Enteral Baclofen for Persistent Stimulus‑Induced Rigidity in Severe Neonatal Tetanus: Facilitating Weaning from Prolonged Mechanical Ventilation in a Low‑Resource NICU – A Case Report

In the quiet hours after a baby is born, the most critical moments often involve the umbilical cord. In many parts of the world, this connection is severed with care and sterile tools, but in settings where medical resources are scarce, the process can be left to chance. When the cord is cut with unclean instruments or tied with dirty thread, a dangerous bacterium called Clostridium tetani can enter the infant's body. This bacterium produces a powerful toxin that travels to the nervous system, hijacking the brain's ability to tell muscles to relax. Instead of moving smoothly, the muscles lock into painful, rigid spasms. This condition, known as neonatal tetanus, is a race against time. The spasms can be so severe that they lock the chest wall, making it impossible for the baby to breathe, or they can trigger seizures that look like the infant is having a fit. Doctors must keep the child alive with a ventilator while waiting for the body to clear the toxin, but the rigid muscles often make it impossible to wean the baby off the machine, trapping them in intensive care for weeks or months.

This story comes from a neonatal intensive care unit in Mogadishu, Somalia, where a team of doctors faced a particularly stubborn case of this disease. An eight-day-old boy, born at home to a mother who had never received the tetanus vaccine, was admitted in critical condition. He arrived with a high fever, a rigid body, and a face locked in a grimace, unable to open his mouth or feed. He was immediately placed on a ventilator to help him breathe, as his chest muscles were too tight to work on their own. For the first few weeks, the medical team fought a multi-front battle. They administered antibiotics to kill the bacteria, a special antibody to neutralize the toxin, and strong sedatives to calm the violent muscle spasms. They also treated the baby for suspected seizures, using medications typically reserved for epilepsy, because the violent shaking looked identical to convulsions.

Over the course of a month, the infection cleared, the fever broke, and the suspected seizures stopped. The baby's blood work returned to normal, and the signs of infection vanished. Yet, a new problem emerged. Despite the infection being gone, the baby's muscles remained locked in a state of extreme stiffness. Every time a nurse touched him or a loud noise occurred, his body would jerk into a rigid spasm. This persistent stiffness made it impossible to take him off the ventilator. When the doctors tried to remove the breathing tube, the baby's chest and throat would spasm so violently that he could not breathe, forcing the team to put the tube back in. They had tried two such attempts, and both failed. The baby was stable, but he was stuck, unable to leave the machine because his muscles refused to relax.

The turning point came when the team decided to try a different approach to calm the muscles. They introduced a medication called baclofen, which is usually given to people with spinal cord injuries to help relax tight muscles. In this case, the doctors administered a high dose of the drug through a feeding tube directly into the baby's stomach. They combined this with a low dose of a sedative to keep the baby comfortable but awake enough to breathe. The effect was noticeable and rapid. The severe stiffness that had held the baby's body in a rigid arch began to soften. The violent jerking triggered by touch or sound diminished significantly. For the first time in weeks, the baby's muscles responded to the medication by relaxing rather than seizing.

With the rigidity under control, the team made a third attempt to remove the breathing tube. This time, it worked. The baby could breathe on his own without the machine. Over the following days, he was able to drink milk from a bottle and eventually breastfeed, something he had been unable to do since the day he was born. After eight weeks in the hospital, the baby was discharged. He still had some stiffness in his legs and would need physical therapy to help his joints move freely, but he was alive, breathing room air, and feeding normally. The doctors followed him as he went home on a tapering dose of the muscle-relaxing medication.

This case report highlights a specific challenge in treating severe tetanus: even after the infection is gone, the nervous system can remain in a state of hyper-excitability that prevents recovery. The authors suggest that adding high-dose baclofen to the treatment plan helped break the cycle of rigidity that was keeping the baby on the ventilator. They note that while the baby's recovery was likely due to a combination of factors, including the clearance of the toxin and the intensive care support, the timing of the improvement coincided with the introduction of the new medication. The report does not claim that baclofen is a cure-all or that it works for every case, but it offers a promising option for other doctors in similar, resource-limited settings who face the same difficult choice of how to help a baby whose muscles will not let them breathe. The story serves as a reminder that while medical science can sometimes find a way to save a life in the most difficult circumstances, the most effective strategy remains preventing the disease in the first place through vaccination and clean delivery practices.