Foreign body ingestion and aspiration are common and potentially serious emergencies. Developmentally appropriate oral exploration places young children at risk for these predominately unintentional injuries. Common household items such as button batteries and high-powered magnets pose a significant risk of morbidity and mortality. Providers must promptly recognize and respond urgently to prevent acute deterioration, life-threatening complications, and long-term morbidity.The presentation of foreign body ingestion varies widely. Some patients present asymptomatically after a caregiver-witnessed event. Symptomatic patients may demonstrate a range of findings including respiratory distress, choking, drooling, stridor, wheezing, coughing, hematemesis, chest pain, abdominal pain, decreased oral intake, vomiting, and fussiness. A high index of suspicion is necessary in unwitnessed cases.A focused history should be obtained, eliciting time of ingestion, object type, and symptoms present. Physical exam should focus on the nasal and oral airways, neck, chest, and abdomen, with close attention for signs of airway compromise, pulmonary injury, mediastinal involvement, or bowel injury. Anteroposterior and lateral radiographs of the nasopharynx, neck, chest, and abdomen should be obtained immediately to help distinguish between aspiration and ingestion and to aid in object identification. Size, location, and number of foreign bodies should be determined. Radiolucent objects will not appear on radiograph, and thus a negative study does not rule out foreign body. In some cases, computed tomography (CT), magnetic resonance imaging, endoscopy, or bronchoscopy may be necessary for further evaluation.In 2015, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition produced guidelines for the management of button battery, magnet, sharp, blunt, and superabsorbent foreign body. Management largely depends on object type, time since ingestion, location of foreign body, and symptoms present.Mortality and morbidity associated with button battery ingestion have increased in recent decades due to the use of larger, lithium-based batteries. Caustic mucosal injury occurs within 15 minutes and may continue for weeks after exposure. Esophageal injuries account for essentially all mortality and morbidity. Risk is greatest in children under 5 years of age, batteries at least 20 mm in diameter, and ingestions involving multiple batteries.If battery ingestion is suspected, radiographs should be obtained immediately while simultaneously preparing for potential endoscopic removal. On radiograph, button batteries can be distinguished from coins by the characteristic “double halo” or “step-off” sign, which is absent in coins (Figure 1A and 1B). Button batteries lodged in the esophagus require emergent endoscopic removal within 2 hours of ingestion. If reported before arrival at the hospital, caregivers should orally administer 10 mL of honey every 10 minutes while en route to the emergency department (for children older than 1 year of age). Upon arrival, an additional dose of honey or a dose of sucralfate may be given. Recency of oral intake should not delay intervention. During endoscopy, battery orientation and location should be noted, as the negative node confers the greatest damage to tissue and identifying nearby structures can help predict risk for complications. After battery removal, injuries should be irrigated and neutralized, and distal mucosa assessed for injury and additional foreign bodies. When significant mucosal damage is present, a feeding tube should be placed, and the child should remain nil per os. If there is concern for airway involvement, bronchoscopy may be indicated.Complications of esophageal button batteries include tracheoesophageal fistula, esophageal perforation and strictures, vocal cord paralysis, mediastinitis, and aortoenteric fistula. Aortoenteric fistulas carry a significant risk of mortality and should be suspected if the child has hematemesis.The management of button batteries distal to the esophagus is controversial. Although distal injury is uncommon, endoscopy is often considered to assess for preceding esophageal injury. Management of distal batteries depends on the patient’s age and the size of the battery. For children younger than 5 years with a distal battery at least 20 mm in diameter, endoscopy should be considered and ideally performed within 24 to 48 hours. For children aged 5 years and older with a distal battery of any size and for children younger than 5 years with a distal battery smaller than 20 mm, outpatient observation can be considered. In such cases, repeat radiographs must be obtained within 48 hours for a distal battery of at least 20 mm and within 10 to 14 days for a distal battery smaller than 20 mm if the family has not observed the battery pass in the stool beforehand. Endoscopic removal is recommended at the time a distal battery is noted on repeat radiograph or sooner if the child develops symptoms.The risk of injury due to magnets occurs when more than 1 magnet is ingested or a single magnet is ingested in the presence of another metal foreign body. When attractive forces cross the bowel wall, necrosis can occur, resulting in fistula formation, obstruction, perforation, peritonitis, and ischemia. Most injuries are due to high-power neodymium magnets. Found in many common toys and household products, these magnets provide much stronger attractive forces than conventional magnets.Radiographs should be used to identify the number of magnets present and their location. Two views are necessary to distinguish single magnets from multiple magnets adhered to one another. Single-magnet ingestions can be managed conservatively, with either endoscopic removal if the magnet is located in the esophagus or stomach or with serial, outpatient radiographs to ensure eventual magnet passage with stool. When multiple magnets are ingested, endoscopic or surgical intervention is warranted depending on the magnets’ location and presence of symptoms in the child. If 12 hours or fewer have passed since ingestion, magnets retained in the esophagus or stomach should be removed endoscopically. If more than 12 hours have passed, surgical consultation is recommended prior to endoscopy, as surgical intervention may be necessary if the endoscopic removal attempt is unsuccessful. When multiple magnets are located distal to the stomach in a child who is symptomatic, surgical removal is recommended. When multiple distal magnets are present in a child who is asymptomatic and has no signs of bowel injury, conservative management in the hospital with serial radiographs, with or without laxative therapy to accelerate passage of the magnets, is appropriate. Magnets should be removed if the child does not pass them with stool within 48 hours or sooner if the child develops symptoms.Complications associated with sharp foreign bodies (eg, fishbone, safety pin) include perforation and migration, abscess, fistula formation, and injury to surrounding structures. Sharp foreign bodies in the esophagus require emergent removal, while management of more distal objects depends on location and symptoms. The orientation of sharp objects influences both the risk of injury and the choice of removal technique, as advancing sharp ends are more likely to cause harm. Observation may be appropriate when the child is asymptomatic. If the child is showing signs of bowel injury or does not pass the foreign body within 3 days, foreign body removal is necessary.Blunt objects, (eg, coins) in the esophagus should be removed within 24 hours, or more emergently if the child is symptomatic. Radiography is used to distinguish tracheal vs esophageal coin location. On anteroposterior radiograph, an esophageal coin appears flat and round (Figure 2A), while a tracheal coin shows only its thin edge. On the lateral view, an esophageal coin lies posteriorly in the mediastinum (Figure 2B), whereas a tracheal coin is seen anteriorly within the airway. Gastric and duodenal objects should be removed depending on the child’s symptoms and the object size. In general, long or large objects (>25 mm diameter, >6 cm length) are unlikely to pass spontaneously. Asymptomatic patients can be observed as outpatients. Stool should be monitored and serial radiographs performed every 1 to 2 weeks until object passage is confirmed. Failure to pass the object within 2 to 4 weeks may require endoscopic removal.Superabsorbent objects can absorb and retain large volumes of water. Found in common household items and toys (eg, water beads), ingestion of superabsorbent objects is dangerous, as their retention of high amounts of fluid cause their rapid expansion and potentially bowel obstruction. Emergent endoscopic removal is recommended. Radiography is not usually helpful in identifying superabsorbent objects, as they are typically radiolucent. When endoscopy does not reveal the foreign body, evaluation for more distal bowel involvement and surgical consultation may be necessary.Foreign body aspiration may present with a range of symptoms. Cough, wheeze, stridor, and respiratory distress or arrest following a choking event may occur. Alternatively, patients may be asymptomatic. Failure to improve from common respiratory illnesses should raise suspicion for foreign body aspiration. Total or near-total airway obstruction requires immediate resuscitation and emergent anesthesia or otolaryngology consultation to secure the airway. When aspiration is suspected in a stable patient, anteroposterior and lateral radiographs of the neck and chest should be performed, with inspiratory and expiratory films obtained when possible. In young children who may not cooperate with expiratory films, decubitus chest films can simulate expiratory views. Radiography may identify the foreign body or demonstrate findings suggestive of aspiration such as unilateral hyperexpansion, atelectasis, mediastinal shift, or pneumonia. Normal radiography does not exclude foreign body aspiration, and radiolucent objects may require CT to aid in diagnosis. When confirmed, patients should undergo rigid bronchoscopy for foreign body retrieval.Foreign body ingestion and aspiration are important pediatric pathologies with potential for life-threatening outcomes. Timely recognition, diagnosis, and intervention can reduce complications.Comment: Seventeen years ago, my extended family and I rented a beach house in which someone had made the regrettable decorating decision to spray-coat the stairway guardrail with sand. The adults in our group avoided the 40-grit banister. However, we repeatedly had to pull my 3-year-old niece away from the railing against her protests of “But my mouth is wanting to try something!” While I don’t know what made the abrasive guardrail so irresistible to my niece, taste is one of our five senses, and young children are eager to engage all of them in exploring their surroundings. Bright, shiny objects including toy magnets and button batteries are particularly attractive and dangerous as Drs Stone and Lembo point out. In 2014, the US Consumer Product Safety Commission prohibited the sale of strong, neodymium magnets, and the number of reported ingestions dropped, only to rise again when the prohibition was reversed by court ruling in 2016. To protect children from the worst consequences of “trying” the world around them, we pediatricians should inform families about the nonprofit National Capital Poison Center’s Poison Control website (http://www.poison.org) and phone number (1-800-222-1222). The Center also staffs a hotline specifically to help with battery ingestions (1-800-498-8666).Linda Y. Fu, MD, MSAssociate Editor, In BriefThe authors thank Dr Erica Poletto for providing radiographic images used in this article.
Stone et al. (Mon,) studied this question.