanus. J Neurol Neurosurg Psychiatry. Sep 2000;69(3):292-301. [Medline].

  23. Fetuga BM, Ogunlesi TA, Adekanmbi F, Olanrewaju D. Neonatal tetanus in the babies of Nigerian mothers immunised against Tetanus. Trop Doct. Jul 2009;39(3):135-7. [Medline].

  24. Geeta MG, Krishnakumar P, Mathews L. Intrathecal tetanus immunoglobulins in the management of tetanus. Indian J Pediatr. Jan 2007;74(1):43-5. [Medline].

  25. Gibson K, Bonaventure Uwineza J, Kiviri W, Parlow J. Tetanus in developing countries: a case series and review. Can J Anaesth. Apr 2009;56(4):307-15. [Medline].

  26. Gindi M, Oravitz P, Sexton R, et al. Unreliability of reported tetanus vaccination histories. Am J Emerg Med. Mar 2005;23(2):120-2. [Medline].

  27. Giovanetti F, Pellegrino A. A case of tetanus in a child whose parents refused immunisation--Piedmont Region, Italy, 2006. Euro Surveill. Jun 2007;12(6):E070621.2. [Medline].

  28. Grunau BE, Olson J. An interesting presentation of pediatric tetanus. CJEM. Jan 2010;12(1):69-72. [Medline].

  29. Hemilä H, Koivula TT. Vitamin C for preventing and treating tetanus. Cochrane Database Syst Rev. Apr 16 2008;CD006665. [Medline].

  30. Hsu SS, Groleau G. Tetanus in the emergency department: a current review. J Emerg Med. May 2001;20(4):357-65. [Medline].

  31. Ilic M, Pejcic L, Tiodorovic B, et al. Neonatal tetanus--report of a case. Turk J Pediatr. Jul-Aug 2010;52(4):404-8. [Medline].

  32. Keegan R, Bilous J. Current issues in global immunizations. Semin Pediatr Infect Dis. Jul 2004;15(3):130-6. [Medline].

  33. Koliou M, Ioannou Y, Stylianidou G. A case of childhood tetanus in Cyprus in 2003: a rarely seen disease. Euro Surveill. 2007;12(2):E070208.5. [Medline].

  34. Konig K, Ringe H, Dorner BG, et al. Atypical Tetanus in a Completely Immunized 14-Year-Old Boy. Pediatrics. Nov 2007;120(5):e1355-e1358. [Medline].

  35. Mandell GL, Douglas RG, Bennett JE. Tetanus. In: Principles and Practice of Infectious Diseases. Vol 2. Philadelphia, Pa: Churchill Livingstone; 2005:2817-22.

  36. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. Mar 2008;22(1):117-43, vii. [Medline].

  37. Moss WJ, Halsey NA. The effects of maternal malaria and HIV-1 infection on the effort to eliminate neonatal tetanus. J Infect Dis. Aug 15 2007;196(4):502-4. [Medline].

  38. Ogunlesi TA, Okeniyi JA, Owa JA, Oyedeji GA. Neonatal tetanus at the close of the 20th century in Nigeria. Trop Doct. Jul 2007;37(3):165-7. [Medline].

  39. Onalo R, Ishiaku HM, Ogala WN. Prevalence and outcome of neonatal tetanus in Zaria, Northwestern Nigeria. J Infect Dev Ctries. Apr 26 2011;5(4):255-9. [Medline].

  40. Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma: a review and recommendations. J Trauma. May 2005;58(5):1082-8. [Medline].

  41. Roper MH, Vandelaer JH, Gasse FL. Maternal and neonatal tetanus. Lancet. Dec 8 2007;370(9603):1947-59. [Medline].

  42. Sakorafas GH, Peros G. Principles of war surgery: current concepts and future perspectives. Am J Emerg Med. May 2008;26(4):480-9. [Medline].

  43. Sanya EO, Taiwo SS, Olarinoye JK, Aje A, Daramola OO, Ogunniyi A. A 12-year review of cases of adult tetanus managed at the University College Hospital, Ibadan, Nigeria. Trop Doct. Jul 2007;37(3):170-3. [Medline].

  44. Sathirapanya P, Sathirapanya C, Limapichat K, Setthawacharawanich S, Phabphal K. Tetanus: a retrospective study of clinical presentations and outcomes in a medical teaching hospital. J Med Assoc Thai. Mar 2009;92(3):315-9. [Medline].

  45. Savage EJ, Nash S, McGuinness A, Crowcroft NS. Audit of tetanus prevention knowledge and practices in accident and emergency departments in England. Emerg Med J. Jun 2007;24(6):417-21. [Medline].

  46. Stubbe M, Mortelmans LJ, Desruelles D, et al. Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study. Emerg Med J. Sep 2007;24(9):648-53. [Medline].

  47. Taplitz RA. Managing bite wounds. Currently recommended antibiotics for treatment and prophylaxis. Postgrad Med. Aug 2004;116(2):49-52, 55-6, 59. [Medline].

  48. [Best Evidence] Thwaites CL, Yen LM, Loan HT. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet. Oct 21 2006;368(9545):1436-43. [Medline].

  49. Tullu MS, Bavdekar SB. Intrathecal tetanus immunoglobulin. Indian J Pediatr. Jul 2007;74(7):697; author reply 697. [Medline].

  50. Validation of neonatal tetanus elimination in Egypt by lot quality-assurance cluster sampling. Wkly Epidemiol Rec. Jun 29 2007;82(26-27):237-42. [Medline].

  51. WHO. Incidence of neonatal tetanus in Kano State, Nigeria, 2006. Wkly Epidemiol Rec. Nov 17 2006;81(46):433-40. [Medline].

 
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Table. Guide to Tetanus Prophylaxis in Wound Management
History of Absorbed



Tetanus Toxoid



Clean Minor WoundsAll Other Wounds
Tetanus-diphtheria-acellular pertussisTIGTdapTIG
Unknown or < 3 dosesYesNoYesYes
3 or more dosesNoNoNoNo
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