TETANUS PADA BAYI DAN ANAK

mts darmawan
deptanakfkuii

Beberapa Hal
Kuliah tamu
Kisah sahabat miskin yang dihindari orang
kaya
Kisah transformasi elang
Kerang rebus vs kerang mutiara

Goals and Targets

MDG 5: Reduce by three quarters (3/4) the
maternal mortality ratio
Strategy : Elimination of maternal and
neonatal tetanus
Target : Reduce incidence of neonatal tetanus
to < 1 case of neonatal tetanus per 1000
live births in every district

Beberapa Terminologi
Eradikasi : polio
Eliminasi: tetanus
Reduksi
: campak

Neonatal Tetanus
First described by Hippocrates
Etiology discovered by Carle and Rattone in
1984
Passive immunity used for treatment and
prophylaxis during World War I
Tetanus toxoid first widely used during World
War II

Definition
Tetanus is an illness characterized by :
an acute onset of hypertonia
painful muscular contractions (jaw and neck)
generalized muscle spasms without other
apparent medical causes.

Despite widespread immunization of

infants and children in the United States
since the 1940s, tetanus still occurs in the
USA.

Statistics
Has declined significantly since the mid1940s due to increased use of Tetanus
immunizations.
Mortality : + 45%.
In the USA :

6% for those who previously had received 1-2

doses of tetanus toxoid and
15% for unvaccinated individuals.
Highest for those > 60 years.

In the USA, African Americans from the rural

south a greater risk of tetanus.

Statistics
Men : are better protected because of the
higher vaccinations received during military
service or other professional activities.
Incidence : with advancing age.
54% > 59 years old.

How it forms
The nonencapsulated spore-forming
bacterium Clostridium tetani causes Tetanus.
Spores that gain entry can survive for months
years
Under anaerobic conditions geminate &
produce tetanospasmin released by the
maturing bacilli is distributed via the
lymphatic and vascular circulations to the end
plates of all nerves.
... enters the nervous system peripherally at
the myoneural junction and is transported
centripetally into neurons of the CNS

How it forms
These neurons become unable of
neurotransmitter release.
The neurons, which release gammaaminobutyric acid (GABA) and glycine, the
major inhibitory neurotransmitters, are sensitive
to tetanospasmin, leading to failure of inhibition
of motor reflex responses to sensory
stimulation.
results in generalized contractions of the
agonist and antagonist musculature
characteristic of a tetanic spasm.
The shortest peripheral nerves are the first to
deliver the toxin to the CNS, which leads to the
early symptoms of facial distortion and back

Causes
77% in the USA after acute injury, including
puncture wounds (49%),
lacerations (22%),
abrasions (12%), and
animal bites (2.6%).
Stepping on a nail accounted for 39% of the
puncture wounds.
Burn victims, patients receiving im injections, and
with frostbite, dental infections (periodontal
abscesses), penetrating eye injuries, and umbilical
stump infections.
After tooth extractions, root canal therapy, and
intraoral soft tissue trauma.

Causes
Neonatal tetanus is caused by:
Unvaccinated mothers, home delivery, and
unhygienic cutting of the umbilical cord.
History of neonatal tetanus in a previous
child is a risk factor for subsequent neonatal
tetanus.

Neonatal Tetanus
Definition
Transmission occurs when there is
contact with broken skin such as an
infants umbilical cord
Poverty, poor hygiene and limited access
to health services increase the risk for
transmission during childbirth

The Spatula Test

This simple test involves touching the
oropharynx with a spatula or tongue
blade.
Usually, this test causes a gag reflex with
the patient, and the patient tries to expel
the spatula. (This means they have
tested negative.)
In tetanus, patients develop a reflex
spasm of the masseters and bite the
spatula (a positive test).

Clinical features in Post Neonatal Tetanus

Clinical features

Number of
cases

Percentage
%

Trismus

38

100

Stiffness and
rigidity

34

89.5

Intermittent spasm

26

55.3

Difficulty in
swallowing

15

39.5

Fever

14

36.4

Showing incubation period

Days

No. of cases

Percentage %

07

18

37.5

8 14

16.7

15 21

> 22

10.4

Not known

17

36.4

Showing Mortality
Neonatal Tetanus

Post neonatal Tetanus

20 %

34.5 %

80 %

65.5 %

Clinical Features
Incubation period : 8 days (3-21 days).
Three clinical forms:
Local (not common)
Cephalilc (rare)
Generalised most common
Descending symptoms of trismus, difficulty
swallowing, muscle rigidity and spasm.
Spasm continues ( consciousness retained)

Neonatal tetanus

A conscious spasm

Management

IV line.
Nasogastric tube feeding.
Minimal handling.
A separate room.

Management
Vaksin Toksoid :
Vaksin yang dibuat dari beberapa jenis bakteri
patogen, dengan memasukkan bakteri yang
dilemahkan.
Bahan bersifat imunogenik dibuat dari toksin.
Hasil pembuatan bahan toksoid yang jadi disebut
sebagai natural fluid plain toxoid yang mampu
merangsang terbentuknya antibodi antitoksin.
Imunisasi bakteri toksoid efektif selama satu
tahun.

Management
Salah satu pilar terapi : netralisasi toksin
tetanus.
Dua pilihan terapi :
anti tetanus serum (ATS) dari serum kuda
Human Tetanus ImmunoGlobulin (HTIG) dari
manusia.

HTIG :memberikan angka kematian > rendah

HTIG : risiko efek samping reaksi hipersensitif
sistemik dan reaksi lokal < dibanding ATS.
Martinus M. Leman, Alan R. Tumbelaka
Sari Pediatri, Vol. 12, No. 4, Desember 2010

Kontroversi ATS vs HTIG

American Academy of Pediatric, Philippine Pediatric
Society :
Terapi spesifik HTIG 3.000-6.000 IU im.
Terdapat literatur dosis 500 IU dengan hasil sama
efektifnya,
Sedangkan ATS hanya pada keadaan HTIG tidak
ada.
Buku Ajar Infeksi dan Pediatri Tropis IDAI 2008 &
Panduan YanMed Dept IKA RS Cipto 2007 :
Terapi netralisasi toksin : ATS 50.000 100.000 IU :
dosis im + iv, uji kulit lebih dulu.
Bila ada HTIG 3.000-6.000 IU im.

Martinus M. Leman, Alan R. Tumbelaka

Sari Pediatri, Vol. 12, No. 4, Desember 2010

Tatalaksana
Bersihkan luka, nekrotomi dan
Antinbiotika
TT 0,5 ml im
ATS (kuda) 20.000 IU : skin test dulu !
hati2 reaksi alergi s/d syok anafilaksi.
HTIG bila TT tidak lengkap
Procain Penicillin (PP) inj 50.000
/kgBB/hr per 12 jam, im.

Antikonvulsan ~ Neonatus
Indikasi saat awal

1.Fenobarbital :
Dosis awal loading dose)
20 40 mg mg/kgBB iv
mulai 20 mg/kg BB bolus
510 menit.
Pantau depresi pernapasan
& TD

Antikonvulsan ~ Neonatus
Merupakan indikasi saat
awal .
Rumatan : 3 5 mg/kgBB
dalam 2 dosis.

Kadar terapi dlm darah

diukur 1 jam setelah
pemberian iv atau 2 4
jam stlh oral dg kadar 15 Fenobarbital = Luminal
45 ugm/mL.

2. Difenil hidantoin ~ Fenitoin

(Dilantin)
Hanya bila tidak respons thd
fenobarbital
Loading dose untuk status
konvulsivus 1520 mg/kgBB iv
bolus
Krn efek iritatif, beri garam
fisiologis sblm & sesudah bolus

2. Difenil hidantoin ~ Fenitoin

(Dilantin)
Awasi bradikardia, aritmia
& hipotensi
Dosis rumat hanya iv (oral
tak efektif) 5 8
mg/kgBB/hari dlm 2-3 dosis.
Kadar terapi dlm darah 12
20 mg/L atau 1-2 mg/L
(hanya untuk Fenitoin
bebas)

3. Lorazepam (Ativan TM)

Bila tidak respons dg
fenobarbital & fenitoin
Dosis : 0.050.10 mg/kgBB
iv dimulai 0.05 mg/kgBB
pelan dlm bbrp menit
Obat akan masuk ke dalam
otak dg cepat & tjd efek
antikonvulsan nyata dlm
waktu < 5.
Awasi depresi napas &
hipotensi

Penanganan kejang pada neonatus

Fenobarbital
Loading dose 20 mg/kg BB im atau iv
pelan
Kejang menetap dalam 30 menit
Fenobarbital 10 mg/kgBB/kali im atau iv
pelan
Tetap kejang

Tidak kejang

Fenitoin loading dose

Fenobarbital dosis rumatan:

20 mg/kg BB

5-8 mg/kgBB/hari

i.v pelan (>

1ml/kgBB/menit)

i.m atau per oral dalam 2

dosis

Fenitoin dosis rumatan

5-8mg/kg BB/hari iv atau per oral
Dibagi dalam 3-4 dosis
(diberikan bersama fenobarbital dosis

Ringkasan profilaksis tetanus pada

penderita luka
Dosis
Tetanus
sblmnya

Luka bersih, minor

Tetanus
Toksoid1

Antitoksin

Luka lain

Antitoksin
Tetanus
Toksoid
1

Tidak jelas/ <

3x
Tiga

atau

lebih 2x

Ya

Tidak

Tidak

Tidak

Ya

Tidak

Ya

Tidak

PERHATIAN
Jangan berikan diazepam untuk neonatus
Diazepam bersama fenobarbital menaikkan risiko
kolaps vaskuler dan gagal napas.

Tetanus : complications

Laryngospasm
Hypoglycemia
Nosocomial infections
Myoglobinuria
Aspiration
Iatrogenic apnoea
Death

Complications
Long bone fractures
Glenohumeral and temporomandibular joint
dislocations
Adverse effects of autonomic instability, such as
cardiac dysrhythmias and hypertension
Malnutrition
Coma, neuropathies, and psychological
aftereffects

Prognosis
Dependent on :
incubation period,
time from spore inoculation to first symptom,
time from first symptom to first tetanic spasm.
Shorter intervals indicate more severe tetanus and
a poorer prognosis.
Patients usually survive tetanus and return to their
predisease state of health.
Recovery is slow and usually occurs over 2-4
months.
Clinical tetanus does not produce a state of
immunity; therefore, patients who survive the
disease require active immunization with tetanus
toxoid to prevent a recurrence.

Key message
No change in occurence of cases.
Its only the tip of an iceberg.
Otogenic tetanus is most common below 6 yrs
while post traumatic tetanus is common above
6 yrs.
Check for tetanus immunisation in all cases
with Otitis Media.
Awareness about birth and cord care practices.
Awareness about immunisation and its practical
implementation in tea garden of upper Assam is
the need of hour to reduce the incidence of
cases.

Appropriate Interval TT
1) two TT doses during the pregnancy (TT3>=2)
2) one TT dose during the pregnancy and at least
one TT dose prior to the pregnancy (TT3=1 AND
TT6>=1)
3) at least two TT doses prior to the pregnancy of
which the last dose was less than 3 years
before the birth
4) with 3 doses within the 5 years before the
pregnancy
5) with 4 doses with the last dose less than 10
years before the pregnancy
6) with 5 doses or more ever (TT6>=5).

Neonatal Tetanus
Prevention
1. Immunization of pregnant women with at
least 2 doses of tetanus toxoid vaccine
(TT2+), passing protection to the newborn
for up to first two months of life
2. Immunization of women of childbearing
age who live in areas of high risk for
transmission (delivery of immunizations
usually through campaigns)
3. Promotion of clean delivery and cord care
practices

Prevention
An entirely preventable disease
Mortality <10% (intensive care treatment) > 70%
without intensive care treatment.

Antenatal Tetanus Toxoid

Pencegahan
Imunisasi TT bagi anak perempuan :
sejak bayi, SD, calon temanten dan saat
kehamilan.
Vaksinasi DPT
DPaT lebih aman dibandingkan DPT
Di AS, DPT tidak digunakan lagi
Diberikan mulai umur 2 bulan : bukan
untuk neonatus.

RINGKASAN
Fenobarbital : anti kejang pilihan
pertama untuk neonatus.
Jangan menggunakan diazepam pada
neonatus sebagi obat anti kejang : lebih
berisiko distress pernapasan.

1. Works Cited
www.emedicine.com Tetanus article by Daniel J.
Dire, MD, FACEP, FAAEM
www.emedicinehealth.com Tetanus article by
Robert N Bilkovski, MD

Terima Kasih