Can Anti-Tetanus Serum (ATS) be given to newborns?

Anti-Tetanus Serum (ATS) in Newborns

Anti-Tetanus Serum (ATS, equine-derived antitoxin) is NOT the standard of care for newborns; instead, prevention through maternal Tdap vaccination during pregnancy (27-36 weeks gestation) is the primary strategy, and if passive immunization is needed for neonatal tetanus treatment, Tetanus Immune Globulin (TIG, human-derived) is strongly preferred over ATS due to superior safety profile. 1, 2

Prevention is the Primary Strategy

Maternal vaccination is the cornerstone of neonatal tetanus prevention:

• Pregnant women should receive Tdap during each pregnancy at 27-36 weeks gestation, regardless of prior vaccination history, to maximize passive antibody transfer to the newborn 1, 2
• Maternal antibodies against tetanus cross the placenta during pregnancy, providing protection to the newborn in the critical first months of life 1
• Previously unvaccinated pregnant women whose child might be born under unhygienic circumstances should receive two doses of Td 4-8 weeks apart before delivery, preferably during the last two trimesters 1

When Newborns Receive Active Immunization

Newborns do not receive tetanus toxoid directly; they receive DTaP as part of routine vaccination:

• The routine childhood vaccination schedule uses DTaP (diphtheria, tetanus, and acellular pertussis) starting at 6 weeks of age, with doses at 2,4, and 6 months 3, 1, 4
• Prematurity is NOT a contraindication—vaccination should begin at the usual chronological age from birth, using full 0.5 mL doses 1
• Infants remain vulnerable until they receive at least 2-3 doses of DTaP, which is why maternal vaccination and cocooning strategies are critical 2

If Neonatal Tetanus Occurs: Treatment Considerations

In the rare event of neonatal tetanus, passive immunization with human Tetanus Immune Globulin (TIG) is preferred:

• Human TIG is the standard of care for passive immunization in tetanus treatment, including neonatal cases 5
• ATS (equine-derived antitoxin) carries significant risks of serum sickness and anaphylaxis compared to human TIG 5
• Historical data from resource-limited settings showed ATS was used for neonatal tetanus with variable mortality rates (30.7% with subcutaneous umbilical infiltration vs. 74% with IV/IM routes), but these studies predate modern TIG availability 6, 7

Critical Clinical Considerations

Important caveats about passive immunization in newborns:

• Neonatal tetanus can occur even with protective maternal antibody levels if the toxin load is overwhelming, particularly with umbilical stump contamination 8
• TIG should not be given intravenously; intramuscular administration in the deltoid or lateral thigh is required (avoid gluteal region due to sciatic nerve risk) 5
• Epinephrine should be available when administering any immunoglobulin preparation, though true allergic reactions to human IgG are rare 5
• Skin testing before TIG administration should NOT be done, as it causes localized inflammation that can be misinterpreted as allergy 5

Common Pitfalls to Avoid

• Do not rely on ATS when human TIG is available—the safety profile of human immunoglobulin is vastly superior 5
• Do not delay maternal Tdap vaccination—it should be given during each pregnancy, even if the woman received Tdap previously 1, 2
• Do not assume maternal vaccination alone is sufficient in high-risk scenarios—maintaining hygienic conditions during delivery and umbilical cord care is essential 9
• Do not confuse DTaP (for children <7 years) with Tdap (for adolescents/adults)—newborns receive DTaP starting at 6 weeks, not tetanus toxoid alone 3, 4