Pediatric Foreign Body Ingestion


Article Author:
Gregory Conners


Article Editor:
Michael Mohseni


Editors In Chief:
Ritesh Menezes


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/23/2019 12:06:14 PM

Introduction

Children commonly swallow foreign bodies. Coins are the most commonly swallowed foreign body that comes to medical attention in the USA; in other countries, those related to food, such as fish bones, are most common.  Pre-schoolers of both sexes, adolescent boys, and children with mental health issues are at highest risk. Even infants may swallow foreign bodies that are given to them, perhaps by older siblings.  Most swallowed foreign bodies will harmlessly pass through the GI tract, but some will lead to health problems if they become lodged (e.g., too large to pass or small objects like a pill that may adhere to a moist surface); traumatize the mucosa (e.g., sharp or pointed object, like a razor blade or pin), or cause caustic burn injury (e.g., biologically active substances, such as a button battery or a medication patch).[1][2][3]

Etiology

Typically, pediatric foreign body ingestion is accidental, although deliberate ingestion can also occur.

Epidemiology

The vast majority of ingestions occur in the six month to three year age range.[4][5][6] Children and mentally ill patients commonly swallow foreign bodies.  Coins are most commonly swallowed in the U.S. while in other countries, fish bones tend to be the most common form of ingestion.[7][8]  Occasional death reports from ingestion occur, but mortality is generally very low from foreign body ingestion.[6][9][10]

Pathophysiology

The most common complication of foreign body ingestion in children is obstruction of the object in the esophagus, although the foreign body may become lodged anywhere in the gastrointestinal (GI) tract. Once lodged, the object may partially or completely obstruct the GI tract. Furthermore, some foreign bodies may erode through the GI tract, causing complications due to perforation or migration of the object.  Certain patients may be at higher risk for retention, obstruction, or perforation.  These include younger patients with smaller anatomy, those with prior upper GI tract surgery, history of significant gastroesophageal reflux or eosinophilic esophagitis, neuromuscular disease states, or presence of congenitral malformations.[11][12]

History and Physical

In cases of suspected foreign body ingestion, the airway (including the oropharynx) and breathing should be evaluated promptly.  A foreign body that has become obstructed within or injured the esophagus may cause chest pain or a foreign body sensation. Symptoms may be more notable when swallowing. Younger children may drool, gag, vomit or refuse food. Hematemesis and cough may be present.  A foreign body lodged in the stomach or intestines may cause abdominal pain, vomiting, or bloody stools.  If present for a prolonged period, fever or weight loss may develop. A foreign body that has completely obstructed the esophagus will cause more dramatic symptoms.

Importantly, however, there may be no signs or symptoms (or they may be subtle and hard to recognize) in pediatric ingestions. Since many foreign body ingestions by children are unwitnessed, the possibility of non-specific symptoms being caused by foreign body ingestion should always be considerd.  In one series, for example, only half of the patients had any symptoms whatsoever despite witnessed ingestion of a foreign body.[13]

Swallowed foreign bodies that contain nickel may cause systemic signs and symptoms, such as rash or pruritus, in patients with nickel sensitivity.

Evaluation

If a complete history and physical examination (including examination of the pharynx) suggest possible foreign body ingestion, the provider must decide whether imaging is indicated.  If so, usually plain radiographs suffice initially. Healthy children with recent, low-risk ingestions may be simply observed.  Metallic swallowed foreign bodies, such as coins and batteries, will show up readily on a plain radiograph. Metal detectors are occasionally used, especially in the setting of known coin ingestion.[14][15][16]  It is not unusual to find an unexpected foreign body on a radiograph obtained for evaluation of non-specific symptoms, such as a cough, fever, or weight-loss.  Most glass fragments are visible on a radiograph. Radiolucent objects, such as a large piece of meat or a plastic toy, may not be apparent on radiographs, although their edges or irregularities may still be noticeable on radiography. Affected patients may require more advanced imaging techniques, such as contrast-enhanced radiography or MRI scanning, but these patients may also be considered for treatment (e.g., endoscopy) without further imaging.[17][18][19]

Button/disc batteries may cause serious injury if lodged in the esophagus, nose, ear, or other orifice for even a brief period.  The highest risk is associated with larger lithium based batteries, but all models carry some risk. Children with suspected button/disc battery ingestion should be managed urgently; a battery lodged in the esophagus should be removed without delay. Treatment algorithms for button/disc battery ingestions are widely available.[20][11] A button/disc battery may be distinguished from a coin when seen on a radiograph by its characteristic two-layer appearance when seen on-end, or a circle-within-a-circle appearance when seen front-to-back. 

Small, powerful magnets, such as those found in some toys and games, may cause serious injury to the intestines, as the strong attraction between two or more magnets may cause them to erode through intervening tissues.[21]  A single swallowed magnet in combination with another metallic object, most notably a button/disc battery, may also cause injury.

Pre-existing GI tract abnormalities, such as previous surgery, strictures, fistulas, diverticula, or functional abnormalities, increases the risk of a swallowed foreign body becoming lodged at the site of the abnormality.

Unusual or recurrent foreign body ingestion should prompt consideration of psychosocial concerns. Foreign body ingestion may be risk-taking or attention-seeking behavior. Abuse or neglect may be present. Mental illness may lead some children to swallow foreign bodies. This may be inadvertent, such as the patient with bulimia who loses grip on a toothbrush used to induce vomiting and swallows it.  Packets of drugs may be swallowed to avoid detection by police.

Prevention of foreign body ingestion in children is a high priority. Caregivers should be educated about preventing small children from contact with small objects that may be harmful if swallowed, especially button/disc batteries, small magnets, and other high-risk objects. This includes items placed into a trash container that may be accessible to children. 

Treatment / Management

Most children who have swallowed a foreign body do not require invasive treatment. Asymptomatic, previously healthy children who have swallowed low-risk foreign bodies typically will do well. Patients/caregivers should be instructed on the signs and symptoms of subsequent potential complications.  [22][23][24]

Foreign bodies that are lodged in the esophagus are most commonly removed endoscopically.[25] Some, especially those lodged in the lower esophagus at the gastroesophageal junction, will pass spontaneously into the stomach after a few hours; this is safe for coins and similar small, inert objects, in children with otherwise normal GI tracts who are at low risk of further complication as the object passes through the remainder of the GI tract. Some centers will remove small esophageal foreign bodies, especially coins, with a bougie or a balloon catheter; these require substantial experience. Endoscopy is also typically used to remove large, sharp/pointed, or other high-risk objects from the stomach, or in patients for whom continued passage of the object through the GI tract poses a risk. Objects in the lower GI tract should be managed in conjunction with a specialist, who may recommend surgical removal.

Medical management of foreign body ingestion is not recommended. Emetics, muscle relaxants, and meat tenderizers are typically ineffective, and are potentially dangerous, in the treatment of children with esophageal foreign bodies.[26] Laxatives are occasionally used to promote the passage of objects from the intestines, but this practice has not been proven effective.

Differential Diagnosis

The differential for pediatric foreign body ingestion is broad but the following entities should be considered (or ruled out) in patients presenting with such complaints:

Prognosis

The outcomes and prognosis in pediatric foreign body ingestion is generally good, with most patients tolerating passage of ingested objects without intervention.  Even in scenarios where intervention is needed, mortality and morbidity is low.  High risk ingestions (button batteries, magnets) can be associated with complications, and in rare instances death.[5][9][10]

Complications

As stated above, esophageal obstruction is the most common complication of foreign body ingestion in children.[27]  However, some foreign bodies may erode through the GI tract, causing complications due to perforation or migration of the object.    The following complications may be observed in rare cases:

  • Esophageal or stomach perforation
  • Pneumothorax
  • Mucosal erosion
  • Aortoenteric fistula
  • Pressure necrosis
  • Failure to thrive secondary to decreased oral intake

Enhancing Healthcare Team Outcomes

Management

Management of children who have swallowed foreign bodies requires an interprofessional approach. Physicians, nurses, poison control specialists, radiology technologists, child life specialists, ambulance personnel, and others must work together to provide continuous, child-friendly care, both acutely and in follow-up. (Levels III, IV, and V) The nurse should educate the parent and caregiver about the dangers of leaving small items around children. In addition, parents should be told never to keep button batteries around children as they are known to cause rapid damage to the GI tract. [28][29](Level V)

Outcomes

The majority of ingested foreign bodies pass through the gastrointestinal tract without any complications. In rare cases, the retained foreign body may cause ulceration, perforation, bleeding or localized stricture formation. The most dangerous foreign bodies are button batteries which can rapidly cause mucosal injury. Magnets are also known to cause mucosal injury in the small bowel leading to perforation. In rare cases, complications are also known to occur during removal of the foreign body- usually from the anesthesia. [1][30](Level V)


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Pediatric Foreign Body Ingestion - Questions

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Which of the following statements best describes foreign body ingestion in children?



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Which method is recommended for removal of an esophageal foreign body in a child?



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What should be the first step in the evaluation of a child who has begun drooling soon after playing with coins?



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Radiographs revealing which of the following foreign bodies in the intestines of a previously normal, healthy child would be most concerning for subsequent complication?



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An otherwise well three-year-old girl has swallowed an unknown object. She is drooling. She has a long-standing red rash on her earlobes near her earrings, and a newer, pruritic rash of her chest, abdomen, back, and extremities. Chest radiographs reveal a circular, metallic disk in the esophagus. What is the likely cause of the rash?



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Which of the following symptoms may be present in children with the aspiration of a foreign body? Select all that apply.



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Which of the following patient populations is least at risk for complications from foreign body ingestion?



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A 5-year-old patient presents with the reports of drooling and refusing food. The following radiograph is obtained (media). What is the next best appropriate step in therapy?

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Pediatric Foreign Body Ingestion - References

References

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Prasad V,Samuel V,Ramakrishnan M,Ravikumar D,Sharna N, Management of foreign body ingestion in children with cerebral palsy: Need for proper trauma management protocol. Journal of family medicine and primary care. 2018 May-Jun     [PubMed]
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