How is tetanus (TD) treated in children?

Treatment of Tetanus in Children

For children with active tetanus infection, immediate treatment consists of tetanus immune globulin (TIG) 250 units IM, wound debridement, antibiotics (penicillin or metronidazole), and intensive supportive care with sedation and mechanical ventilation for severe cases. 1, 2

Immediate Management of Active Tetanus

Passive Immunization

• Administer human TIG 250 units intramuscularly as soon as tetanus is suspected clinically to neutralize circulating toxin 3, 1
• TIG must be given using a separate syringe at a different anatomic site if tetanus toxoid is administered concurrently 3
• Note that TIG cannot reverse damage already caused by toxin that has bound to neural tissue 4

Antibiotic Therapy

• Use penicillin combined with metronidazole as the recommended antibiotic regimen per WHO guidelines 2
• Metronidazole is preferred by some experts as it may be more effective at eliminating Clostridium tetani 2
• Continue antibiotics for 10-14 days to eliminate the organism and prevent further toxin production 3

Wound Management

• Perform thorough surgical debridement of all necrotic tissue to remove the anaerobic environment where C. tetani thrives 1, 2
• Copious irrigation and removal of all debris harboring spores is critical 1

Supportive Care for Severe Disease

• Approximately 66% of pediatric tetanus cases are severe, with half requiring total muscle paralysis and mechanical ventilation 5
• Control muscle spasms and sympathetic overactivity with morphine 0.5-1 mg/kg/dose given 1-4 times daily 5
• Younger children show relative resistance to drug control of sympathetic overactivity 5
• Prolonged sedation and analgesia may be required for weeks in severe cases with dysautonomia 6

Active Immunization During Treatment

• Administer age-appropriate tetanus toxoid vaccine (DTaP for children <7 years) during acute treatment, as natural infection does not confer immunity 1, 2, 7
• Complete the full primary vaccination series during recovery and follow-up 1

Prevention: Tetanus Prophylaxis for Wounds

For Children <7 Years Old

• Use DTaP as the preferred vaccine for wound prophylaxis in inadequately vaccinated children 3, 1
• DT may be substituted if pertussis vaccine is contraindicated 3

Vaccination History Assessment

• Consider any child with unknown or uncertain vaccination history as having received no previous tetanus toxoid doses 3, 1
• Verify completion of the 3-dose primary series (given at 2,4, and 6 months) plus boosters at 15-18 months and 4-6 years 1

Clean, Minor Wounds

• Administer DTaP booster only if >10 years since last dose 3, 1
• No TIG is needed if primary series is complete 1

Tetanus-Prone Wounds (Contaminated, Puncture, Crush Injuries)

• Give DTaP booster if >5 years since last dose, even with complete primary series 3, 1
• Administer TIG 250 units IM if vaccination history is uncertain or incomplete (<3 doses) 3, 1
• When both TIG and tetanus toxoid are indicated, use separate syringes at different sites 3

Critical Pitfalls to Avoid

• Do not delay TIG administration while awaiting laboratory confirmation—tetanus is a clinical diagnosis based on history and examination findings 2, 8
• Do not assume immunity from natural infection—patients recovering from tetanus must still receive active immunization as the disease does not confer protective immunity 7
• Do not overlook wound prophylaxis in vaccinated children with high-risk wounds >5 years from last booster—this is a common error that can lead to preventable tetanus 6
• Maintain high clinical suspicion in unvaccinated children presenting with trismus, muscle rigidity, or fever following any injury, as delayed diagnosis significantly worsens outcomes 8

Prognosis and Follow-Up

• Overall mortality in pediatric tetanus is 14.5%, with all deaths occurring in severely affected cases 5
• Long-term motor sequelae may persist despite appropriate treatment and require prolonged physiotherapy 2
• The case fatality rate remains 18-21% even with modern intensive care 1
• Ensure completion of the full primary vaccination series during recovery to prevent future episodes 1, 2