Pediatrics, Foreign Body Ingestion: Treatment & Medication
Most children who have swallowed a foreign body do not require specialized care.
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.
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 (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. This suggests that not all foreign bodies whose ingestions were witnessed were really ingested.
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 should be removed as rapidly as possible to avoid further injury to the esophageal mucosa. Impacted button (disk) batteries are notorious for rapidly causing local necrosis and should be removed from the esophagus without delay.
Because endoscopy is relatively invasive and expensive, 2 other methods of esophageal foreign body removal have been investigated and are probably more cost-effective when used appropriately. Both have been performed most commonly on children with esophageal coins.
Foley catheter method: Blunt foreign bodies may be removed by use of a Foley catheter. The patient is restrained in a head-down position on a fluoroscopy table, and an uninflated catheter is inserted distal to the object. The catheter is then inflated and gently withdrawn, drawing the foreign body with it. 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 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.
In recent studies, the Bougienage method has been shown to be far more cost-effective than endoscopy, for properly selected patients.9,10,11
More recently, use of Magill forceps for removal of foreign bodies high in the esophagus has been described.
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.12,9 Although blunt foreign bodies located in other areas of the esophagus are less likely to spontaneously pass, this strategy may be an appropriate alternative for stable children with normal esophageal anatomy and a foreign body in the thoracic inlet or the mid esophagus. 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.
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.
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.
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.