By Keshawadhana Balakrishnan, MD & Howard Bostwick, MD
Gastroenterology, Maria Fareri Children’s Hospital, Valhalla, NY
Infants and toddlers explore their world by putting just about anything they find into their mouths. Ingestion of foreign bodies is primarily a pediatric problem, as more than 80 percent of cases occur in children. The majority of the children who ingest foreign bodies are less than 3 years old.
Most foreign body ingestions are relatively harmless. In the U.S, coins are the most commonly ingested foreign body. Other objects include toys, magnets, batteries, pins, bones, laundry detergent pods and many more. Eighty to 90 percent of foreign bodies pass spontaneously through the gastrointestinal tract without any interventions, while 10–20 percent will require endoscopic removal and 1 percent or less may need surgical intervention. However, some foreign body ingestions are true emergencies and can have life-threatening consequences.
Potentially the most serious of these ingestions are button batteries and magnets. Sharp objects and caustic ingestions can also cause serious harm. Button battery ingestions are a growing problem and are most commonly encountered in children less than 6-years-old. There has been a 6.7-fold increase in button battery ingestions from 1985 to 2009 due to increased use of the larger and more powerful, 20-25mm lithium button batteries.
Lithium batteries can be found almost everywhere in the home. They are used to power toys, watches, calculators, remote controls, toys, musical greeting cards, calculators and other electronics.
The shiny objects seem innocent enough, but they can be deadly when swallowed as these batteries may get stuck in the esophagus. The saliva triggers an electric current which causes a chemical reaction that can severely burn the esophagus in as little as two hours. Signs that may indicate ingestion of a battery will include drooling, chest pain and difficulty in breathing or eating.
Batteries that have lodged in the esophagus may lead to complications including perforation, abnormal connections between the esophagus and major blood vessels and hemorrhage. Numerous deaths have been reported. These batteries must be endoscopically removed from the esophagus immediately.
High powered magnets (rare earth magnets- boron, neodymium) are five to 10 times more powerful than traditional iron magnets. They are found frequently in desk toys, magnetic construction sets and jewelry. If only one magnet is ingested, it is generally harmless and passes through the gastrointestinal tract with no issues. However, when two or more than two are ingested, attractive forces between them can lead to these serious complications, including significant damage to the intestinal wall, bowel obstruction and perforation.
Ingestion of sharp objects including bones, safety pins, needles and tooth picks commonly occurs. Sharp objects may always carry a 35 percent risk of complication including perforation. Therefore, every attempt should be made to endoscopically retrieve magnets and sharp objects from the stomach, before they move into the lower GI tract.
In children, caustic ingestions are typically accidental and generally involve small volumes of ingested material in contrast to intentional intake in adolescents or adults. Around 5,000- 18,000 accidental caustic ingestions are reported per year in the United States, which experts believe represent only 10 percent of actual incidents. Alkali ingestions are more frequent than acidic ingestions. Caustic ingestions occur most frequently in children between 1 and 4 years old.
Alkalis include detergents, lye, oven cleaners and drain cleaners. Ingestion of these agents can cause severe injury to the lining of the esophagus and can sometimes lead to creating a hole or narrowing in the esophagus. Common acids can be found in toilet bowel cleaners, pool cleaners or drain cleaners.
Children can present with symptoms including difficulty or painful swallowing, drooling, abdominal pain or chest pain, refusing to eat. It is important to note that sometimes oral lesions may be absent, despite injury to the esophagus.
Brightly colored laundry detergent pods pose a much greater risk to young children than other types of detergents. They look like candy. A recent study showed that 36,000 children were treated at emergency departments for exposure to laundry detergents between 2012 and 2014, ten thousand of which were due to laundry pods.
Children younger than 6 years old accounted for 94 percent of laundry pod cases. Nearly 75 percent of these children were diagnosed with respiratory distress as a result of ingestion of these pods. If laundry pod products are made less “appealing” — for example, using childproof containers, muted colors and opaque packaging, such ingestions might be prevented.
While this move may help reduce the incidence of exposures, the responsibility ultimately falls on the care givers to recognize the appeal of these products to younger children and the dangers involved.
It is important to recognize that food may become impacted in the esophagus. This presents with sudden onset of difficulty swallowing and drooling during a meal. Breathing is not usually affected. There is generally an underlying disorder called eosinophilic esophagitis. In our experience, food impactions typically happen to adolescent males eating chicken or steak. Endoscopy is the standard treatment option for removing food impactions.
Coins are the most common foreign body retained in the esophagus. Children may be asymptomatic or can present with symptoms including cough, difficulty breathing or swallowing, chest pain or drooling. Significant esophageal injury can occur if coins are allowed to remain in the esophagus for too long. In asymptomatic patients, a 12 to 24 hour period of observation prior endoscopy may be acceptable, during which some coins will pass spontaneously.
Ingestion of FBs by children remains a significant problem faced by emergency department personnel. Awareness of the potential injury caused by ingestion of these foreign bodies by the general population, manufacturers, and retailers can reduce exposures and decrease the likelihood of occurrence.