Pediatric Foreign Body Ingestion

Practice Essentials

As children explore and interact with the world, they will inevitably put foreign bodies into their mouths and swallow some of them.

Most swallowed foreign bodies pass harmlessly through the gastrointestinal (GI) tract. Foreign bodies that damage the GI tract, become lodged, or have associated toxicity must be identified and removed. Children with preexisting GI abnormalities (eg, tracheoesophageal fistula, stenosing lesions, previous GI surgery) are at an increased risk for complications.

Although adults most often present to the ED because of health problems related to ingestion of radiolucent foreign bodies (typically food), children usually swallow radiopaque objects, such as coins, pins, screws, button batteries, or toy parts. Although children commonly aspirate food items, it is less common for small children to present because of foreign body complications due to food ingestion. Swallowed objects are shown in the images below.

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A swallowed coin lodged at the thoracic inlet. Image courtesy of Gregory Conners, MD, MPH.

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A swallowed radiolucent object (plastic guitar pick) is made visible in the upper esophagus after ingestion of barium. Image courtesy of Raymond K. Ta....

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Pathophysiology

Esophagus

Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at one of three typical locations.^[1] The most common site of esophageal impaction is at the thoracic inlet. Defined as the area between the clavicles on chest radiograph, this is the site of anatomical change from the skeletal muscle to the smooth muscle of the esophagus. The cricopharyngeus sling at C6 is also at this level and may "catch" a foreign body. About 70% of blunt foreign bodies that lodge in the esophagus do so at this location. Another 15% become lodged at the mid esophagus, in the region where the aortic arch and carina overlap the esophagus on chest radiograph. The remaining 15% become lodged at the lower esophageal sphincter (LES) at the gastroesophageal junction.

Children with preexisting esophageal abnormalities (eg, repair of a tracheoesophageal fistula) are likely to have foreign body impaction at the site of the abnormality. If a child with no known esophageal pathology has a blunt foreign body lodged at a location other than the 3 typical locations described above, the possibility of a previously unknown esophageal abnormality should be considered. The presence of eosinophilic esophagitis has been recognized as contributing to adult esophageal foreign body impaction and may be its presenting feature; although less common in children, eosinophilic esophagitis has also been associated with pediatric esophageal food impaction.^[2]

Pointed objects, such as thumbtacks, may become impaled and, therefore, lodged anywhere in the esophagus. Small objects, such as pills and smaller button batteries, may adhere to the slightly moist esophageal mucosa at any point.

Stomach/lower gastrointestinal tract

Once a swallowed foreign body reaches the stomach of a child with a normal GI tract, it is much less likely to lead to complications. Foreign bodies occasionally become lodged at the ileocecal valve.^[3] Coins made largely from zinc, most notable United States cents, have been reported to interact with stomach acid leading to stomach ulceration.^[4] Foreign-body — induced appendicitis has been reported.^[5] Other exceptions include pointed or toxic foreign bodies or objects too long (ie, >6 cm) or too wide (ie, >2 cm) to pass through the pyloric sphincter.

Another important exception is the child who has swallowed more than one magnet; reports exist of swallowed toy magnets attracting and adhering tightly to each other through the GI tract, leading to small bowel obstruction or necrosis of intervening tissues, sometimes with severe sequelae.^{[6, 7, 8]} Magnets may also attract other ferrous swallowed foreign bodies, causing similar problems.^[9]

Children with known GI tract abnormalities are more likely to encounter complications. Previous surgery may cause abnormalities of peristalsis, increasing the likelihood of foreign body impaction. For example, children who have had surgery to correct pyloric stenosis are more likely to retain a foreign body in the stomach.

Previously unsuspected lower GI tract abnormalities may present as a complication of foreign body ingestion. For example, a small foreign body may become lodged in a Meckel diverticulum.

Impacted foreign bodies

A foreign body lodged in the GI tract may have little or no effect; cause local inflammation leading to pain, bleeding, scarring, and obstruction; or erode through the GI tract. Migration from the esophagus most often leads to mediastinitis but may involve the lower respiratory tract or aorta and create an aortoenteric fistula. Migration through the lower GI tract may cause peritonitis.

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Etiology

Most cases occur as children discover and place small objects in their mouths.

Foreign body ingestion, especially if a repeated problem, may suggest a chaotic home environment and neglect.

Children with known GI tract abnormalities or previous complications of foreign body ingestion are more likely to have complications.

Older children may be seeking attention or be manifesting psychological abnormalities.

Ingestion of unusual foreign bodies may suggest an underlying abnormality. For example, an association exists between toothbrush ingestions and bulimia in teenaged girls.^[10]

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Epidemiology

United States statistics

Although exact figures are unavailable, foreign body ingestion is clearly common among children. More than 125,000 ingestions of foreign bodies by people aged 19 years and younger were reported to American Poison Control Centers in 2007.^[11] In a cross-sectional survey of parents of more than 1500 children, 4% of the children had swallowed a coin (the most commonly swallowed foreign body in many studies).^[12]

A study that analyzed emergency department (ED) visits involving magnet ingestion in children from 2002 to 2011 found that there has been an alarming increase in ED visits for magnet ingestion in children. A national estimate of 16,386 children presented to EDs in the United States during the 10-year study period with possible magnet ingestion. ED visits due to possible magnet ingestion increased 8.5-fold from 2002 to 2011 with a 75% average annual increase per year. The majority of patients reported to have ingested magnets were younger than 5 years (54.7%).^[13]

International statistics

Pediatric foreign body ingestion is a worldwide problem. Impaction of swallowed fish bones is more commonly observed in countries where fish is a major dietary staple, including Asian countries.^[14] A massive database describing pediatric foreign body injury in European and other countries, the "Susy Safe project," recently published information regarding nearly 17,000 cases in children aged 14 years and younger; about 18% of these involved foreign body ingestion.^[15]

Sex- and age-related demographics

The male-to-female ratio in young children is 1:1. In older children and adolescents, males are more commonly affected than females.

Children of all ages ingest foreign bodies. However, incidence is greatest in children aged 6 months to 4 years. This reflects the tendency of small children to use their mouths in the exploration of their world. Younger children may be "fed" foreign bodies by older children or be intentionally given foreign bodies by abusive adults. In the teenaged years, concomitant psychiatric problems, mental disturbances, and risk-taking behaviors may lead to foreign body ingestion.

Up to 80% of all cases of esophageal foreign bodies occur in children aged 6 months to 3 years. The most common site is the cricopharynx.^[16]

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Prognosis

Morbidity/mortality

Most foreign bodies pass harmlessly through the GI tract and are eliminated in the stool.

Systemic reactions, such as from nickel allergy, are unusual but have been reported, typically in massive ingestions or occupational exposures.

Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring, or perforation. Complications include the following:

• Esophageal foreign body migration may lead to peritonitis, mediastinitis, pneumothorax, pneumomediastinum, pneumonia, or other respiratory disease.
• Migration into the aorta may produce an aortoenteric fistula, a horrific complication with a high mortality rate.
• Esophageal button batteries may cause substantial mucosal injury in as few as 2 hours.^[17]
• Swallowed magnets in the intestines may strongly attract other swallowed magnets or metallic objects through mucosal tissues, leading to ulceration, pressure necrosis, fistula creation, or perforation.^{[6, 7, 8]}  A swallowed combination of magnets and button batteries may be especially dangerous.^[9]

Complications of removal procedures may lead to iatrogenic morbidity or mortality from the procedure or from accompanying sedation/anesthesia.

Traumatic epiglottitis has been reported in conjunction with foreign body ingestion, due to epiglottis injury from a finger sweep or from the swallowed object itself, even after the object has been removed or expelled.^[18]

Complications

Esophageal foreign bodies complications include the following:

• Mucosal abrasion
• Esophageal stricture/obstruction
• Retropharyngeal abscess
• Failure to thrive
• Esophageal perforation may lead to mediastinitis, pneumothorax, pneumomediastinum, aortoesophageal fistula formation (and resulting hemorrhage), and tracheal compression.

Stomach/lower GI tract foreign body complications include the following:

• Mucosal abrasion
• Intestinal obstruction

Intestinal perforation may lead to peritonitis and sepsis.

Button (disk) batteries

Data suggest that ingestion of button batteries has become an increasingly important cause of morbidity and mortality in children, likely because of button batteries' increased availability and the increased production of electrical current in modern lithium batteries of ≥20 mm diameter.^[19]  Children 4 years or younger who have swallowed lithium batteries ≥20 mm diameter are at greatest risk of complication.^[17]  A study by Lee et al that included 5 cases of pediatric lithium battery ingestion, found that all cases had moderate to major complications to their esophagus or gastric mucosa, even in children who did not exhibit symptoms post ingestion. Urgent removal within 24 hours is recommended for even the asymptomatic child with a known lithium battery ingestion.^[20]

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History

Children commonly come to medical attention after a caregiver witnesses the ingestion of a foreign body or after a child reports an ingestion to a caregiver. Alternatively, the child may present because of signs or symptoms of a complication of ingestion. Occasionally, the caregiver discovers a foreign body that has passed in the stool and brings the child in for evaluation.

Children with significant complications of foreign body ingestion may be initially asymptomatic. Children may have vague symptoms that do not immediately suggest foreign body ingestion. When caring for children, always keep the possibility of foreign body ingestion in mind.

Esophageal foreign body symptoms include the following:

• Dysphagia
• Food refusal, weight loss
• Drooling, gagging
• Emesis/hematemesis
• Foreign body sensation
• Chest pain, sore throat
• Stridor, cough
• Unexplained fever
• Altered mental status

Stomach/lower GI tract foreign body symptoms include the following:

• Abdominal distention/pain, vomiting
• Hematochezia
• Unexplained fever

A study by Labadie et al of 415 button battery ingestions identified the following symptoms associated with severe adverse effects and death^[21] ​:

• Dyspnea
• Cough
• Dysphagia
• Drooling
• Fever
• Hemodynamic instability
• Pain
• Pallor
• Vomiting

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Physical Examination

Specific physical examination findings are unusual.

Physical findings may suggest complications of foreign body migration, such as peritoneal irritation or rales.

Abrasions, streaks of blood, or edema in the hypopharynx may be evidence of proximal swallowing-related trauma. Inspection of the oropharynx may occasionally reveal an impacted foreign body.^[22]

Drooling or pooling of secretions suggests an esophageal foreign body but may be due to an esophageal abrasion as a result of a swallowed foreign body.

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Laboratory Studies

Children with foreign body ingestion typically do not require laboratory testing.

Laboratory studies may be indicated for workup of specific complications, such as potential infection.

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Imaging Studies

Chest/abdominal radiography

Most ingested foreign bodies are radiopaque (in contrast to inhaled foreign bodies which usually are radiolucent).

If the swallowed object may be radiopaque, a single frontal radiograph that includes the neck, chest, and entire abdomen is usually sufficient to locate the object. Subsequent, focused radiographs may then be used to more fully evaluate the patient, as noted below.

If the object is below the diaphragm, further radiographs are generally unnecessary (in the absence of previous GI disorders, such as repaired pyloric stenosis).

If the object is in the esophagus, frontal and lateral chest radiographs are necessary to precisely locate and better identify the object and to be sure that the foreign body is not, in fact, two adherent objects.

Button (disk) batteries typically have distinctive appearances on radiographs. A lateral view reveal a distinctive 2-step border, as opposed to the smooth borders of most coins (although this may also be the result of 2 adherent coins of different size^[23] ). Frontal views may suggest a corresponding ring just inside the outermost ring of the battery. A magnified digital radiographic image of an object may reveal identifying characteristics allowing identification of the swallowed object, such as the distinctive design of a well-known coin.^[24]

Coins and similarly shaped objects in the chest may be localized to either the esophagus or the airway by their position on a frontal radiograph. With rare exceptions,^[25] coins in the esophagus appear in the coronal orientation (ie, coin seen as a disk on frontal view), while coins in the trachea appear in the sagittal orientation (ie, coin seen from the side on frontal view).

If the ingested object is radiolucent, the object's location may be inferred from effects (eg, airway compression) seen on plain radiographs. However, such findings are not reliable.

Radiolucent objects in the esophagus may be better visualized by repeating the study after having the child drink a small amount of dilute contrast (esophagram). This should not be done if endoscopy is planned. Special care must be taken if the esophagus could possibly be obstructed or perforated.

When a foreign body is strongly suspected on clinical grounds, visualization by endoscopy, which has the added advantage of allowing removal of the object, may be the most efficient method of management.

CT and MRI

CT scan or MRI is rarely indicated but may enhance the detection of foreign bodies or complications (eg, perforations) in special cases.

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Other Tests

Metal detectors

The use of handheld metal detectors to identify the location of ingested metallic objects (especially coins) has proven sensitive and specific.^[26] In the case of aluminum (eg, flip top of a soda can), a metal detector may be more sensitive since aluminum is often radiolucent.^[27] The operator should have experience with this modality before using it for patient care.

Patients with coins localized to the abdomen may be safely observed. However, patients with coins localized in the esophagus probably should have confirmatory plain radiographs.

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Procedures

Endoscopy

Endoscopy (esophagoscopy) may be diagnostic and therapeutic.

Children who require extensive radiologic investigation may be best served by referral to a pediatric gastroenterologist or surgeon for endoscopy, which is safe and highly effective.

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Prehospital Care

Most children who have swallowed a foreign body do not require specialized care. For the large majority, providing comfort care while transporting to an emergency department is all that is required.

Patients with drooling may require suction.

Children benefit by being allowed to remain with their parents and being allowed to assume a position of comfort.

Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Children should not routinely be intubated to protect their airways.

Similarly, do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.

If available, discussions regarding management of unusual foreign bodies with the local poison control center may be helpful.

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Emergency Department Care

The usual goal of ED management is to localize the position of the ingested foreign body. Patients with drooling, marked emesis, or altered mental status (likely from excess vagal stimulation) may require supportive measures to protect the airway.

Most patients should undergo radiographic imaging as described above. Metal detectors may be used to locate metallic foreign bodies. Even radiopaque foreign bodies may be difficult to localize. Referral for endoscopy should be considered.

Remember that children with no symptoms may have impacted foreign bodies and that children with foreign body sensation or pain may not. Radiographs of about 15% of children presenting to the ED after witnessed coin ingestions do not show a coin. Although some will have vomited or otherwise removed the ingested object before their evaluation, this suggests that not all children with even witnessed foreign body ingestions have truly ingested something.

Esophageal foreign bodies

Objects found within the esophagus should generally be considered impacted. Because impacted esophageal foreign bodies may lead to significant morbidity (and even mortality), removal of impacted esophageal foreign bodies is mandatory. An important exception is blunt esophageal foreign bodies (except button [disk] batteries) that are well tolerated and are known to have been in place for less than 24 hours (see Spontaneous passage below).

Endoscopy (esophagoscopy) is by far the most commonly used means of removal and is usually the procedure of choice. Most children with esophageal foreign bodies are stable. Endoscopy usually can be delayed until the child's stomach is emptied and a surgical team is assembled. However, pointed objects, such as an embedded esophageal thumbtack, should be removed as rapidly as possible to avoid further injury to the esophageal mucosa and mediastinitis. Impacted button (disk) batteries are notorious for rapidly causing local necrosis and should be emergently removed. Children with esophageal food impaction, an unusual finding in childhood, may benefit from endoscopic evaluation, perhaps with biopsies, of the esophageal mucosa.^[2]

Because endoscopy is relatively invasive and expensive, other methods of esophageal foreign body removal have been investigated^[28] and are probably more cost-effective when used appropriately. Both have been performed most commonly on children with esophageal coins. Because any esophageal foreign body may pass spontaneously, chest radiography should be performed immediately prior to any removal procedure. Other methods of esophageal foreign body removal are as follows:

• Foley catheter method: Blunt foreign bodies may be removed by use of a Foley catheter. Typically, the patient is restrained in a head-down position on a fluoroscopy table, and an uninflated catheter is passed until distal to the object. The catheter is then inflated and gently withdrawn, drawing the foreign body with it. One some occasions, the object is dislodged and passed into the stomach. Progress is typically monitored fluoroscopically. This procedure is performed without radiographic monitoring at some centers with extensive experience.  Only experienced personnel should perform this procedure, and it should be reserved for previously healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.
• Bougienage method: Blunt esophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the esophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat radiograph should follow any removal procedure to rule out retained foreign bodies and other complications (eg, pneumomediastinum). Because any esophageal foreign body may pass spontaneously, chest radiography should be performed immediately prior to any removal procedure. Again, only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.
• The Foley catheter and bougienage methods have been shown to be more cost-effective than endoscopy, for properly selected patients.^{[29, 30, 31, 32, 33]}
• Emergency department rapid sequence intubation, followed by removal of esophageal coins with Magill forceps and/or a Foley catheter, may be effective in children.^[34]
• Spontaneous passage: Blunt foreign bodies located at the LES often spontaneously pass within several hours of ingestion. This has been best studied in coin ingestions. Previously healthy children may be given food and drink and have repeat radiographs 24 hours following ingestion. Often, the coin passes through the LES, and a removal procedure can be avoided.^{[1, 35]} This may be most successful in asymptomatic children.
• Complications: Children with significant complications such as airway involvement, peritonitis, or hematemesis (possibly heralding exsanguination from an aortoenteric fistula), should be referred to an appropriate surgeon without delay.

Stomach/lower GI tract

Most swallowed foreign bodies harmlessly pass through the GI tract once they have reached the stomach. Treatment of children with known abnormalities of the GI tract or previous problems with foreign bodies should be discussed with a specialist, preferably one familiar with the child.

Unusual foreign bodies: Very sharp or pointed objects may perforate the GI tract (sewing needles are notorious). Therefore, such objects should be endoscopically removed from the stomach. If such an object has passed into the intestines, early consultation with a surgeon is recommended. Objects that are too long (eg, >6 cm) or too wide (eg, >2 cm) to pass through the pyloric sphincter should be removed from the stomach.

Button (disk) batteries in the stomach or intestines do not need to be removed immediately, as they generally pass through the lower GI tract without difficulty. Button batteries retained in the stomach or at a fixed spot in the intestines should be removed. One strategy is to instruct families to observe the stool for the battery and to return for a repeat radiograph if it is not passed in 2-3 days. If a battery is still in the stomach at that time, it should be endoscopically removed. If it is in the intestines, its progress should be intermittently monitored via radiographs, to be sure it is progressing.

Body packers (ie, patients who have ingested wrapped packages of drugs to avoid detection during transport) are at risk of death if the packets rupture. Such patients should be hospitalized and whole-bowel irrigation considered. Consultation with a poison control center is suggested.

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Consultations

The treatment of children with known GI tract disorders should be discussed with a physician familiar with the child whenever possible.

Experienced personnel, such as a pediatric surgeon, otolaryngologist, or gastroenterologist, should perform endoscopy.

Psychiatric consultation is indicated for those with a suspected or confirmed associated psychiatric problem.

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Surgical Care

A study presented the outcome of surgical treatment of esophageal perforations due to foreign body impaction in children along with a management algorithm. The study concluded that esophageal perforation following foreign body impaction is rare and requires prompt treatment. Surgical treatment tailored to the needs of individual patients is associated with a successful outcome and decreased morbidity.^[36]

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Medication Summary

Although drugs such as glucagon, benzodiazepines, and nifedipine have been successfully used to relax the lower esophageal sphincter in adult patients with esophageal foreign bodies, these measures are generally unsuccessful in children.

Laxatives are occasionally prescribed to hasten the passage of intestinal foreign bodies. While they likely lead to speedier passage, this is not necessarily associated with improved health of the patient, and so laxative use is not generally recommended. Specific circumstances may exist in which laxatives may be helpful, however.

The use of meat tenderizer (papain) to attempt to digest meat impacted in the esophagus is no longer recommended. Such usage may severely injure the esophagus.

Inducing vomiting may lead to aspiration, and so should be avoided.

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Further Outpatient Care

After an esophageal foreign body is removed, children with uncomplicated courses do not need to undergo further evaluation.

A healthy child with repeated foreign body impaction or impaction at an unusual site should be evaluated for an underlying esophageal disorder.

Most children with foreign bodies in the stomach or lower GI tract have no complications and may be safely discharged from the emergency department. Caregivers of discharged children should be alerted to return if signs or symptoms of the occasional complication (eg, abdominal pain or distention, hematochezia, unexplained fevers, constipation, vomiting) develop.

Patients with known abnormalities of the GI tract, previous problems with foreign bodies, or unusual foreign bodies may require special treatment.

In general, straining of the stool for the foreign body is unnecessary.

Except in special instances, serial radiographs to document progress are unnecessary. This would be most useful if the results would be used to direct therapy, such as prolonged gastric retention of zinc coins, which may be indications for gastroscopic removal. Button batteries remaining in the stomach for 4 or more days, especially if associated with symptoms or if the battery is ≥15 mm in diameter in a child younger than 6, should be considered for removal.^{[17, 37]}

The continued presence of a metallic foreign body may be documented by serial metal detector scans.

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Further Inpatient Care

Children who require endoscopic foreign body removal are usually taken directly to the operating room or endoscopy suite or are admitted preoperatively. These patients should be given nothing by mouth (NPO) and be given glucose-containing intravenous fluids until the procedure.

Preprocedure radiographs to verify the location of the foreign body are recommended, as some foreign bodies may pass into the stomach while awaiting endoscopy.

General anesthesia often is used for endoscopic foreign body removal. However, sedation performed by experienced personnel may be successful in selected cases.

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Transfer

Most children do not require a removal procedure, and they may be treated at any facility capable of obtaining radiographs of children.

Children who require foreign body removal procedures should be referred to a facility with experienced personnel.

Familiarity with pediatric airway emergencies is essential.

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Deterrence/Prevention

Parents and other caregivers of children should be cautioned about leaving small objects where young children may find them and place them into their mouths. This is especially common at times of unusual activity, such as parties, holidays, when visitors are present in the home, or during travel.

Button batteries have become an increasingly common source of morbidity and even mortality as their use has increased in recent years. Special care must be exercised around their use in toys and other objects to which children have access, when they are discarded, and when stored around the home.^{[17, 38]}

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