Ingestion of foreign bodies and caustic substances in children

Learning objectives.

By reading this article you should be able to.

• •Identify high-risk foreign body and caustic substance ingestions.
• •Discuss red flag signs and symptoms that require urgent intervention.
• •Explain the challenges for the anaesthetist in managing children for ingestion of foreign bodies and caustic substances.
• •Describe the short- and long-term complications of high-risk ingestions.

Key points.

• •Most foreign body ingestions pass spontaneously.
• •Button batteries lodged in the oesophagus are a time-critical emergency.
• •Ingestion of multiple neodymium magnets requires urgent review by a paediatric surgeon.
• •The signs and symptoms of caustic ingestion do not correlate well with the severity of tissue damage seen at endoscopy.
• •General anaesthesia is usually required to facilitate endoscopy for removal of foreign bodies or staging of tissue injury from caustic ingestion in children.

Ingestion of foreign bodies and caustic substances are encountered in children of all ages, most commonly between the ages of 6 months and 3 yrs as part of normal exploratory development. This behaviour leaves them at risk of injury and even death from accidental ingestion of objects commonly found in home environments such as coins, toys, magnets, button batteries and caustic substances. Older children with developmental or behavioural problems are at risk as well as those with psychiatric health problems (particularly adolescents) who may deliberately ingest foreign substances or objects as a form of self-harm. Despite national safety initiatives such as the Product Stewardship Programme, National Patient Safety Agency alerts and manufacturers' warnings, there has been an increase in the numbers of children presenting to hospital with button battery and magnet ingestions, with increasingly severe and fatal outcomes.^1,2

It is imperative that clinicians can identify high-risk ingestions and act in a timely manner to prevent unnecessary morbidity and mortality. Most ingested foreign bodies pass spontaneously, but 10–20% of cases require endoscopic removal and up to 1% could require surgical extraction or treatment of a complication.³ Ingestion of caustic substances, magnets and button batteries require urgent expert care.^1,3 It can be challenging to identify high-risk cases in children because the event may have been unwitnessed, the presentation delayed and the history vague. The severity of injury varies depending on the nature, size and shape of the object relative to the child, which further complicates treatment algorithms. The associated risks of systemic poisoning or impaction of an object must also be considered but will not be discussed further in this article.

General approach to any ingestion

All children with a history of ingestion should be assessed thoroughly and attention paid to ‘red flags’ (Table 1) which need to be acted upon immediately (within 2 h) or urgently (within 24 h). Those with complex/congenital gastrointestinal (GI) malformations may suffer from damage to the GI tract from subjectively ‘low risk’ objects. Children who have ingested an unidentified object or those presenting late (who may also be in extremis from sepsis or shock) present a diagnostic challenge. Any suspicion of poisoning warrants a check of the Toxbase (UK) or equivalent poisons advice service.

Table 1.

’Red flag’ features with ingestions in children. GI, gastrointestinal.

Local GI tract damage	Impaction	Poisoning
Caustic substances Batteries Magnets Sharp objects	Large objects (>6 cm long ∼2.5 cm wide)1 Super absorbent polymers Complex GI malformations	Lead-containing substances Medications, illicit substances or plants

Examination

A full general examination of a paediatric patient is required, paying particular attention for airway, respiratory, cardiovascular or GI compromise. Delayed presentation occurs in children: they can present with sepsis, respiratory or abdominal signs and may not volunteer a history of foreign body ingestion.³

• •Consider airway inhalation risk if there is any evidence of coughing, choking, wheeze, stridor or respiratory distress.
• •Examine the oral cavity for ulceration, lacerations, bleeding points, increased salivation or swelling.
• •Evaluate for signs and symptoms of oesophageal or GI ingestion: drooling, dysphagia, odynophagia, vomiting or GI bleeding; and examine the abdomen for tenderness, rigidity and guarding.
• •Consider and look for local or systemic poisoning symptoms and signs, and examine for evidence of systemic poisoning.

Principles of management

• •Early resuscitation using an ‘ABC’ approach if required.
• •Laboratory blood tests are rarely indicated in children who are stable, but signs of haemodynamic instability or sepsis should warrant immediate blood testing.
• •Imaging. A plain X-ray is warranted if there is any suspicion of ingestion of:

Batteries; magnets; high risk radio-opaque items (multiple batteries, co-ingestion of battery and a magnet or other magnetic object, sharp objects and large objects that may become impacted); suspicion of ingested high-risk items; in an unwell child with a history of probable ingestion; or a child with complex needs at risk of ingesting an item. This should allow visualisation of radio-opaque matter but may also show pneumoperitoneum/mediastinum or subcutaneous emphysema in cases of perforation.

In children X-rays should cover the neck, chest and abdomen for a clear view of where the foreign body might be as they are at higher risk of ingesting multiple foreign bodies.

For ingested foreign bodies, patients will be categorised as stable or unstable and the removal classed as immediate/emergent (<2 h) or urgent (<24 h).⁴

The unstable child should be resuscitated immediately alongside efforts to address the causation of the instability. Children presenting with airway compromise, drooling, perforation or active bleeding with evidence of ingested foreign matter are likely to require urgent removal of the foreign body after a period of resuscitation and stabilisation.

Children requiring immediate removal of a foreign body must be presumed to have a full stomach. The approach should be to facilitate rapid control of the airway while maintaining cardiovascular stability, thereby allowing necessary interventional procedures to be carried out in a timely way. An i.v. rapid sequence induction is the ‘gold standard’ for managing unstarved patients; however, in practice an inhalation induction is often more appropriate in managing children. This is particularly true for infants without i. v. access or in cases of airway or respiratory compromise, to avoid distressing the child further and potentially compounding a ‘brittle’ airway. Further details about anaesthetic management for inhaled foreign bodies in the respiratory tract is covered elsewhere.

The nature of the foreign body and possible complications should be carefully considered and appropriate expertise available to manage potential complications of removal, such as perforation or bleeding. Difficult intubation or ventilation may result from laryngeal oedema or the impacted foreign body itself, and requires incorporation into the preoperative planning for airway management. An ENT (ear, nose, throat) surgeon must be present in the operating theatre for children undergoing anaesthesia for a compromised airway or impaction in the oropharynx. Gastroenterologists or paediatric surgeons will deal with oesophageal, stomach and GI tract ingestions as necessary. Of the 10–20% that require removal, this is usually achieved by endoscopy or colonoscopy. Only in rare cases (under 1%) does this progress to surgery.³

A surgical approach may be required in some specific cases, for example ingestion of multiple magnets, perforation or peritonitis. Of note, endoscopy is contraindicated in those with cardiovascular instability, peritonitis or perforation. For these cases, a laparotomy should be the first-line procedure. Most rectal foreign bodies can be removed under general anaesthesia transanally and rarely require surgical intervention.

Most foreign body or foreign matter ingestions are low risk and can pass through the body without medical intervention. Ingestion of caustic substances, batteries and magnets have a greater associated morbidity and mortality and specific management strategies are discussed below.

Caustics

Ingestion of caustic agents can cause catastrophic injuries in children. Alongside the acute presentations there can be challenging long-term sequelae. This is a worldwide problem as despite increased education and regulation, caustic substances are readily found in common household cleaning products (Table 2). There is a classic bimodal presentation, accidental ingestion by children between the ages of 1–5 yrs often attracted by colourful packaging and ease of access, with a second peak seen in adolescence usually after deliberate self-harm attempts; these are associated with a higher mortality.⁵

Table 2.

Caustic agents in some commonly ingested products.

	Caustic agent	Products containing caustic agent
Alkali	Sodium hydroxide (caustic soda) Potassium hydroxide (lye/potash) Lithium hydroxide Ammonia Sodium hypochlorite	Oven cleaners, drain blockers, disc batteries, Oven cleaners, drain blockers, paint strippers Hair relaxers Household cleaners, dishwasher tablets Bleach, swimming pool chlorinator
Acid	Sulphuric, hydrochloric, nitric acid	Toilet cleaners, rust removers, swimming pool cleaners
Bleach	Hydrochloric acid or peroxide	Mildew removers (Domestic bleaches are usually weaker and may be of a neutral pH)

Ingested caustics with pH<2 or pH>11 indicate an especially bad prognosis, but endoscopy should be performed in all symptomatic children with suspected caustic ingestions.⁴ Home cleaning products such as detergents and bleach are the most commonly encountered. Strong alkalis such as sodium or potassium hydroxide found in dry cleaning agents or dishwasher tablets are responsible for the most severe injuries, often being responsible for lifelong morbidity.^6,7

Mechanism of injury

The injury pattern is determined by the caustic substance ingested. Alkalis are usually tasteless and denser than water so are often ingested distally into the GI tract.^8,9 Stronger alkalis tend to adhere to the oral or oesophageal mucosa and cause severe local injuries, but are relatively sparing of the stomach unless the volume is high when they can affect stomach and small intestines.¹⁰ Acids are irritant and usually cause gagging or choking. They cause coagulative necrosis and go on to form an eschar which is postulated to limit deeper penetration, though pooling in the stomach is thought to predispose patients to gastric perforation and stricture.^7,10 Weaker acids may be more solid (such as granules) and these cause more localised laryngeal injury. Neutral pH substances can also be caustic, for example bleaches or mildew removers. They do not tend to cause extensive oesophageal damage but may cause airway and laryngeal oedema on presentation.⁷ Symptoms of airway compromise after ingestion of powdered caustics may take 1–2 h to develop and may mimic anaphylaxis.⁹

Management

Signs of airway compromise must be identified and managed as a priority, with expert anaesthetic and ENT clinicians present. Awake airway assessment using nasendoscopy is impractical in most children. Giving nebulised adrenaline and i. v. corticosteroids may help to reduce the laryngeal oedema in symptomatic patients but should not be relied upon or delay early tracheal intubation, which is the gold standard for symptomatic cases. An evolving injury and worsening oedema can cause an already difficult intubation to become even more challenging.¹¹ Careful preparation for a difficult airway is essential and the presence of an experienced ENT surgeon in the operating theatre is advised for intubation in cases of severe injuries. There should be clearly defined roles and a plan to proceed from intubation to surgical tracheostomy if the need transpires. Postoperative care should be arranged in a paediatric intensive care unit and extubation (if appropriate) performed under controlled conditions, with expertise available to reintubate in the event of failure. After severe airway burns, early elective tracheostomy is advisable. This may become permanent for those who suffer progressive scarring between the trachea and hypopharynx. Laryngeal injuries requiring airway management are reported as 6–12% of caustic ingestions and tracheostomy in 1% of cases.⁹ Caustic substances can cause a delayed onset of symptoms and may not initially reflect the severity of injury and airway injury and consequent management may become more difficult with time. A period of observation and being kept nil by mouth may be appropriate.¹¹

The joint paediatric endoscopy guidelines from European Society of Gastrointestinal Endoscopy and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESGE/ESPHGHAN) recommends symptomatic children (oral lesions, vomiting, drooling, dysphagia, haematemesis, dyspnoea, retrosternal or abdominal pain) with a suspected caustic ingestion should have endoscopy within 24 h to identify all digestive tract lesions.⁴ General anaesthesia will be required to facilitate this. If the child is asymptomatic, endoscopy is not indicated, but follow-up should be arranged by the appropriate team.⁴ Personal protective equipment during laryngoscopy and endoscopy is to be considered to protect staff from transfer of the caustic substance.⁵ Vomiting can cause further mucosal damage and antiemetic drugs should be given. Activated charcoal should be avoided: it is of little benefit and limits the ability to identify mucosal damage. Suspicion of oesophageal, mediastinal or gastric perforation should prompt an erect chest X-ray to be performed. Antibiotics are indicated in cases of perforation but should not be given routinely. Signs or symptoms of gastro-oesophageal reflux (GOR) should be sought before surgery especially in those with strictures, because active treatment with drugs such as proton pump inhibitors will be needed. In cases of severe burns, a nasogastric tube should be placed under direct vision to facilitate early enteral nutrition; if this is not possible, an alternative such as a gastrostomy tube should be placed. Avoid blind passage of nasogastric tubes as these may cause local mucosal damage or even perforations.

Stricture development is associated with both alkali and acid ingestion, and children may present for repeated procedures such as serial dilatations and should be managed as a potential difficult airway risk. Reviewing previous anaesthetic records is imperative as is accurate recording of airway findings and techniques used each time.

There is some evidence that giving i. v. dexamethasone (1 g 1.73 m⁻² daily) for 3 days in patients with Grade IIb oesophagitis helps prevent strictures, but there is no evidence for other grades of oesophagitis. There is a 1000-fold increase in the risk of oesophageal cancer in the future.^11,12

The medical team should consider whether there any concerns around child protection or non-accidental injury that need to be explored. There may be complex family dynamics after ingestions, and patients and their families may benefit from support from clinical psychology. Behavioural changes may be seen after disfiguring injuries and schooling may be affected by absences for repeated surgery or loss of speech.⁵

Batteries

Button battery ingestion is potentially life threatening and when lodged in the oesophagus is a time-critical medical emergency.

Mechanism of injury

Button batteries generate hydroxide ions at the negative pole. This accumulates, producing a localised alkaline caustic injury with resulting tissue liquefaction and necrosis. Most severe complications follow oesophageal impaction as it is narrow and has weaker peristalsis, leading to more accumulation of the alkali. Lithium batteries especially can generate greater voltage and current which causes increased hydroxide accumulation. Corrosive injury can develop within 2 h of lodgement. Chemical burns from leaking alkali and pressure necrosis are unusual causes of damage from batteries but can contribute.³

The severity of injury depends on many factors: size, current, impacted time and several ‘red flag’ elements highlighted in Table 3. Batteries of any size may pass through to the stomach where they cause less corrosive damage.¹³ Batteries co-ingested with magnets are high risk for causing damage through perforations.

Table 3.

‘Red flag’ characteristics of ingestion of caustic substances, batteries and magnets.

Ingestion	Red flag
Caustic ingestion	•Burns to lips, mouth or face, swelling of tongue •Stridor, hoarseness, drooling and signs of respiratory distress suggest laryngeal or epiglottic damage •Dysphagia (acute or chronic) •Abdominal or retrosternal pain, haematemesis •Oesophageal, gastric or bowel perforation •Mediastinitis, tracheoesophageal fistula, bleeding •pH <2 or >11
Battery ingestion	•Size: >20 mm •Age: <4 yrs •Type: Lithium •Site: oesophageal lodgement •Time: >2 h
Magnet ingestion	•Large magnets causing impaction or obstruction •Two or more neodymium magnets •Two or more magnets •Magnet plus another ferrous object

Management

Any child with a witnessed ingestion of a battery, the suspicion of missing batteries, ingestion of an unknown foreign body or shiny items, or displaying symptoms of ingested foreign body should have a full history, examination and an X-ray covering neck, chest and abdomen. Very young children, those with complex learning needs or autistic children should have a lower threshold of suspicion.

Ingestion may be unwitnessed and batteries can be mistaken for coins on imaging (Fig 1). Up to one-half of fatal cases in the USA arose from misdiagnosis secondary to non-specific symptoms.² The type and size of the battery and where it lodges influences the speed of which it should be removed. A summary of the joint ESGE and ESPGHAN paediatric endoscopy guidelines are provided below ⁴:

Fig. 1.

Classical double halo sign of button battery. Large button battery lodged in oesophagus at level of T2. Trachea pushed to right.¹⁴ (X-ray courtesy of Dr Yair Glick, Radiopedia.org, rID 52187.).

Removal of button batteries endoscopically within 2 h is advised in the following circumstances:

• •Battery lodged in the oesophagus
• •Battery in the stomach and patient is symptomatic
• •The child has known GI tract abnormalities (e.g. Meckel's)
• •Concurrent ingestion of a button battery and a magnet

Button batteries >20 mm in the stomach in an asymptomatic child can be monitored, but if they remain there 48 h later (confirmed on X-ray), then they should be removed endoscopically. Button batteries <20 mm in the stomach of an asymptomatic child may be reviewed on an outpatient basis, with an X-ray within 10–14 days if it has not been passed in the stool. If this shows that it remains in the stomach, it should be removed endoscopically, or sooner if the child develops GI symptoms.

Cylindrical batteries

• •In the oesophagus: urgent endoscopic removal needed (within 24 h)
• •In the stomach: remove as soon as possible if symptomatic; no intervention if asymptomatic, but monitor for any symptoms requiring further investigation

Late presentations may present with a different history including oesophageal perforation, tracheal–oesophageal fistula, mediastinitis, tracheal stenosis, aorta-oesophageal fistula with catastrophic haemorrhage and stricture formation. Some of these, such as oesophageal fistulae, may take days to form and others such as strictures become evident over weeks and months. Children who are severely affected face multiple surgeries and anaesthesia after the initial battery ingestion for varying procedures such as repairing of trachea–oesophageal fistula, stricture dilatation, long-term feeding access and imaging or repeat endoscopies.

Anaesthetic management

These cases require urgent removal; do not wait for the child to be fasted before proceeding to anaesthetise as catastrophic and potentially fatal consequences may arise. Anaesthetise and provide airway protection with a form of modified rapid sequence induction. Late presentations may be more challenging especially if they present with cardiovascular collapse secondary to aorta-oesophageal fistula, respiratory symptoms secondary to trachea-oesophageal fistulae, tracheal stenosis or sepsis from mediastinitis which requires careful anaesthetic and specialist surgical management. If a late presentation is suspected, the need for more invasive monitoring and a high-care bed postoperatively should be considered amongst the usual anaesthetic management.

Magnets

Single magnet ingestions should pass spontaneously, provided they are not large enough to cause impaction. However, the ingestion of multiple magnets, a magnet plus another metallic object or ingestion of two or more neodymium magnets can result in significant harm. Caution should be taken in diagnosing if there is more than one magnet present, and two different views of radiographs should be taken to exclude a second object.

The prevalence of neodymium magnets in household appliances and toys has increased in the UK despite significant potential harm associated with accidental ingestion.¹⁵ They are small and shiny, making them attractive to young children and easy to swallow. Adolescents and older children may also suffer accidental ingestion when using the magnets to make them look like facial piercings.¹⁶ They appear like ball bearings on X-ray, and care should be taken that they are not misdiagnosed. Tightly bound neodymium magnets can appear as one magnet. Data from the National Electronic Injury Surveillance system showed an 8.5-fold increase in ingestions of magnets between 2002 and 2011.¹⁷ They have recently been the focus of a recent UK National Patient Safety notice (July 2021), which highlights the risk of bowel perforation or necrosis and the need for urgent assessment and surgical review for all patients.¹⁷

Mechanism of injury

Ingestion of large magnets may cause problems because of impaction or obstruction. If more than one magnet is ingested or if one magnet is co-ingested with a metallic foreign body, then the attractive forces of magnets can trap adjacent loops of bowel resulting in pressure necrosis and ischaemia with serious complications. The strong attractive forces between neodymium magnets make this type of injury more likely. Injuries reported after magnet ingestion include bowel ulceration, perforation, necrosis, rupture, stricture and fistula formation, haemorrhage, mediastinitis, gastric outlet and bowel obstruction, volvulus, sepsis and death.

Management

Symptomatic children and those with ‘red flag’ features (Table 3) may require surgical intervention and warrant urgent discussion with paediatric surgeons in a tertiary centre. Children may present with perforation and fistula formation within 2–5 days. In those with multiple magnet ingestions that are amenable to endoscopic retrieval, this should be done as a matter of urgency, even if the child is asymptomatic.

If the child requires surgery, do not wait for the child to be starved. Provide anaesthesia and airway protection with the knowledge that they may have a full stomach and a form of modified rapid sequence induction and intubation will be required. Children presenting late may arrive with cardiovascular instability from perforation, fistula formation, erosion of blood vessels or sepsis. For late or unstable presentations, consider the need for invasive monitoring and a high acuity care bed postoperatively.

Conclusions

Ingestions in children can present in a number of ways making diagnosis and management challenging. Most patients are managed conservatively, but for those requiring endoscopic or surgical intervention the need for expert paediatric services needs to be carefully balanced against the risk of delaying management of ingestion to transfer the child elsewhere. Understanding the short- and long-term complications of high-risk ingestions will help clinicians balance this risk. Patients may be complex because of other comorbidities, the nature of what has been ingested or the timing of ingestion. Careful preoperative assessment, the support and expertise of senior clinicians and input from the multidisciplinary team are essential to anticipate and manage the acute and longer-term complications associated with high-risk ingestions.

Declaration of interests

The authors declare that they have no conflicts of interest.

Biographies

Jayne Sutherland BSc (Hons) FRCA is a consultant paediatric anaesthetist at the Children's Hospital for Wales. She is passionate about global health and improving the preoperative care of children both in the UK and abroad.

Lowri Bowen MRCS FRCA is a consultant paediatric anaesthetist at the Children's Hospital for Wales. She is co-lead for the SAFE Paediatrics global and GBI teaching course. Her major interests are anaesthesia for orthopaedics and trauma, and global health provision and education.

Matrix codes: 1A02, 2D01, 3D00

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