Management of Foreign Body Ingestion in Children

While most foreign body ingestions in children are asymptomatic and unwitnessed, foreign body ingestion accounts for an estimated 116,000 emergency department visits per year. Coins are the most commonly ingested object; most coins pass through the gastrointestinal tract without complication or intervention. Approximately 10% to 20% of patients require specialist consultation or intervention, particularly if the coin is lodged in the esophagus.

As reviewed in a recent American Family Physician article, common symptoms of foreign body ingestion include choking, gagging, emesis, dysphagia, and drooling. On physical exam, no typically obvious signs of ingestion are seen.

Diagnosis of foreign body ingestion is best made with initial x-rays of the neck, chest, and abdomen if the location of the suspected object is unknown. The sensitivity of x-ray varies by object, with the highest sensitivity for coins (100%). Chest x-ray is only about 30% sensitive for ingested bones (eg, chicken, fish). If x-ray is unable to determine the location of the foreign object, computed tomography (without oral contrast, which may obscure the object on esophagogastroduodenoscopy) is the modality of choice.

After a foreign object is identified, management depends on the object ingested, the location of the object, and any resulting complications. More than 60% of ingested objects pass without intervention.

The size of the object ingested may affect its ability to pass spontaneously. Objects larger than 6 cm in length or 2.5 cm in diameter are less likely to pass, getting stuck in the proximal esophagus (most commonly), pylorus, duodenum, or ileocecal valve. Objects that are not sharp (excluding magnets and button batteries) and less than 1 cm that have cleared the stomach or that are larger and have passed the duodenum may be monitored without intervention.

Generally, removal by esophagoduodendoscopy (EGD) is recommended for objects located in the stomach or esophagus that are large (≥ 2.5 cm), sharp, or could cause harm without removal (eg, button battery, multiple magnets). Emergent EGD is recommended for children with a button battery in the esophagus, multiple batteries ingested, food impaction, or symptoms of complete obstruction. Surgical removal may be needed for objects that are immobile (have not moved for more than 1 week) and are unable to be removed by EGD.

The National Capital Poison Center has an algorithm to guide management of known or suspected battery ingestion. The National Battery Hotline (800-498-8666) is also available for support. Vomiting should not be induced because it may cause further damage. No published trials in humans are available, but honey has been studied to reduce damage to esophageal tissue from lithium battery ingestion by coating the battery to reduce the generation of hydroxide (and increase in pH) by the battery. In children 12 months of age or older who have swallowed a lithium battery within the last 12 hours and can swallow comfortably, it is recommended to give 2 teaspoons of honey every 10 minutes for up to six doses on the way to the emergency department. Sucralfate may be similarly used in a hospital setting.

For additional management recommendations specific to the type of object ingested (eg, coins, magnets), please see the AFP article on foreign body ingestion in children.