Foreign Body Ingestion in Children

It is inevitable that children will put objects into their mouths from time to time, and sometimes they end up swallowing them. The age group most prone to swallowing foreign bodies is preschoolers. Most of the time, it is either coins or non metallic sharp objects. X-rays can detect 100 percent of metallic objects swallowed, and about 85 percent of glass objects, while detection of fish bones is only about 25 percent. Children who swallow foreign bodies are not always symptomatic. About 50 percent have no symptoms at all. Often, non metallic sharp objects that are swallowed are lodged in an area that can be successfully removed with direct laryngoscopy alone. About 40 percent of swallowed coins can be removed in this manner. Absence of symptoms should not preclude presence of a foreign body in children. Particular attention should be paid to mentally handicapped children with vague GI symptoms.
Most swallowed foreign bodies pass harmlessly through the GI tract. However, if it has a sharp edge, is greater than 1 inch in diameter, or batteries, the patient must be evaluated as soon as possible. Children with preexisting GI abnormalities (eg. tracheoesophageal fistula, stenosing lesions, previous GI surgery)are at increased risk of complications and are more likely to retain foreign bodies in the stomach.
Most complications of pediatric foreign body ingestion are due to esophageal impaction either at the thoracic inlet, cricopharyngeus sling or the mid esophagus. Once the 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. Foreign-body induced appendicitis has been reported. Besides sharp, pointed, toxic, or objects that are too long or wide, 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. Systemic reactions, such as a nickel allergy, are unusual but have been reported.
Retained foreign bodies may cause GI mucosal erosion, abrasion, local scarring or perforation. 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 foreign body symptoms may include dysphagia, food refusal or weight loss, drooling, emesis or hematemesis, foreign body sensation, chest pain, sore throat, stridor, cough, unexplained fever or altered mental status.
Stomach/lower GI tract foreign body symptoms may include abdominal distention/pain, vomiting, hematochezia, or unexplained fever.
Most children who have swallowed a foreign body do not need specialized care. Although a theoretical risk of spontaneously vomiting and then aspiration of a foreign body exists, this is unusual. Do not attempt to dislodge a foreign body from a spontaneously breathing patient by giving abdominal thrusts or syrup of ipecac.
If the child is not at increased risk, asymptomatic, and the object swallowed is not determined to be harmful, homecare advice can be given. Reassure the parent that most anything that can get to the stomach will pass through the intestines over the next 3-4 days without difficulty. Test the child's ability to swallow foods. If no symptoms are present and the object was small and smooth, ask the parent to give the child some water to drink. If the water is swallowed easily, the child should be able to eat some bread or other soft foods. Inform the parent that most foreign bodies are passed in a normal BM in 3-4 days, and there is nothing you can do to hurry the process. Have the parent call back if the foreign body was not passed in 3 days, abdominal pain, vomiting or bloody stools develop, or the child becomes worse.