Pediatric foreign body: Difference between revisions

(Created page with "'''Pediatric foreign body''' refers to the ingestion, aspiration, or insertion of a foreign object by a child, most commonly occurring in children aged 6 months to 3 years.<ref>Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB. Foreign-body ingestions of young children treated in US emergency departments: 1995-2015. ''Pediatrics''. 2019;143(5):e20181988.</ref> Foreign bodies may lodge in the airway, esophagus, gastrointestinal tract, ear, Nasal...")
 
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'''Pediatric foreign body''' refers to the ingestion, aspiration, or insertion of a foreign object by a child, most commonly occurring in children aged 6 months to 3 years.<ref>Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB. Foreign-body ingestions of young children treated in US emergency departments: 1995-2015. ''Pediatrics''. 2019;143(5):e20181988.</ref> Foreign bodies may lodge in the airway, esophagus, gastrointestinal tract, [[Ear foreign body|ear]], [[Nasal foreign body|nose]], or [[Vaginal foreign body|vagina]].
==Background==
*Pediatric foreign body refers to the ingestion, aspiration, or insertion of a foreign object by a child, most commonly occurring in children aged 6 months to 3 years.<ref>Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB.
*Foreign-body ingestions of young children treated in US emergency departments: 1995-2015. ''Pediatrics''. 2019;143(5):e20181988.</ref>
*Foreign bodies may lodge in the airway, esophagus, gastrointestinal tract, [[Ear foreign body|ear]], [[Nasal foreign body|nose]], or [[Vaginal foreign body|vagina]].
 


==Background==
* Foreign body ingestion and aspiration are among the most common pediatric emergencies
* Foreign body ingestion and aspiration are among the most common pediatric emergencies
* Peak incidence is between 1 and 3 years of age<ref>Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the airways: a meta-analysis of published papers. ''Int J Pediatr Otorhinolaryngol''. 2012;76 Suppl 1:S12-19.</ref>
* Peak incidence is between 1 and 3 years of age<ref>Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the airways: a meta-analysis of published papers. ''Int J Pediatr Otorhinolaryngol''. 2012;76 Suppl 1:S12-19.</ref>
* Male-to-female ratio is approximately 2:1<ref>Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign bodies: a critical review for a common pediatric emergency. ''World J Emerg Med''. 2016;7(1):5-12.</ref>
* Male-to-female ratio is approximately 2:1<ref>Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign bodies: a critical review for a common pediatric emergency. ''World J Emerg Med''. 2016;7(1):5-12.</ref>
* '''Ingestion''' accounts for the majority of cases
* Ingestion accounts for the majority of cases
** Coins are the most commonly ingested foreign body in the United States<ref>Conners GP. Pediatric foreign body ingestion: complications and patient and foreign body factors. ''Sci''. 2022;4(2):20.</ref>
** Coins are the most commonly ingested foreign body in the United States<ref>Conners GP. Pediatric foreign body ingestion: complications and patient and foreign body factors. ''Sci''. 2022;4(2):20.</ref>
** Most ingested objects (80-90%) pass spontaneously through the GI tract
** Most ingested objects (80-90%) pass spontaneously through the GI tract
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* [[Retropharyngeal abscess]]
* [[Retropharyngeal abscess]]
* [[Anaphylaxis]]
* [[Anaphylaxis]]
* [[Globus sensation]]
* Globus sensation


==Evaluation==
==Evaluation==


===Workup===
===Workup===
* '''Radiographs'''
* Radiographs
** AP and lateral views of neck, chest, and abdomen for suspected ingestion or aspiration
** AP and lateral views of neck, chest, and abdomen for suspected ingestion or aspiration
** Coins in the esophagus appear as a round disc on AP view (en face) and a line on lateral
** Coins in the esophagus appear as a round disc on AP view (en face) and a line on lateral
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** Normal radiographs do not exclude foreign body (radiolucent objects such as fish bones, plastic, wood are not visible)
** Normal radiographs do not exclude foreign body (radiolucent objects such as fish bones, plastic, wood are not visible)
** Inspiratory/expiratory films or bilateral decubitus films may demonstrate air trapping in aspirated foreign body
** Inspiratory/expiratory films or bilateral decubitus films may demonstrate air trapping in aspirated foreign body
* '''CT''' — consider if plain films are negative but clinical suspicion remains high
* CT — consider if plain films are negative but clinical suspicion remains high
* '''Metal detector''' — can be used for rapid identification of metallic objects in the esophagus<ref>Lee JB, Ahmad S, Gale CP. Detection of coins ingested by children using a handheld metal detector: a systematic review. ''Emerg Med J''. 2005;22(12):839-844.</ref>
* Metal detector — can be used for rapid identification of metallic objects in the esophagus<ref>Lee JB, Ahmad S, Gale CP. Detection of coins ingested by children using a handheld metal detector: a systematic review. ''Emerg Med J''. 2005;22(12):839-844.</ref>
* '''Barium swallow''' — generally NOT recommended (risk of aspiration, coats mucosa making endoscopy more difficult)
* Barium swallow — generally NOT recommended (risk of aspiration, coats mucosa making endoscopy more difficult)


===Diagnosis===
===Diagnosis===
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===Immediate airway management===
===Immediate airway management===
* If '''complete airway obstruction''':
* If complete airway obstruction:
** Infant (<1 year): 5 back blows followed by 5 chest thrusts
** Infant (<1 year): 5 back blows followed by 5 chest thrusts
** Child (>1 year): abdominal thrusts (Heimlich maneuver)
** Child (>1 year): abdominal thrusts (Heimlich maneuver)
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===Esophageal foreign body===
===Esophageal foreign body===
* '''[[Button battery ingestion]] in esophagus''' = '''EMERGENT removal within 2 hours'''<ref>Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. ''J Pediatr Gastroenterol Nutr''. 2015;60(4):562-574.</ref>
* [[Button battery ingestion]] in esophagus = EMERGENT removal within 2 hours<ref>Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. ''J Pediatr Gastroenterol Nutr''. 2015;60(4):562-574.</ref>
** Can cause liquefactive necrosis, perforation, and fistula formation within hours
** Can cause liquefactive necrosis, perforation, and fistula formation within hours
** Administer honey (10 mL every 10 min if age >12 months) or sucralfate as temporizing measure while awaiting endoscopy<ref>Anfang RR, Jatana KR, Engel RM, et al. Use of honey to mitigate lithium coin battery injury: a laboratory study. ''Laryngoscope''. 2019;129(10):2237-2243.</ref>
** Administer honey (10 mL every 10 min if age >12 months) or sucralfate as temporizing measure while awaiting endoscopy<ref>Anfang RR, Jatana KR, Engel RM, et al. Use of honey to mitigate lithium coin battery injury: a laboratory study. ''Laryngoscope''. 2019;129(10):2237-2243.</ref>
** Contact [[Poison control]] (National Battery Ingestion Hotline: 1-800-498-8666)
** Contact [[Poison control]] (National Battery Ingestion Hotline: 1-800-498-8666)
* '''Multiple magnets or magnet + metallic object''' = '''Emergent endoscopic removal'''
* Multiple magnets or magnet + metallic object = Emergent endoscopic removal
** Can cause pressure necrosis, fistula, perforation, and bowel obstruction between loops<ref>Nugud AA, Tzivinikos C, Assa A, et al. Pediatric magnet ingestion, diagnosis, management, and prevention: an ESPGHAN position paper. ''J Pediatr Gastroenterol Nutr''. 2023;76(4):523-532.</ref>
** Can cause pressure necrosis, fistula, perforation, and bowel obstruction between loops<ref>Nugud AA, Tzivinikos C, Assa A, et al. Pediatric magnet ingestion, diagnosis, management, and prevention: an ESPGHAN position paper. ''J Pediatr Gastroenterol Nutr''. 2023;76(4):523-532.</ref>
** Single magnet ingestion can typically be observed if asymptomatic
** Single magnet ingestion can typically be observed if asymptomatic
** Confirm single magnet with lateral radiograph (multiple magnets may stack)
** Confirm single magnet with lateral radiograph (multiple magnets may stack)
* '''Sharp or pointed objects in esophagus''' = '''Urgent endoscopic removal'''
* Sharp or pointed objects in esophagus = Urgent endoscopic removal
* '''Coins or blunt objects in esophagus'''
* Coins or blunt objects in esophagus
** Observe for up to 12-24 hours (may pass spontaneously in ~30% of cases)<ref>Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. ''Pediatrics''. 2005;116(3):614-619.</ref>
** Observe for up to 12-24 hours (may pass spontaneously in ~30% of cases)<ref>Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. ''Pediatrics''. 2005;116(3):614-619.</ref>
** [[Esophageal foreign body removal with foley catheter|Foley catheter removal]] may be considered for smooth, blunt objects impacted <24 hours
** [[Esophageal foreign body removal with foley catheter|Foley catheter removal]] may be considered for smooth, blunt objects impacted <24 hours
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===Ear and nasal foreign body===
===Ear and nasal foreign body===
* See [[Ear foreign body]] and [[Nasal foreign body]]
* See [[Ear foreign body]] and [[Nasal foreign body]]
* '''[[Button battery ingestion]] in ear or nose''' = '''Emergent removal'''
* [[Button battery ingestion]] in ear or nose = Emergent removal
* Multiple removal techniques available (irrigation, suction, alligator forceps, balloon catheter, "parent's kiss")
* Multiple removal techniques available (irrigation, suction, alligator forceps, balloon catheter, "parent's kiss")


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==Disposition==
==Disposition==
* '''Admit/OR''' if:
* Admit/OR if:
** Esophageal [[button battery ingestion]] (emergent OR)
** Esophageal [[button battery ingestion]] (emergent OR)
** Multiple magnet ingestion with concern for impaction
** Multiple magnet ingestion with concern for impaction
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** Airway foreign body requiring bronchoscopy
** Airway foreign body requiring bronchoscopy
** Symptomatic patient with signs of perforation, obstruction, or respiratory compromise
** Symptomatic patient with signs of perforation, obstruction, or respiratory compromise
* '''Discharge''' if:
* Discharge if:
** Asymptomatic with blunt object beyond the esophagus
** Asymptomatic with blunt object beyond the esophagus
** Successful removal of foreign body with asymptomatic post-removal observation
** Successful removal of foreign body with asymptomatic post-removal observation
** Provide strict return precautions: abdominal pain, vomiting, bloody stools, fever
** Provide strict return precautions: abdominal pain, vomiting, bloody stools, fever
** Caregiver education on prevention (keep small objects out of reach, age-appropriate foods)
** Caregiver education on prevention (keep small objects out of reach, age-appropriate foods)
* '''Follow-up'''
* Follow-up
** Serial imaging for retained gastric/intestinal foreign bodies if not removed
** Serial imaging for retained gastric/intestinal foreign bodies if not removed
** Return for repeat radiograph if object not passed within 4 weeks
** Return for repeat radiograph if object not passed within 4 weeks

Latest revision as of 09:30, 22 March 2026

Background

  • Pediatric foreign body refers to the ingestion, aspiration, or insertion of a foreign object by a child, most commonly occurring in children aged 6 months to 3 years.[1]
  • Foreign bodies may lodge in the airway, esophagus, gastrointestinal tract, ear, nose, or vagina.


  • Foreign body ingestion and aspiration are among the most common pediatric emergencies
  • Peak incidence is between 1 and 3 years of age[2]
  • Male-to-female ratio is approximately 2:1[3]
  • Ingestion accounts for the majority of cases
    • Coins are the most commonly ingested foreign body in the United States[4]
    • Most ingested objects (80-90%) pass spontaneously through the GI tract
  • Aspiration is responsible for approximately 7% of accidental deaths in children under 3 years of age[5]
    • Organic material (nuts, seeds) most common in younger children
    • Inorganic objects (toy parts, pen caps) more common in older children
  • Risk factors include:
    • Absence of molar teeth (unable to properly grind food)
    • Immature swallowing coordination and laryngeal protective reflexes
    • Tendency to explore the environment orally
    • Eating while playing or running

Clinical Features

Ingested foreign body

  • Often asymptomatic if object has passed beyond the esophagus
  • Dysphagia
  • Drooling
  • Odynophagia
  • Vomiting or refusal to eat
  • Chest or abdominal pain
  • Globus sensation
  • If esophageal impaction: risk of airway obstruction, pooling of secretions

Aspirated foreign body

  • Classic triad: acute choking, cough, and wheezing[6]
  • Stridor (if laryngeal or tracheal)
  • Unilateral decreased breath sounds
  • Recurrent or persistent pneumonia (delayed presentation)
  • Asymptomatic period may follow initial choking episode ("symptom-free interval")

Ear foreign body

Nasal foreign body

Differential Diagnosis

Evaluation

Workup

  • Radiographs
    • AP and lateral views of neck, chest, and abdomen for suspected ingestion or aspiration
    • Coins in the esophagus appear as a round disc on AP view (en face) and a line on lateral
    • Button battery ingestion appears as a "double contour" or "halo sign" on AP view — critical to distinguish from coin[7]
    • Normal radiographs do not exclude foreign body (radiolucent objects such as fish bones, plastic, wood are not visible)
    • Inspiratory/expiratory films or bilateral decubitus films may demonstrate air trapping in aspirated foreign body
  • CT — consider if plain films are negative but clinical suspicion remains high
  • Metal detector — can be used for rapid identification of metallic objects in the esophagus[8]
  • Barium swallow — generally NOT recommended (risk of aspiration, coats mucosa making endoscopy more difficult)

Diagnosis

  • Diagnosis is often based on history (witnessed event, acute choking)
  • High index of suspicion in young children with unexplained respiratory symptoms, dysphagia, or recurrent pneumonia
  • Up to 40% of cases may have no witnessed aspiration event
  • Bronchoscopy is both diagnostic and therapeutic for airway foreign bodies

Management

Immediate airway management

  • If complete airway obstruction:
    • Infant (<1 year): 5 back blows followed by 5 chest thrusts
    • Child (>1 year): abdominal thrusts (Heimlich maneuver)
    • If object is visible, remove with Magill forceps — do NOT perform blind finger sweep
    • If unable to ventilate: attempt intubation (may push object distally, converting to partial obstruction)
    • Last resort: Cricothyrotomy (needle or surgical) or tracheostomy
  • See Aspirated foreign body

Esophageal foreign body

  • Button battery ingestion in esophagus = EMERGENT removal within 2 hours[9]
    • Can cause liquefactive necrosis, perforation, and fistula formation within hours
    • Administer honey (10 mL every 10 min if age >12 months) or sucralfate as temporizing measure while awaiting endoscopy[10]
    • Contact Poison control (National Battery Ingestion Hotline: 1-800-498-8666)
  • Multiple magnets or magnet + metallic object = Emergent endoscopic removal
    • Can cause pressure necrosis, fistula, perforation, and bowel obstruction between loops[11]
    • Single magnet ingestion can typically be observed if asymptomatic
    • Confirm single magnet with lateral radiograph (multiple magnets may stack)
  • Sharp or pointed objects in esophagus = Urgent endoscopic removal
  • Coins or blunt objects in esophagus
    • Observe for up to 12-24 hours (may pass spontaneously in ~30% of cases)[12]
    • Foley catheter removal may be considered for smooth, blunt objects impacted <24 hours
    • Endoscopy if object does not pass or if symptomatic

Gastric and intestinal foreign body

  • Most blunt objects that reach the stomach will pass without intervention
  • Indications for endoscopic removal from the stomach:
    • Objects >2.5 cm in diameter or >6 cm in length
    • Sharp objects
    • Button battery ingestion remaining in stomach >48 hours (controversial; some experts advocate earlier removal)
    • Symptomatic patients
  • Expectant management with serial imaging for small, blunt, asymptomatic objects
    • Repeat imaging if object has not passed within 4 weeks

Ear and nasal foreign body

Airway foreign body

  • Rigid bronchoscopy is the gold standard for removal in children[13]
  • Flexible bronchoscopy may be used as an adjunct
  • Consider ENT and/or anesthesia consultation
  • Post-removal: consider dexamethasone, bronchodilators, and/or racemic epinephrine

Disposition

  • Admit/OR if:
    • Esophageal button battery ingestion (emergent OR)
    • Multiple magnet ingestion with concern for impaction
    • Sharp esophageal foreign body
    • Airway foreign body requiring bronchoscopy
    • Symptomatic patient with signs of perforation, obstruction, or respiratory compromise
  • Discharge if:
    • Asymptomatic with blunt object beyond the esophagus
    • Successful removal of foreign body with asymptomatic post-removal observation
    • Provide strict return precautions: abdominal pain, vomiting, bloody stools, fever
    • Caregiver education on prevention (keep small objects out of reach, age-appropriate foods)
  • Follow-up
    • Serial imaging for retained gastric/intestinal foreign bodies if not removed
    • Return for repeat radiograph if object not passed within 4 weeks

See Also

External Links

References

  1. ↑ Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB.
    • Foreign-body ingestions of young children treated in US emergency departments: 1995-2015. Pediatrics. 2019;143(5):e20181988.
  2. ↑ Foltran F, Ballali S, Passali FM, et al. Foreign bodies in the airways: a meta-analysis of published papers. Int J Pediatr Otorhinolaryngol. 2012;76 Suppl 1:S12-19.
  3. ↑ Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign bodies: a critical review for a common pediatric emergency. World J Emerg Med. 2016;7(1):5-12.
  4. ↑ Conners GP. Pediatric foreign body ingestion: complications and patient and foreign body factors. Sci. 2022;4(2):20.
  5. ↑ Passali D, Lauriello M, Bellussi L, Passali GC, Passali FM, Gregori D. Foreign body inhalation in children: an update. Acta Otorhinolaryngol Ital. 2010;30(1):27-32.
  6. ↑ Zerella JT, Dimler M, McGill LC, Pippus KJ. Foreign body aspiration in children: value of radiography and complications of bronchoscopy. J Pediatr Surg. 1998;33(11):1651-1654.
  7. ↑ Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177.
  8. ↑ Lee JB, Ahmad S, Gale CP. Detection of coins ingested by children using a handheld metal detector: a systematic review. Emerg Med J. 2005;22(12):839-844.
  9. ↑ Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562-574.
  10. ↑ Anfang RR, Jatana KR, Engel RM, et al. Use of honey to mitigate lithium coin battery injury: a laboratory study. Laryngoscope. 2019;129(10):2237-2243.
  11. ↑ Nugud AA, Tzivinikos C, Assa A, et al. Pediatric magnet ingestion, diagnosis, management, and prevention: an ESPGHAN position paper. J Pediatr Gastroenterol Nutr. 2023;76(4):523-532.
  12. ↑ Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116(3):614-619.
  13. ↑ Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010;111(4):1016-1025.
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