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February 1982, Volume 32, Issue 2

Original Article

A New Method of Grading Tetanus Neonatorum

Suleman Daud  ( Department of Child Health, Khyber Medical College, Peshawar. )
Tufail Mobammad  ( Department of Child Health, Khyber Medical College, Peshawar. )
Ashfal Ahmad  ( Department of Child Health, Khyber Medical College, Peshawar. )


Neonatal Tetanus is one of the major killers in the early period of life.
The disease has got a definite course and the early institution of therapy has a substantial role in altering this. The authors have devised a new method of grading the disease in order to assess the severity. Accordingly the disease has been given four grades.
The grading has proved to have diagnostic and prognostic implications ,specially for purposes of research (JPMA 32:41, 1982).


Neonatal Tetanus is a major killer in the developing countries. According to a rough estimate it is responsible for 38 .4% of neonatal deaths in Pakistan. The field survey conducted by E.P.I. (Expandad Poly Immunization Programme) in collaboration with WHO showed that the mortality of the disease was l00%. In order to gauge the magnitude of the problem a prospective study is under way in the Department of Child Health Khyber Medical College) Peshawar.
Since the disease has a definite course, the early institution of therapy has substantial prognostic value. The severity of the disease has to be determined in order to establish the value of a treatment protocol, For this purpose a system of grading has been devised by the authors which seems to have diagnostic and prognostic implications.

Material and Methods

All cases of Neonatal Tetanus admitted to the unit were included in this study. The diagnosis in each case was confirmed by the consultant incharge of the unit. The essentials of diagnosis were considered to be either of the following:-
1. Trismus/Regional rigidity.
2. Reflex Spasms/Residual rigidity in between the spasms.
3. Growth of Cl. Tetani with I or 2 of the above.
After establishing the diagnosis the babies were isolated in a dark room and were put under observation in order to grade the intensity of the disease. The grading was done according to the schedule shown in Table 1.


In all 105 cases were admitted from 15th December 1979 to 15th December 1980. They were graded as in Table II.

They were all treated conservatively and the cure rates in different grads was as shown in Table III.


Neonatal Tetanus is one of the most fatal disease of the Central Nervous System in the neonatal period. The local lesion is always very mild yet the exotoxin produced is lethal enough to cause death. After peripheral absorption the toxin reaches the Central Nervous System by passing along the motor trunks and spreads up the spaces between nerve fibres (Drewett 1972; Gillespie). It acts by interfering with the inhibitory mechanisms at the motor neurones. This accounts for the generalized increase in tone in local tetanus. The condition usually starts with stiffness and spasms in the area of infection but it usually goes unnoticed. This is followed by trismus due to masseteric spasm, dysphagia, spasms of the facial muscles and finally generalized spasms in which there may be opisthotonus. The clinical grading devised by us simply depends upon the stage of the disease when it is first presented.
Such a method of grading has obvious utility as regards the prognosis of the disease. In our series the cure rate in grade I and grade II was 100% with conservative measures as compared to 78.8% in grade III and 34.6% in grade IV.
The grading is also invitable in selecting cases for research purposes. As the prognosis differs considerably and if the cases are taken at random, the inferences are likely to be biassed.
The system though may be of help in diagnosis, has definite limitations. This is due to the fact that the early symptoms are non specific and are present in other Neonatal disorders. So we recommend that the case should be graded after either of essentials of diagnosis have been satisfied.


1. Drewett, S.E., Payne, J.H., Tuke, W. and Verdon, D.J.H. (1972) Eradication of pseudomonas aeruginosa infection from a special-care nursery. Lancet, 1:946.
2. Gillespie, W.A., Linton, K.B., Miller, A. and Slade, N. (1960) The diagnosis, epidemiology and control of Urinary infection in Urology and gynaecology. J. Clin. Pathol.,13:187.

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