Ingested foreign body – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with a suspected or confirmed ingested foreign body.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from ENT, Surgery and Gastroenterology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Ingested foreign bodies are more common in the following children:

• aged six months to three years
• pica
• intellectual impairment
• with older siblings

Commonly ingested objects include coins, small toys and household objects. Older children and adolescents with psychiatric problems may intentionally ingest non-food items.

While most foreign bodies (80%) that reach the gastrointestinal tract (GI) pass spontaneously,¹ those that become impacted are at risk of causing significant harm and even death. An estimated 10-20% of objects require endoscopic removal with less than 1% needing further surgical intervention.²

Objects may lodge in areas of physiological narrowing in the oesophagus including the upper and lower oesophageal sphincter and level of aortic arch.³ Impaction in other areas of the oesophagus may indicate underlying pathology.

Complications of ingested foreign bodies include:

• complete or partial oesophageal obstruction in immediate phase
• oesophageal perforation from sharp foreign bodies which may present with neck swelling, crepitus +/- pneumomediastinum
• erosion of surrounding structures leading to tracheo-oesphageal or aorto-oesophageal fistula which can be fatal
• strictures
• weight loss due to feeding difficulties or recurrent aspiration in delayed diagnosis
• intestinal obstruction or injury if object lodges more distally (rare).

Button batteries

The incidence of button battery ingestions resulting in significant morbidity or death is increasing. The majority of ingestions occur in children aged from one to five years but have also occurred in younger children (possibly fed batteries by siblings) and older children.

For the majority of cases with severe outcomes, diagnosis was delayed as the event was unwitnessed and the clinical presentation was non-specific.
Be vigilant for the risk of button battery ingestion in a child presenting to ED. A denial of ingestion in a child of any age cannot exclude it.

There are two main mechanisms by which button batteries can cause necrosis:

• where there is sufficient retained battery charge, hydrolysis and creation of hydroxide ions in adjacent tissues leads to mucosal burn at battery’s negative pole
• direct pressure

Oesophageal perforation has been reported within two hours of ingestion. Further erosion of structures can result in fistulae (tracheo-oesophageal / into adjacent vessels). Aorto-oesophageal fistulae can be fatal. Despite prompt removal, the risk of injury can continue up to weeks post-ingestion due to residual alkali and weakened tissues.⁴

Damage is proportionate to charge. Spent batteries greater than 15mm diameter may still have sufficient residual charge to cause injury.

Magnets

Magnets pose a risk if ingested in multiples or with other ferrous objects (including batteries) as they may attract across layers of bowel leading to pressure necrosis, fistula development, volvulus, perforation, infection or obstruction. Ulceration and indentation of the mucosa may occur within eight hours.

Superabsorbent polymers (expandable foreign bodies)

Toys and beads composed of superabsorbent polymers (original size 1mm-1cm) are designed to expand when placed in water so can expand following ingestion when contact is made with gastrointestinal fluids introducing the risk of pyloric or more distal obstruction.

Food bolus impaction

Oesphageal soft food bolus impaction is rare in children and more frequent in children with eosinophilic oesophagitis or prior oesophageal surgery such as tracheo-oesphageal fistula repair

Assessment

Conduct an initial assessment of airway, breathing and circulation as per APLS guidelines and undertake appropriate action.

When to suspect an ingested foreign body

Most children with an ingested foreign body are asymptomatic. A history of ingestion may be reported by the child or the caregiver. Where the history of the foreign body ingestion is unknown, children may present with non-specific symptoms rather than with a history of an ingested foreign body. This makes diagnosis difficult.

Ingested foreign body must be considered in children presenting with the following symptoms regardless of history of ingestion:^5,3,2

• drooling / pooling secretions
• odynophagia / dysphagia
• food refusal / poor feeding
• retrosternal pain / grunting (may be due to chest pain in preverbal child)
• coughing / choking
• cyanotic episode
• stridor / wheezing
• vomiting or regurgitation
• unexplained gastrointestinal bleeding

Consider the possibility of foreign body ingestion in a pre-verbal child with sudden onset of symptoms.

History

Initial questioning should identify the risk of button battery or multiple magnet ingestion to enable early referral.

Questioning should include the following:

• time of ingestion – crucial for button battery or multiple magnet ingestion
• specific details on the ingested foreign body including:
  • size – objects greater than 2cm are unlikely to pass through the pylorus or ileocaecal valve, objects greater than 6cm often become impacted in the ileocaecal region
  • nature and shape– sharp objects carry risk of perforation; superabsorbent polymers pose risk of obstruction
  • likelihood of being radio-opaque – consult local medical imaging department if unsure

In the event of a missing button battery, consider the potential for ingestion by a sibling/other child.

Examination

Conduct a systematic physical examination and cardio-respiratory monitoring with an initial focus on airway and breathing. All children at risk following a missing button battery incident should be assessed.

Abdominal examination should focus on signs of obstruction or perforation.

A child with a sharp object lodged in the tonsil usually presents with odynophagia, focal pain and may drool.

A child who has ingested a foreign body containing lead may experience acute toxicity (presents as vomiting and lethargy) within 90 minutes

Urgent referral to ENT (onsite or via Retrieval Services Queensland (RSQ)) is required for children with a history of:

• button battery ingestion
• foreign body ingestion and inspiratory stridor, cough or wheeze or inability to swallow secretions

Urgent referral to Paediatric Surgery (onsite or via RSQ) is required for child with suspected GI perforation or obstruction.

Investigations

Contact RSQ to arrange urgent transfer of child with suspected button battery ingestion if no X-ray facilities onsite.

Button batteries

• Plain neck, chest and abdominal films are recommended to localise the button battery.
• When more than one child is involved in a missing button battery incident, X-rays should begin with one child and continue until the button battery is identified or can be excluded in all children.
• Review imaging for signs of perforation or obstruction.
• The presence of double rim or halo effect on a battery on an AP X-ray may differentiate it from a coin. Treat as a button battery if unsure as appearance can be subtle and affected by windowing.
• Lateral films may be required on specialist advice. On a lateral film, the step off is on the negative side of the battery (as the negative pole has a slightly smaller diameter). Damage is more severe in the tissue adjacent to negative pole (think 3Ns: negative-narrow-necrotic).
• Contrast studies are not recommended prior to removal due to the risk of aspiration with oesophageal obstruction and potential to obscure visualisation on subsequent endoscopy.
• X-rays should NOT be repeated prior to theatre in acute oesophageal button battery presentations. The child will undergo exploratory endoscopy regardless of subsequent passage.
• CT imaging prior to theatre may be required on specialist advice to detect the risk of a catastrophic bleed in a child who presents more than 24 hours post-ingestion.

Other foreign bodies

For all other children, plain neck, chest and abdominal films are the recommended first-line investigation to localise radiopaque foreign body or bodies. Review imaging for signs of perforation or obstruction. Indirect evidence of ingestion such as an air-fluid level in the oesophagus may be present in a child who has ingested a non-radiopaque object.

In addition, lateral X-rays are recommended in a child with a history of magnet ingestion to differentiate single from multiple magnets which may overlap on a single view. They may be required for other children on specialist advice.

Contrast studies are not recommended prior to removal due to the risk of aspiration with oesophageal obstruction and potential to obscure visualisation on subsequent endoscopy.

Serum lead levels are recommended if acute lead toxicity is suspected (lethargy and vomiting).

Seek advice from Poisons Helpline (Ph: 13 11 26) if:

• acute lead toxicity is suspected
• unsure of toxicity of object

Management of suspected button battery ingestions

Refer to flowchart [PDF 236.4 KB] for a summary of the emergency management for children presenting with suspected button battery ingestions:

Evaluate and manage airway compromise in accordance with APLS guidelines.⁶

Urgently seek the most senior assistance available onsite (such as critical care/ENT/anaesthetics) to manage airway as needed.

Seek urgent paediatric surgical advice (onsite or via RSQ) for a child with suspected GI perforation or obstruction.

Management is directed by the location of the ingested battery.

Seek urgent ENT advice (onsite or via RSQ) for child with oesophageal button battery.

Seek prompt paediatric gastroenterology advice (onsite or via Children’s Advice and Transport Coordination Hub (CATCH)) for a child with button battery in stomach or below.

Honey is recommended for children over one year of age with an oesphageal button battery who present within 12 hours of ingestion to reduce the risk of caustic damage whilst awaiting theatre.

Deliberate ingestions

Refer to mental health team after removal as per local practice in deliberate ingestions.

Management of non-button battery ingestions

Refer to flowchart [PDF 236.4 KB] for a summary of the emergency management for children presenting with suspected non-button battery ingestions:

Evaluate and manage airway compromise in accordance with APLS guidelines.⁶

Urgently seek the most senior assistance available onsite (such as critical care/ENT/anaesthetics) to manage airway as needed.

Seek urgent ENT advice (onsite or via RSQ) for a child with a confirmed or suspected oesophageal foreign body and any of:

• inspiratory stridor, cough or wheeze
• unable to swallow secretions
• suspected GI perforation or obstruction

The need for, and urgency of, endoscopic removal is determined by the object (including size, nature and shape) and its location (in consideration of time of ingestion). Patients with known gastrointestinal tract abnormalities or previous surgery may require additional intervention such as oesophageal dilatation.

*Will refer to Paediatric Surgery if required

Seek urgent advice via RSQ if not onsite

Seek prompt advice via onsite / local specialist service

Seek advice if:

• symptomatic or
• greater than 24 hours post-ingestion in case of oesophageal foreign body
• GI abnormalities

Deliberate ingestions

Refer to mental health team as per local practice for deliberate ingestions.

Specific foreign bodies

Magnets

Ingestion of multiple magnets or a magnet and a metallic object mandates endoscopic removal, if accessible, or serial imaging and examination if beyond reach and there is no concern about the objects joining. Surgical intervention may be required to reduce the risk of bowel adhesion across the bowel wall in symptomatic children and those who fail to pass the magnets.

If a single magnet past the oesophagus is confirmed on X-ray and the child is asymptomatic, expectant management is appropriate. Caregivers, however, must be educated with regards to the need for a safe environment and close supervision to avoid ingestion of another magnet or metallic object.

Food bolus impaction

Administration of hyoscine butylbromide or glucagon is not routinely recommended.

The use of effervescing agents such as carbonated drinks is supported by case reports and retrospective cohort studies but may be associated with vomiting.

Seek gastroenterology advice regarding management of a child with a history suggestive of eosinophilic oesophagitis (such as recurrent food impaction, feeding difficulties, atopy, and failure to thrive).

Expectant management

Expectant management is recommended for all children not requiring specialist referral.

Repeat X-ray and follow-up is only routinely recommended for oesophageal foreign bodies as complications can occur (including transmural erosion, perforation and fistulae) if not passed spontaneously. In such cases, close observation is recommended with repeat X-rays within 24 hours.  Consider admission to an inpatient service during this time

Prompt referral to relevant subspecialty team as per local practice is required for a foreign body that remains in the oesophagus after 24 hours.

Escalation and advice outside of ED

Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Transfer is recommended if specialist removal is required and no onsite facilities are available.

Critically unwell or ingested foreign body requiring time-critical care

*Refer to Management section for further details

Non-critical child or requiring non-time critical care

*Refer to Management section for further details

Inter-hospital transfers

Disposition

When to consider discharge from ED

Discharge and follow-up as per advice for children requiring specialist referral.

Consider discharge for the following children not requiring specialist referral:

• X-ray not required (refer to Investigation section for criteria)
• X-ray is normal or shows the object is beyond the oesophagus, the child is asymptomatic and able to eat and drink
• X-ray shows the object is in the oesophagus, the child is asymptomatic and able to eat and drink and the caregiver is able to return for repeat X-ray within 24 hours or earlier if symptomatic.

On discharge educate the caregivers regarding:

• potential complications such as obstruction or perforation and advise to seek prompt medical attention if any of the following occur:
  • breathing or feeding difficulties
  • abdominal pain or distension
  • cramping
  • bleeding
  • vomiting
  • other concerns
• in the case of single magnet ingestion, the need to provide a safe environment and close supervision to avoid the ingestion of another magnet or metallic object
• accident prevention including:
  • safe storage of small objects including marbles, coins, button batteries and balloons to ensure out of reach of infants and young children
  • age-appropriate toys for play (follow the age recommendations on packages)

Follow-up

Advise caregivers to re-present to ED if early review is required to ensure completion of care.

When to consider admission

Children requiring an endoscopy will usually require admission to an inpatient service.

Consider inpatient admission for observation of children with oesophageal foreign bodies not requiring specialist referral. Admission of other children with ingested foreign bodies for expectant management is at the discretion of speciality teams.