eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Foreign Body Ingestion

Author: Gregory P Conners, MD, MPH, Chief, Division of Emergency Medical Services, Children's Mercy Hospital; Vice Chair of Pediatrics for Emergency and Urgent Care; Professor of Pediatrics and Emergency Medicine, University of Missouri-Kansas City School of Medicine
Contributor Information and Disclosures

Updated: Apr 21, 2009

Introduction

Background

As children explore 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 after 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.

A swallowed coin lodged at the thoracic inlet. Im...

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

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A swallowed coin lodged at the thoracic inlet. Im...

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


A swallowed radiolucent object (plastic guitar pi...

A swallowed radiolucent object (plastic guitar pick) is made visible in the upper esophagus after ingestion of barium. Image courtesy of Raymond K. Tan, MD, and Gregory Conners, MD, MPH.

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A swallowed radiolucent object (plastic guitar pi...

A swallowed radiolucent object (plastic guitar pick) is made visible in the upper esophagus after ingestion of barium. Image courtesy of Raymond K. Tan, MD, and Gregory Conners, MD, MPH.


Pathophysiology

Esophagus

Most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at 1 of 3 typical locations. 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.

Pointed objects, such as thumbtacks, may become impaled and, therefore, lodged anywhere in the esophagus. Small objects, such as pills, 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.1 Foreign-body induced appendicitis has been reported.2  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.3,4,5

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.

Frequency

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 2007.6 In a recent 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).

International

International data are scant, but 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.

Mortality/Morbidity

  • 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 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.7

Sex

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

Age

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.

Clinical

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
    • Dysphagia
    • Food refusal, weight loss
    • Drooling
    • Emesis/hematemesis
    • Foreign body sensation
    • Chest pain, sore throat
    • Stridor, cough
    • Unexplained fever
    • Altered mental status
  • Stomach/lower GI tract foreign bodies
    • Abdominal distention/pain, vomiting
    • Hematochezia
    • Unexplained fever

Physical

  • 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.
  • 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.

Causes

  • Most cases occur as children discover and place small objects in their mouths.
  • Repeated cases 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, a well-established association exists between toothbrush ingestions and bulimia in teenaged girls.8

More on Pediatrics, Foreign Body Ingestion

Overview: Pediatrics, Foreign Body Ingestion
Differential Diagnoses & Workup: Pediatrics, Foreign Body Ingestion
Treatment & Medication: Pediatrics, Foreign Body Ingestion
Follow-up: Pediatrics, Foreign Body Ingestion
Multimedia: Pediatrics, Foreign Body Ingestion
References
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References

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Further Reading

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Keywords

foreign body ingestion in children, swallowed object, battery ingestion, swallowed magnet, swallowed foreign bodies, coins, pins, screws, button batteries, disk batteries, toy parts, esophageal impaction, aortoenteric fistula, esophageal foreign body, stomach foreign body, lower GI foreign body, mucosal abrasion, intestinal obstruction, esophageal obstruction, retropharyngeal abscess, esophageal perforation

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Contributor Information and Disclosures

Author

Gregory P Conners, MD, MPH, Chief, Division of Emergency Medical Services, Children's Mercy Hospital; Vice Chair of Pediatrics for Emergency and Urgent Care; Professor of Pediatrics and Emergency Medicine, University of Missouri-Kansas City School of Medicine
Gregory P Conners, MD, MPH is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Wayne Wolfram, MD, MPH, 
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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