Check out the PedsDocTalk YouTube Video: Foreign Body Ingestion in Children for more details about the most common foreign bodies ingested by children, symptoms to monitor, when foreign body removal is typically indicated, and what endoscopic removal looks like.
You turn your head for one second, and when turning back, you realize your toddler has something in their mouth. Despite our best intentions, sometimes mistakes happen. You get them to spit it out, but wonder, what if they had actually swallowed something? When should you be worried? What should you look for?
Foreign body ingestion is when a child swallows an object not meant to be swallowed. Unfortunately, this is common, with over 100,000 incidents reported each year. More than 75% of those incidents occur in children. The most common age for foreign body ingestion is six months to three years. In this age group, 98% of objects swallowed are objects that are commonly found in households, including coins, beads, toys, jewelry, magnets, and batteries.
What are the signs of foreign body ingestion?
Many children have no symptoms at all and only present for evaluation because a caregiver witnessed ingestion. If symptoms do occur, they typically depend on where the object is located in the gastrointestinal (GI) tract.
If the object is in the esophagus, children may present with refusal to eat, drooling, trouble swallowing, noisier breathing, wheezing, or choking. Older children may report feeling something stuck in their throat or chest or complain their chest hurts.
Once the object passes through the esophagus into the stomach or intestines, the risk for injury is generally much lower (with a few exceptions). Typically, at this point, kids are asymptomatic unless the object is causing a blockage, which may present with vomiting, stomach pain, and inability to pass stool.
What is the evaluation of foreign body ingestion?
If there is a concern about a swallowed foreign object, it is 100% recommended to speak to your clinician’s office to discuss the next steps. The management will depend on what object was swallowed.
X-rays of the neck, chest, and abdomen may be needed. X-rays should be performed at two angles, from the front to the back and the side, to get the best look at the object. Some objects, like metal objects, show up really well on X-rays. Other objects are more challenging to see on X-rays. For example, objects made of glass are 43% detectable, fish bones are 26% detectable, and wood is completely radiolucent, meaning you cannot see it on an X-ray.
If the X-ray is negative, but there is still a high suspicion of a foreign body, a more detailed image, such as a CT or MRI, may be considered. If there is a high concern for a more dangerous foreign body or a child is showing symptoms, it may be recommended to proceed to an endoscopic evaluation. An endoscopy is a procedure that allows a doctor to look at the inside of a person’s body.
In an upper GI endoscopy, a pediatric GI doctor will insert a small tube with a camera on the end into the patient’s mouth to assess their upper GI system, including their esophagus, stomach, and the beginning of the small intestine. For this procedure, children are typically sedated with general anesthesia. Foreign bodies are commonly removed by endoscopy because it is minimally invasive and allows the clinician to visualize the foreign object, assess the GI tract for damage, and remove the foreign object.
When is intervention for foreign body ingestion needed?
Intervention depends on the type of object that was swallowed. Let’s talk about a few commonly ingested objects, such as button batteries, magnets, water beads, coins, pointed objects, and large objects.
Button batteries are the highest risk object if swallowed. These small, coin-shaped batteries can be found in remote controls, thermometers, watches, calculators, hearing aids, flashlights, toys, and even singing greeting cards. Even after being removed from the device, they still have a strong current.
An alkalizing reaction can occur when they come into contact with saliva, causing extensive tissue damage in as little as two hours. If the button battery is lodged in the esophagus, the risk for tissue damage is most significant, and immediate intervention is needed. Typically, emergent endoscopy is indicated.
Magnets are also commonly swallowed by children and can cause tissue damage. The swallowing of multiple magnets, in particular, carries a high risk of damage to the bowels and can even cause a perforation, or hole, in the bowels as magnets at different locations pull towards each other through body organs.
If two magnets are noted on the X-ray, endoscopic retrieval is necessary. Usually, if only one magnet is noted, observation is warranted. Sometimes removal is recommended if there is concern for the magnet being a rare earth magnet or if there is a concern that there may be two magnets stuck together.
Water beads or other superabsorbent materials
Superabsorbent polymers are used in various household products, like disposable diapers and feminine hygiene products, as well as toys, like water beads. These products can retain up to 100 times their weight in water. Toy water beads can rapidly expand with water, increasing in size by 30 to 60 times their original size. Several of these products were removed from the market in 2012 due to the risk, but many products still remain.
The management of these ingestions is particularly challenging because they are radiolucent, making them difficult to see on X-ray, and they generally pass easily through the GI tract until they reach the intestines, where they can rapidly increase in size, causing GI damage or obstruction. If there is a concern for ingestion of water beads or a similar product, emergent endoscopic removal is necessary, since they can grow in size and cause an obstruction In the bowel.
Coins are the most commonly swallowed object in children in the US, with over 250,000 reported in a 10-year period. The ability to pass the coin spontaneously without intervention depends on the size of the coin, the age of the child, and its position in the esophagus. On average, 30% of coins pass on their own. If an X-ray shows a coin in the esophagus, removal is typically recommended within 24 hours or sooner if respiratory symptoms develop.
Observation is typically recommended once the coin has passed to the stomach or intestines and the child has no symptoms. Monitoring the stools in the days and weeks following to look for the coin is often recommended. Repeat X-rays every 1-2 weeks are also commonly recommended until clearance can be documented. If the coin doesn’t pass within four weeks, or new symptoms develop concerning obstruction, such as abdominal pain, vomiting, or fever, the patient should be quickly re-evaluated, and endoscopic removal is usually necessary at that time.
Common pointed objects include straight pins, open safety pins, fish bones, open earrings, hairbrush bristles, and pine needles. A sharp object in the esophagus is a medical emergency due to the risk of puncture or perforation of the esophagus.
Regardless of the location of the sharp object, if the child is showing any discomfort or symptoms, endoscopic removal is recommended. But if the child is asymptomatic, feeling well, and the object has already moved to the intestines, observation with repeated X-rays until the object has passed can be considered. On average, objects pass at 3.6 days, so removal is typically indicated if it has not passed in that time or symptoms develop.
Large or long objects are also of concern. Objects greater than 25 mm in diameter or greater than 5 cm in length are unlikely to be passed spontaneously and should be removed.
From a safety standpoint, one of the most significant ways we can prevent the ingestion of these dangerous items is by being aware of the impact it can cause and not having them around the house or in access to a child unattended.
- If you are concerned that your child swallowed a water bead, button battery, magnet, or a very long or large object, head to your closest ER.
- If you are concerned that your child swallowed a coin, speak to your clinician’s office immediately about the next steps, and if they aren’t available, go to an urgent care or ER.
- Go to the closest ER if your child swallowed a foreign object and is showing serious symptoms, like excessive drooling, inability to swallow, repetitive vomiting, increased work of breathing, or noisy breathing.
- If your child swallowed a small object not mentioned above and is otherwise acting well, bring them to their clinician. They will guide you on the next steps and determine if an X-ray is needed.