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.
View Image | A swallowed coin lodged at the thoracic inlet. Image courtesy of Gregory Conners, MD, MPH. |
View Image | A swallowed radiolucent object (plastic guitar pick) is made visible in the upper esophagus after ingestion of barium. Image courtesy of Raymond K. Ta.... |
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.
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.
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.
United States
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.[10] 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).[11]
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%).[12]
International
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.[13] 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.[14]
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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.
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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.
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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.[32]
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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For excellent patient education resources, visit eMedicineHealth's Digestive Disorders Center. Also, see eMedicineHealth's patient education article Battery Ingestion.