Managing Pediatric Foreign Body Ingestions

Abstract

Foreign body ingestion is common among children. A variety of foreign bodies are ingested, most of which are harmless and pass spontaneously through the gastrointestinal (GI) tract. There are a few particularly harmful and life threatening objects that should be identified and removed immediately to avoid serious complications.

Background

As far back as 1692, when the Crown Prince of Brandenburg, Frederick the Great, swallowed a shoe buckle at four years of age, case reports of foreign body ingestions have been common in the pediatric literature.¹ Coins are the most commonly swallowed objects (other than food), followed by small toys, metal objects and other more concerning foreign bodies such as magnets and button batteries.^2,3 Most objects pass through the GI tract easily. They may cause little or no sequelae, but some ingested objects (e.g., button batteries, magnets), if not discovered early, can cause significant morbidity and mortality. The challenge to the emergency physician is to avoid over-testing and over-treating, while recognizing and intervening for high-risk foreign body ingestions.

Epidemiology

Because toddlers and preschoolers explore the world with their mouths and are developing fine and gross motor skills, they are responsible for the majority of pediatric foreign body ingestions.⁴ Older children, most commonly boys, also ingest foreign bodies, typically due to poor situational decision-making.⁵ Over 100,000 emergency department (ED) visits are made annually for foreign body ingestions.⁶ Ingestions may also be brought to the attention of primary care physicians, urgent care providers, or poison control centers. A large majority of cases are either unrecognized, or are managed at home without the involvement of health care professionals.⁷

Pathophysiology

The large majority of foreign bodies ingested by children pass through the GI tract without complication. The most common complication of foreign body ingestion is impaction within the GI tract; the esophagus is the most common site of foreign body impaction. Although complications of foreign body ingestion may be seen in any child, patients who have underlying GI tract abnormalities or who have ingested high risk objects (e.g., button batteries, pointed or sharp objects, or small, powerful magnets) are at the highest risk of health problems related to foreign body ingestion.⁸

There are three distinct sites within the esophagus where foreign bodies are predisposed to become impacted due to esophageal narrowing. (See Figures 1, 2, 3.) The most common site of impaction, representing about 70% of esophageal impactions, is at the thoracic inlet, with the remainder about equally divided between the levels of the aortic arch and of the gastroesophageal (GE) junction area.^2,4 The thoracic inlet, near the first portion of the esophagus, is where the skeletal muscle transitions to smooth muscle and the cricopharyngeus muscle. On chest radiography, the impacted object is seen at the level of the clavicles. Objects impacted at the level of the aortic arch are seen at the level of the carina on a chest radiograph. Objects impacted at the GE junction are seen just above the stomach bubble on a chest radiograph. Children with abnormal esophageal anatomy or function, such as those who have had tracheoesophageal fistula surgical repair, are at greatest risk of esophageal foreign body impaction.⁹

Figure 1.

Coin impacted at the thoracic inlet.

Figure 2.

Coin impacted at the level of the aortic arch.

Figure 3.

Coin impacted at the gastro-esophageal junction.

Once an object has passed to the stomach, it will likely pass on its own. No intervention is needed unless significant signs or symptoms are experienced, which may be due to previously-unsuspected anatomic abnormalities of the GI tract. Exceptions include objects that are too long to traverse the pylorus, sharp or pointed objects, and those that are not chemically or physically inert. Children with known or suspected GI tract abnormalities, such as those who have had surgery or with motility issues, are at special risk, and should be referred to a pediatric gastroenterologist or general surgeon, for endoscopy.

History and Physical Examination

Children frequently are brought in for care of foreign body ingestions after witnessed ingestion or disclosure of having swallowed something. Key elements of history should include what was ingested and when the event may have occurred. This information is not always possible to obtain, but trying to tease out a good timeline and the nature of the swallowed objects allows providers to understand whether immediate action is needed or not. An understanding of the level of supervision and prior similar episodes also helps clinicians evaluate for potential neglect or mental/cognitive impairment.

Most children are asymptomatic after ingestions. If they are symptomatic, the presenting signs and symptoms may include: vomiting, apparent choking, drooling, gagging, pain, foreign body sensation, dysphagia or food refusal.¹⁰ Physical examination is typically non-contributory, may reveal unswallowed saliva, or an occasional foreign body lodged in the posterior pharynx. A search of the ears and nose for additional foreign bodies is sometimes revealing.

Identification of Ingested Foreign Bodies/Diagnostic Studies

Goals of imaging include identification and localization of the swallowed foreign body, and to identify children who require intervention due to ongoing or potential morbidity.

Coins: The Management of Change

Coins are the most frequently swallowed foreign bodies in children, comprising as much as 80% of swallowed pediatric foreign bodies coming to medical attention.¹¹ Metallic, radiopaque, blunt and inert (except rare cases of nickel allergy), swallowed coins usually do not cause significant morbidity if ingested unless they become impacted, which typically occurs in the esophagus. Thus, an important goal of assessing the child who has swallowed a coin is to determine whether or not it is in the esophagus. Since children with esophageal coins are often asymptomatic, we suggest imaging of all children who have swallowed coins who present to an ED.

Radiography

The initial evaluation of most children in the Emergency Department suspected of swallowing a non-food object will include plain films. The majority of these objects are radiopaque, and therefore radiography is an effective means of demonstrating their presence and location.12 PA and lateral films of the neck and chest are particularly useful for coin ingestions. Esophageal coins typically appear en face (ie, a white disk) on the PA film and as a white line segment on lateral film (See Figures 1, 2, 3). Coins that appear on-edge on the PA film and en face on the lateral film may, instead, have been aspirated and be in the trachea.

The presence of a foreign body in the esophagus on a radiograph should prompt obtaining a lateral chest film, if this was not initially done. A lateral view helps confirm both the nature and location of the object. What appears to be a coin on a frontal view may laterally show the typical two-level appearance of button battery (See Figure 4B), or of adherent coins. Objects apparently in the esophagus may actually be in the more anterior trachea. Free air or local swelling may suggest complications.

Figures 4A & 4B.

Button battery lodged in the esophagus.

Figure 4A: “Circle in circle” pattern on PA view.

Figure 4B: “Two-layer” pattern on lateral chest x-ray.

Patients who may have ingested radiolucent objects may require additional imaging, such as an esophagram, or be better served by proceeding directly to endoscopy. CT or other forms of advanced imaging may be useful in children who are symptomatic but whose initial imaging studies are negative.

It is not unusual for radiographic evaluation of fever, cough, or another medical problem to reveal an “incidental” foreign body. There are numerous reports of swallowed objects remaining in the esophagus for months or even years. These children should be referred to a pediatric gastroenterologist or general surgeon for evaluation, as they are at high risk for complications of a removal procedure.

Use of a hand held metal detector may eliminate the need for radiography, thus avoiding exposure to ionizing radiation. Use of this technology is simple and effective, as long as the patient does not have any other metal on or in the body, nor in close vicinity in the room. Metal detectors have been shown to have high specificity and sensitivity in identifying location of metal foreign bodies such as coins.¹³ The most beneficial use of the hand-held metal detector is to determine whether the location of the foreign body is above the diaphragm (essentially, within the esophagus) or below it. Results suggesting an esophageal coin typically are confirmed with a traditional radiograph. While they work well in coin ingestion, hand held metal detectors have limited utility in obese patients or those who have ingested a very small metallic, or non-metallic object, so one should not rely solely on it to determine if a metal object was ingested. Diagnostic use of hand held metal detectors, however, is not yet widespread, with most institutions moving directly to radiography.

Interventions

The nature of a swallowed foreign body, its location, and the child’s health status dictate management. The principal goal of managing children with foreign body ingestions is to prevent (further) complications. Children with lower GI tract foreign bodies who have symptoms or signs suggesting complication (typically perforation or obstruction) should be discussed with a pediatric gastroenterologist or general surgeon. Lodgment within the esophagus is associated with risk of such complications as esophageal obstruction, mucosal scarring, perforation, or migration, leading to mediastinitus or even creation of an aorto-esophageal fistula.

Inflammatory changes may be seen in as few as 12 hours. Thus, therapy should be aimed at early removal of esophageal foreign bodies, either through their removal or advancement into the stomach. While medications, such as glucagon and diazepam, have been used in adults with lower esophageal meat impaction, this has not been shown to be successful in children.^14,15 Inducement of emesis is associated with potential aspiration risk. Thus, non-pharmacologic techniques are currently used for removal or advancement of esophageal foreign bodies.

Interventions Aimed at Removal of Esophageal Foreign Bodies

Foley Catheter technique

A healthy child with a round or blunt foreign body, such as a coin, can have it removed by this easy and cost-effective means. A Foley catheter is gently passed beyond the object, typically using fluoroscopic guidance. The balloon is then inflated, and the catheter is gently withdrawn with the balloon with the hope of drawing the object back into the mouth. To prevent inadvertent airway obstruction by the dislodged coin, the child should be placed in the Trendelenberg position, and instructed to spit out the coin. This technique should not be used to remove sharp or pointed objects. Repeated attempts after a failed one, or the use of multiple catheters, should be avoided for concerns of causing esophageal injury. This technique is generally recommended only in the first 24 hours following ingestion.¹⁶

Endoscopy/Esophagoscopy

Endoscopy remains the most common technique for removal of esophageal foreign bodies. It is the procedure of choice for removal of objects from uncooperative children or those with important health problems, and for removal of objects that are sharp, pointed, or have been actually or potentially in the esophagus for over 24 hours. Endoscopy is extremely safe and effective.

Endoscopic removal has certain advantages. It serves both diagnostic and therapeutic purposes. The extent of esophageal injury can be assessed at the same time of removal. However, endoscopy is costly, since it is performed under general anesthesia or deep sedation, and requires specialized equipment and providers (i.e. pediatric gastroenterologists, otolaryngologist or surgeons).^16,17

Interventions Aimed at Advancement of Esophageal Foreign Bodies

Bougienage

Bougienage is the gentle passage of a flexible esophageal dilator, or bougie, into the esophagus, through either the nose or mouth, to a depth estimated to advance a blunt object to the stomach. The principal advantage of bougienage is that is can be done quickly, effectively, and safely by trained emergency physicians, and does not require sedation or anesthesia. Bougienage should not be performed on children with underlying esophageal abnormalities or if the object has been present for more than 24 hours. Since the object must then traverse the GI tract, it should not be used for sharp, pointed, or large or long foreign bodies, nor should the technique be used in children with abnormalities of the stomach or lower GI tract. Failed procedures should not be repeated; instead, the child should be referred for endoscopy. Once the procedure is completed, children may be treated as would other children with gastric foreign bodies.¹⁷

Spontaneous Passage

Children with blunt esophageal foreign bodies may experience delayed spontaneous passage of the object into the stomach. This has been well described in the case of esophageal coins. Spontaneous passage typically occurs within the first few hours of foreign body ingestion, most commonly with objects lodged at the gastroesophageal junction. Administration of food or drink may enhance this process, but must be balanced against the risk of a “full stomach” should other removal procedures, such as endoscopy, be required. ^10,18

Special Foreign Bodies

Button/Disc Batteries¹⁹

Button batteries are found in a variety of objects, such as hearing aids, watches, calculators, and other small devices. As their use has grown greatly over the past several years, so has the opportunity of their discovery and ingestion by children. Button batteries typically only cause damage when lodged, such as in the ear, nose, vagina, or esophagus; once in these locations, tissue damage occurs in just a few hours, and maybe quite severe. Button batteries are easily swallowed and may be confused with coins when ingested or seen on radiographs. They do, however, have a distinctive appearance on frontal (“circle within a circle”) and lateral (“two-layer” profile) radiographs. (See Figures 4A, 4B.) These may be missed when the battery is imaged obliquely, or is very small.

Complications of button battery ingestion are believed to be due to a combination of pressure necrosis and the creation of a local current in a moist, mucosal environment. Damaged batteries may also leak toxic contents. Large lithium batteries are most dangerous, but any button battery, even those discarded as “dead,” may cause important injury. Management of esophageal button batteries should include their immediate removal by endoscopy, which allows both removal and inspection for tissue injury. Children with button batteries in the stomach and lower GI tract may be observed, as they are typically safely passed without complication. Children with abnormal GI tract anatomy or function should be discussed with a pediatric gastroenterologist or surgeon.

The National Battery Ingestion Hotline, at 202-625-3333, can provide valuable information regarding management of button batteries, including information regarding battery type if the ID number is available.²⁰

Pointed / Sharp Objects

Ingestion of pointed objects (e.g., a push pin) or those with a sharp edge (e.g., a razor blade) carries an associated risk of perforation of the GI tract. Smaller objects like thumb tacks may become embedded in the esophagus. Perforation can lead to contents spilling into the peritoneal cavity causing significant consequences such as peritonitis or mediastinitis. Sewing needles are notoriously associated with GI perforation. These objects should be removed endoscopically from either the esophagus or stomach. Special devices have been designed to close or cover open safety pins in order to prevent perforation during removal via endoscopy. Management of children with sharp or pointed foreign bodies in the lower GI tract should be discussed with a pediatric gastroenterologist. Fortunately, unless they are very sharply pointed, small pieces of broken glass are not typically associated with GI tract perforation.

Long Objects

Swallowed objects longer than 4–6 centimeters often become lodged in the stomach. Thus, they will require endoscopic removal. The circumstances of ingestion of long objects should be investigated, as it may be a sign of psychiatric disorder. The presence of an esophageal toothbrush has been termed “a radiologic clue of bulimia.”²¹

Small Magnets

Magnet ingestion has caused increased concern over recent years and have been the focus of several publications. Separately ingested small magnets strongly attract each other across the bowel, causing bowel wall necrosis/perforation, fistula formation, obstruction or volvulus. Many children have required surgery; deaths have been reported. Small magnets are found in toy sets, jewelry sets, and building sets, and may be ingested in multiples or with other metallic objects. The popular magnet toy “Buckyballs” were recently voluntarily recalled due to injury risk.²²

Swallowed magnets may also be attracted to other metallic objects. Cases of combined button battery/small magnet ingestion, an exceptionally dangerous combination, have been reported.²³ Children who have ingested small magnets or magnets and other metallic objects should have abdominal radiography performed; if verified, their care should be discussed with a pediatric gastroenterologist or general surgeon.

Prevention

The ideal management of foreign body ingestion is its prevention. As noted in the 2010 American Academy of Pediatrics Policy Statement on the Prevention of Choking Among Children,²⁴ caregiver education and attention to toy safety are vital to preventive measures. Pediatricians should include anticipatory guidance on prevention and safety to parents during every well child visit. Emergency physicians should capitalize on a visit for foreign body ingestion as a “teachable moment” regarding appropriate toys and foods.

The United States Consumer Product Safety Commission is a valuable resource for families and physicians. It enforces toy regulations and recalls for the safety of children.

Conclusion

Foreign body ingestion is common in childhood, and may be a potential health risk. Coins are the most commonly ingested non-food item. Children with GI tract abnormalities are at highest risk of complication. Most foreign bodies traverse the GI tract and are eliminated without complication, but some become lodged in the GI tract, most commonly in esophagus, often requiring removal. Ingestion of button batteries, pointed, sharp, or long objects, or small magnets presents special risks. As is the case with all injuries, education and injury prevention are important deterrents.

Biography

Dharshinie Jayamaha, MD, (left) and Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP, (right) are in the Division of Emergency and Urgent Care at Children’s Mercy Hospitals and Clinics in Kansas City and in the Departments of Pediatrics and Emergency Medicine at the University of Missouri-Kansas City School of Medicine in Kansas City, Mo.

Contact: djayamaha@cmh.edu.