The onset of symptoms is variable but usually appears within 3 to 14 days after birth. The typical, early manifestations are weak and poor suck due to trismus (contraction of the jaw muscles causing an inability to open the mouth). This develops rapidly within hours, to body stiffness and generalized spasms. Severe rigidity can manifest as board-like abdominal rigidity and backward arching of the back (opisthotonus). Other manifestations of the disease are apnoeic episodes, asphyxia, cyanosis and fever.

The classic presentation includes a trismus or “lockjaw,” which prevents the newborn from feeding properly, along with generalized rigidity and spasms. Opisthotonos (severe hyperextension) can also occur. Additionally, affected newborns could present with features of complications such as aspiration pneumonitis, hypoglycaemia and acute renal failure.

A fully developed neonatal tetanus is unarguably distinct from other diseases. Hypocalcaemia could, however, manifest with facial spasms, apnoea, irritability, jitteriness, stridor and poor feeding. However, unlike tetanus, neonates with hypocalcaemia could present with focal or generalized seizures. Other conditions that can present with poor suck, apnoea or fever include sepsis, meningitis, perinatal asphyxia and intracranial haemorrhage.

The diagnosis of neonatal tetanus is primarily clinical as there are no specific laboratory tests. However, laboratory tests such as biomarkers of bacterial sepsis e.g., C-reactive protein, full blood count and blood culture could be conducted to rule out differential diagnoses. Also, random blood sugar and electrolyte profiles are required to monitor complications.

Management is usually multimodal and involves:

1. Neutralization of circulating toxins – A single intramuscular injection of antitetanus serum i.e., Human Tetanus Immunoglobulin (TIG) at a dose of 500 units (could be as high as 3,000 – 6,000 units) is also recommended. If TIG is unavailable, an alternative is equine- or bovine-derived tetanus antitoxin (TAT) administered at a dose of 10,000 units, half given intramuscularly and half intravenously.
2. Eradication of Clostridium tetani – This is achievable by cleaning the infected umbilical cord stump and antimicrobial therapy. Choices of antibiotics include oral or intravenous metronidazole 7.5mg /kg/dose 8 hourly or IV penicillin G 100,000 U/kg/day 6 hourly for 10-14 days.
3. Spasm control – achievable with bolus diazepam at a dose of 0.1 – 0.2 mg/kg IV every 6 hours or continuous IV infusion titrated to spam control at a dose of 15 – 40 mg/kg/day. Additionally, phenobarbitone is administered at a loading dose of 10 – 20 mg/kg and a maintenance dose of 5 mg/kg/day.
4. Supportive care – Nutritional support is important and should be provided early to satisfy the neonates' high caloric and protein demands. Enteral feeding and dextrose infusion should be prioritized in resource-poor settings where parenteral nutrition is may not achievable. Often, a nasogastric tube is easily passed following the loading dose of sedatives. Care should be provided in a quiet environment and regular gentle suctioning is essential to clear oral secretions. Ventilatory support might be required if available in cases of recurrent apnoea.

The prognosis of the disease depends on several factors. Poor prognostic factors include age at the onset of the disease less than five days, shorter incubation period, the presence of fever and occurrence of complications. Survivors of neonatal tetanus should receive standard doses of tetanus immunization.

Prevention strategies include immunization of pregnant women with tetanus toxoid, promoting clean delivery practices, and proper cord care. Education on hygiene and vaccination are key components of control programs

Neonatal tetanus remains a significant health issue in low-income settings, often due to unhygienic birth practices and limited access to maternal vaccination. Prevention through proper maternal immunization, clean delivery environments, and educating birth attendants is critical. Early recognition and treatment are key to reducing mortality, though access to healthcare services can be challenging. Strengthening vaccination programs and improving neonatal care can greatly reduce the burden of neonatal tetanus in these areas.