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Foreign body ingestion


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Foreign Body inhalation
    Acute upper airway obstruction
    Poisoning – Acute Guidelines for Initial Management
    High-risk – Low-dose paediatric ingestions

    Key Points

    1. The majority of ingested foreign bodies (FBs) are low risk objects and can be managed without imaging or intervention.
    2. Button batteries and magnets are high risk objects and require imaging.
    3. Large sized objects and objects impacted in the oropharynx require surgical review.
    4. Ingested objects may be toxic.  Consider consulting local Poison Information Services.

    Background

    • Children of all ages may ingest a FB, however the highest incidence is between the ages of 6 months and 3 years, and in those with developmental or behavioural problems.
    • Older children with underlying psychiatric problems may intentionally ingest FBs and require a mental health review.
    • Gastrointestinal tract obstruction or impaction by a FB depends on the physical properties of the object, including its size, shape and composition.

    Assessment

    Red Flags

    High-risk FBs include:

    • Button batteries lodged in the oesophagus need immediate removal, however once they enter the stomach, they are less concerning
      • NB parents may be advised to offer honey to children >12 months of age with suspected button battery ingestion; continue at regular intervals until reaching hospital
    • Large objects (>6 cm long and/or >2 cm wide) may become entrapped at the pylorus 
    • Superabsorbent polymers may also cause impaction
    • Magnet + a Metal object or >1 Magnet ingestion can cause serious and potentially life-threatening complications
    • Lead based objects that fail to transit through the stomach may cause acute systemic lead absorption 
    • Multicomponent objects may break apart and progress separately in the gastrointestinal tract (e.g. Toys with lights, motors and batteries) and may require removal

    High risk children include those with:

    • pre-existing gastrointestinal tract abnormalities such as congenital malformations (repaired or unrepaired) 
    • eosinophilic oesophagitis  
    • neuromuscular disease 

    It is rare for sharp objects to penetrate the mucosal wall of the GI tract, and these require no intervention if the child is otherwise well.

    History

    • Clarify type of object and timing of ingestion
    • Have high suspicion for high-risk FB and/or high-risk child (see above)
    • Coughing, drooling of saliva, pain on swallowing, reduced oral intake, abdominal pain or vomiting, melaena or GI bleeding 
    • If evidence of coughing, choking, respiratory distress - consider inhalation. See Foreign Body inhalation

    Examination

    • Signs of airway compromise. See  Acute upper airway obstruction
    • Inspection of the oropharynx for excessive drooling, abrasions, ulcers or lacerations
    • Respiratory distress. See Inhaled foreign bodies
    • Tender abdomen on palpation, signs of peritonitis or obstruction

    Management

    Investigations

    • X-rays are unnecessary in an asymptomatic child, with no possibility of button battery or magnet ingestion, a reliable history and no significant past medical history
    • Imaging is required in: suspected or known button battery, magnet/s, other high-risk radiopaque object, unknown object, high risk or unwell child
    • In smaller children, a single X-ray to include neck, chest and abdomen is often adequate

    Note that most metallic objects will show up on X-ray with the exception of aluminium (variably detected). AP and lateral views are required if magnets are suspected.

    Further examination of the faeces is not recommended. Repeat X-rays are not necessary.

    Treatment

    Suspected FB ingestion

    • Specialist referral may depend on ingested object and local services – discuss with senior clinician. See advice here
    • Objects impacted in the oropharynx require urgent ENT evaluation.
    • Button batteries can erode mucosal surfaces (i.e. lodged in the oesophagus) <2 hours and need immediate removal
    • Ingestion of multiple magnets +/- metal require early endoscopic removal. One magnet seen on X-ray may still be high risk, as two may have been swallowed which give the appearance of one.
    • Fish bones may lodge in tonsils and require removal
    • A FB lodged in the lower oesophagus, and where the child is able to swallow saliva successfully, may be observed for 24 hours to ensure that it transits. If it does not pass it will need to be removed
    • Larger objects (>6 cm long and/or >2.5 cm in diameter) in the stomach require a Gastroenterology or Surgical opinion due to the increased risk of obstruction
    • Offering fizzy drinks to children with food bolus obstruction appears to be safe and may be effective

    Consider consultation with local paediatric team when:

    • Child is symptomatic
    • Immediate FB removal needs to be facilitated
    • The FB is lodged in the oesophagus
    • Concerns that the FB is toxic
    • Child has significant past medical history and/or behavioural issues leading to ingestion

    Consider transfer when:

    Children requiring care (including surgical services) above the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services .

    Consider discharge from Emergency Department when:

    Child meets following criteria:

    1. Looks well
    2. Is pain free
    3. Has no respiratory distress
    4. Is able to eat and drink
    5. Has a reliable history and a low risk FB has been ingested.

    Discharge advice should be given, and the child/parents should be instructed to seek medical advice or return to ED if any of the following symptoms occur:

    • Breathing problems
    • Abdominal pain
    • Fever
    • Vomiting
    • Unable to tolerate food and drink
    • Melaena or haematemesis

    Parent information sheet

    Swallowed (ingested) foreign bodies

    Updated April 2020

  • References

    1. A-Kader, H. Hesham. "Foreign body ingestion: children like to put objects in their mouth." World journal of pediatrics 6.4 (2010): 301-310.
    2. Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. “pH‐neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury.” The Laryngoscope. 2019 Jan;129(1):49-57.
    3. Arana, Alvaro, et al. "Management of ingested foreign bodies in childhood and review of the literature." European journal of pediatrics 160.8 (2001): 468-472.
    4. Horton, L. Kimberlee, et al. "Sonography and radiography of soft-tissue foreign bodies." American Journal of Roentgenology 176.5 (2001): 1155-1159.
    5. Hunter, Tim B., and Mihra S. Taljanovic. "Foreign bodies." Radiographics 23.3 (2003): 731-757.
    6. Karakoç, Fazilet, et al. "Foreign body aspiration: what is the outcome?" Pediatric pulmonology 34.1 (2002): 30-36.
    7. Uyemura, Monte C. "Foreign body ingestion in children." American family physician 72.2 (2005).
    8. Valente, Jonathan H., et al. "Aluminum foreign bodies: do they show up on x-ray?" Emergency radiology 12.1-2 (2005): 30-33.
    9. Wu, Iuan-Sheng, et al. "Value of lateral neck radiography for ingested foreign bodies using the likelihood ratio." Journal of Otolaryngology--Head & Neck Surgery 37.2 (2008).