Tetanus neonatorum is a severe, high mortality disease caused by Clostridium tetani, an anaerobic species of bacteria. Children born to unimmunized mothers under unsanitary delivery conditions may be exposed to this pathogen. Early diagnosis and prompt therapy are potentially lifesaving, but prevention by population immunization is the optimal approach.
In some regions of the world, tetanus neonatorum is known as "seventh day evil" , because this is when symptoms first set in. In underdeveloped countries, this is the cause of up to half of neonatal deaths, while infection of all types represents the reason for 15% of newborn deaths worldwide . Newborns develop the generalized form of the disease because exposure is made via the umbilical stump, when asepsis is not achieved. Other infectious agents leading to sepsis can also be transmitted to the child in this manner . In some areas, the umbilical stump is covered with dust or spider webs, that are thought to promote healing, but actually contain Clostridium tetani. Proper umbilical cord handling  and population vaccination may help reduce tetanus neonatorum .
The incubation period for tetanus neonatorum is 3 to 10 days, but most newborns develop it at the end of their first week of life, when they present with irritability, feeding difficulties due to trismus and an inability to swallow, excessive crying caused by hunger, rigidity and generalized muscle spasms induced by touch, including those of the face, and opisthotonus. Patients exhibit tachycardia and tachypnea, are febrile and may have convulsions. The sooner generalized spasms occur, the worse the prognosis, with mortality usually higher than 70%   . During spasms, the child may be cyanotic. Death is caused by hemodynamic instability as a consequence of dysautonomia or heart arrhythmias, hydro-electrolytic imbalance or asphyxia.
Tetanus neonatorum diagnosis is mainly clinical. Careful history inquiry should include metoclopramide administration. The clinician should search for meningeal signs  and labor related cerebral injury. Once the suspicion is raised, the physician is required to perform a spatula test. This consists of trying to elicit a gag reflex by touching the oropharynx with a spatula. In tetanus newborns, this reflex is replaced by masseter muscles spasm, leading them to byte the spatula. This maneuver is highly specific  and is sometimes involuntarily performed by mothers while attempting to feed the baby. The next step in the clinical evaluation is to assess the severity of the disease, based on the state of the limbs: flexed or extended and the presence of generalized rigidity.
Laboratory workup offers little information, because no specific diagnosis test is available. Serum muscle enzyme levels are increased due to the muscle spasms. The calcium blood level should be measured in order to exclude hypocalcemia, which is an important differential diagnosis. If an antitoxin level test is feasible, a titer of more than 0.01 IU/mL is considered to be protective. Umbilical stump secretion can be cultured and the bacteria may be found there, but this does not necessarily mean the patient has tetanus. On the other hand, in a patient with clear clinical signs of tetanus, the pathogen may be absent from the secretion. Blood cultures are not useful in this disease.
The electrocardiogram may show nonspecific changes or several types of arrhythmia, while the electromyogram describes continuous discharge of motor subunits, the substrate of spasms and rigidity.