Foreign Body Ingestion & Aspiration

ER – Pediatrics

Introduction

• Epidemiology: Young children are at high risk due to oral exploration and immature airway protective reflexes.
• Burden: Tens of thousands of foreign-body exposures in children ≤5 years are reported annually; ER visits for ingestions in <6 years have risen significantly over recent decades.
• Pathways: Once in the mouth, objects may be:
  • Ingested and enter the GI tract
  • Retained in the pharynx
  • Aspirated into the respiratory tract
• Clinical spectrum (aspiration): From self-limited “choking episodes” to:
  • Acute life-threatening airway obstruction
  • Subtle, slowly evolving pneumonia or chronic cough/wheeze
• Clinical spectrum (ingestion): Most objects are well tolerated and pass unnoticed; severity depends on:
  • Object type (blunt, sharp, long, battery, magnet)
  • Location in the GI tract
• High-risk items: Button batteries and multiple magnets are disproportionately dangerous and time-sensitive.

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Pathophysiology

Determinants of Lodgment

• Anatomic factors:
  • Airway: Gradual narrowing distal to the larynx; common sites include supraglottic region, trachea, and bronchi.
  • GI tract: Multiple physiologic narrowings (upper esophageal sphincter, aortic arch level, lower esophageal sphincter, pylorus, duodenum, ileocecal valve).
• Object size & shape: Influence likelihood of obstruction and specific lodgment site.
• Tissue distensibility: Stiffer segments (e.g., cricopharyngeus) more prone to impaction.

Object Composition & Tissue Reaction

• Button batteries: Rapid caustic injury and liquefaction necrosis; can erode through esophageal wall within hours.
• Magnets (multiple): Magnetic attraction across bowel walls → pressure necrosis, fistula, perforation, obstruction.
• Organic material (e.g., peanuts): Fatty oils provoke intense inflammatory reaction in bronchi; higher risk of post-obstructive pneumonia.
• Inert/blunt objects (e.g., coins): Often benign if they pass beyond the esophagus, but dangerous when lodged in the esophagus.

Functional Consequences

• Airway: Depending on orientation and location, foreign bodies may cause:
  • Minimal or intermittent obstruction (ball-valve effect)
  • Complete obstruction with acute respiratory collapse
• Chronic airway effects: Prolonged retention → inflammation, granulation tissue, infection, air trapping, bronchiectasis.
• GI tract: Sharp or reactive objects may cause perforation, hemorrhage, abscess, or fistula formation.

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Esophageal Foreign Bodies

Common Objects & Risk Groups

• Most common site: The esophagus is the most frequent lodgment site for ingested foreign bodies in children.
• Typical pediatric objects: Round/spherical objects; coins account for ~50–75% of esophageal foreign bodies.
• Adult pattern: Food bolus (meat) and bones (fish/chicken), usually with underlying esophageal disease (strictures, dysmotility, extrinsic compression).
• Pediatric anatomy: Most children with esophageal foreign bodies have structurally and functionally normal esophagi.
• High-risk pediatric subgroups:
  • Acquired strictures (e.g., prior caustic ingestion)
  • Repaired esophageal atresia or tracheoesophageal fistula
  • Known esophageal dysmotility
• Time sensitivity: Any esophageal foreign body is time-sensitive; button batteries and sharp objects are true emergencies.

Typical Lodgment Sites

• Thoracic inlet (cricopharyngeus): 60–80% of esophageal foreign bodies.
• Gastroesophageal junction: 10–20%.
• Level of the aortic arch: 5–20%.
• Abnormal anatomy: Lodgment level varies with location of strictures or repaired segments.

Clinical Concerns & Complications

• Symptoms (especially proximal objects):
  • Dysphagia, odynophagia, refusal to eat
  • Drooling, gagging, retrosternal discomfort
  • Cough, stridor, or respiratory distress from airway compression
• Potential complications of retained esophageal foreign bodies:
  • Upper airway compromise and respiratory distress
  • Esophageal perforation
  • Mediastinitis
  • Tracheoesophageal or aortoesophageal fistula (especially with button batteries)
• Imaging nuance: Distinguish coins from button batteries (e.g., “double rim” or “halo” sign on AP view).

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Stomach and Lower Gastrointestinal Tract

General Principles

• Natural history: Objects that reach the stomach usually traverse the remainder of the GI tract without complication.
• Documented safe passage: Various foreign objects, including some sharp items (screws, tacks, staples), have been reported to pass uneventfully.
• Size-related risk:
  • Long objects (>5–6 cm) may not negotiate the pylorus or duodenal sweep, especially in younger children.
  • Wide objects (>2–2.5 cm) are less likely to pass the pylorus.
• Location of potential impaction: Duodenum or ileocecal region are common sites when passage fails.

Sharp Objects & Complications

• High-risk sharp objects: Bones, needles, pins, and other very sharp items.
• Complication profile:
  • Bowel wall perforation
  • Peritonitis
  • Abscess formation
  • GI hemorrhage
• Magnets beyond the stomach: Ongoing risk of:
  • Magnetic attraction across bowel loops
  • Pressure necrosis and fistula formation
  • Obstruction or perforation

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Evaluation & Decision – Unknown Location

Clinical Clues to Location

• History: Symptom complex and event description often suggest GI vs. airway location.
• Airway-predominant symptoms:
  • Cough, respiratory distress
  • Tachypnea, retractions
  • Stridor, wheezing
  • Asymmetric aeration on exam
• Esophageal-predominant symptoms:
  • Gagging, vomiting
  • Drooling
  • Dysphagia or odynophagia
• Overlap: Foreign bodies in either location may cause minimal or nonspecific symptoms, especially after the acute event.

Initial Imaging

• When history/physical are unclear: Obtain chest radiograph including neck and upper abdomen to look for radiopaque foreign body.
• Additional views for suspected aspiration:
  • Expiratory chest radiograph
  • Lateral decubitus films in young children
• Limitations:
  • Many aspirated objects are radiolucent (e.g., nuts, plastic).
  • Normal radiographs do not exclude an airway foreign body when suspicion is high.
• Next step when suspicion remains high: Urgent airway evaluation (often rigid bronchoscopy) despite negative or equivocal imaging.

Gastrointestinal Foreign Body

Esophageal Foreign Body – Diagnosis

History & Symptoms

• Typical history: Often a clear ingestion history, either witnessed by caregivers or reported by the child.
• Common symptoms of esophageal impaction:
  • Dysphagia or refusal to eat
  • Foreign-body sensation or localizing neck/chest pain
  • Drooling, gagging, vomiting
• Diagnostic challenge: Same symptoms may occur with gastroenteritis, pharyngitis, gingivostomatitis, etc., especially without a clear ingestion history.
• Physical exam: Thorough exam of mouth, oropharynx, neck, chest, and abdomen is required in any child with swallowing difficulty.

Imaging & Initial Evaluation

• Asymptomatic cases: Up to ~40% of children with esophageal coins may be asymptomatic.
• Radiographs:
  • Recommended for most children with a history of ingested foreign body.
  • In asymptomatic patients, imaging is generally urgent but not emergent, except for button batteries and multiple magnets.
• Endoscopy:
  • Indicated when symptoms suggest esophageal impaction.
  • Preferred for visualization and removal of the object.
• Contrast studies: Oral contrast is generally avoided due to aspiration risk and interference with endoscopic visualization.
• CT scan: Considered in special circumstances (e.g., suspected perforation, radiolucent object with high suspicion).
• High-risk populations: Children with tracheoesophageal fistula repair, esophageal strictures, or eosinophilic esophagitis have higher risk of food/foreign-body impaction.

Handheld Metal Detectors

• Use: Can be used as an initial screen when coin ingestion is suspected.
• Performance: Comparable to radiography for detecting coins and estimating location.
• Limitations:
  • Less reliable for other metallic objects.
  • Reduced accuracy in obese patients.
• Practice considerations:
  • Requires operator experience with x-ray confirmation before radiography is abandoned.
  • Ensure reliable follow-up, as some objects may be missed.

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Esophageal Foreign Body – Removal

Timing & Indications

• General principle: Once an esophageal foreign body is detected, it should be removed promptly.
• Emergent removal (<2 hours, regardless of NPO status):
  • Symptomatic patients (respiratory distress, inability to handle secretions, severe pain).
  • Any esophageal button battery due to rapid tissue injury and risk of catastrophic complications.
• Urgent removal (<24 hours):
  • Sharp objects (nails, straight pins, open safety pins).
  • Multiple magnets.
  • Long objects (>6 cm in length).
  • Large objects (>2.5 cm in diameter).

Spontaneous Passage of Esophageal Coins

• Influence of location:
  • Distal third of esophagus: ~47% spontaneous passage into stomach.
  • Middle third: ~10% spontaneous passage.
  • Proximal third: ~26% spontaneous passage.
• Time frame: Up to one-fourth of esophageal coins pass spontaneously within 8–16 hours.
• Observation strategy:
  • Reasonable to observe for 8–16 hours for spontaneous passage of round, noncorrosive objects (e.g., coins) in asymptomatic patients.
  • Only appropriate when there is no history of esophageal disease and close follow-up is assured.

Removal Techniques

• Endoscopic methods:
  • Flexible endoscopy (commonly used).
  • Rigid esophagoscopy.
  • Magill forceps for objects at or above the cricopharyngeus.
• Advantages of endoscopy:
  • Safe and effective across object types.
  • Allows direct visualization of esophageal mucosa.
  • Can be used in patients with respiratory distress (with appropriate airway management).
• Alternative techniques (for noncorrosive, blunt objects <2 days):
  • Balloon-tipped catheter passed beyond the object and withdrawn to extract it.
  • Bougienage to advance the object into the stomach.
  • Fluoroscopic-guided grasping forceps covered by a soft rubber catheter.
• Risks of alternative methods: Potential for perforation, aspiration, or failure; should only be used by experienced clinicians and in carefully selected cases.

Pharmacologic Adjuncts

• Glucagon:
  • Intended to relax the lower esophageal sphincter and facilitate passage into the stomach.
  • Evidence is equivocal; overall success is limited.
  • Generally not recommended, except possibly for distal esophageal coins when endoscopy is not readily available and the patient is stable.

Gastrointestinal Foreign Body

Stomach & Lower GI Tract

Management Principles

• Watchful waiting is appropriate for most asymptomatic patients.
• Most sharp objects pass without complication, but endoscopic removal is preferred if reachable due to morbidity risk.
• Large objects (>2.5 cm diameter) and long objects (>6 cm length) should be removed if within endoscopic reach.
• Objects beyond endoscopic reach in asymptomatic patients require serial abdominal radiographs every 2–3 days and serial exams.
• Most round objects (e.g., coins) pass in 3–8 days without complications.
• Some inert objects (e.g., quarters) may remain in the stomach for weeks; prolonged observation is acceptable if asymptomatic.
• Any symptomatic patient requires endoscopic or surgical intervention.

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Button Battery Ingestion

Risk & Mechanism

• Major morbidity and mortality have increased due to widespread use of 20‑mm lithium batteries.
• Children <4 years account for most severe outcomes.
• Injury mechanisms include pressure necrosis, external electrolytic current causing liquefaction necrosis, and caustic leakage.

Diagnosis & Imaging

• Button batteries must be distinguished from coins on radiographs.
• Suggestive signs:
  • “Double rim” or “halo” sign on AP view
  • Step‑off pattern on lateral view

Management

• Esophageal batteries: Emergent removal within 2 hours.
• Stomach or beyond (asymptomatic):
  • Allow spontaneous passage if battery <20 mm or child ≥5 years.
  • Parents inspect stool; repeat radiograph at:
    • 2 days for ≥20‑mm batteries
    • 10–14 days for <20‑mm batteries
• Endoscopic removal if battery remains in stomach beyond expected time or if symptoms develop.
• Children <5 years with ≥20‑mm battery in stomach should undergo endoscopic removal within 24–48 hours and evaluation for esophageal injury.
• Complications include tracheoesophageal fistula, strictures, perforation, mediastinitis, vocal cord paralysis, and aortoesophageal fistula (most common cause of death).

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Magnet Ingestions

Risk Profile

• Single magnets behave similarly to coins and can be monitored.
• Multiple magnets pose high risk due to attraction across bowel walls → obstruction, necrosis, perforation.

Management

• Remove a single magnet if risk of further ingestion exists.
• All multiple magnet ingestions require surgical and/or GI consultation.
• Multiple magnets in esophagus or stomach → endoscopic removal.
• Multiple magnets beyond stomach (asymptomatic) → serial radiographs and abdominal exams.
• Symptomatic patients with magnets beyond stomach → surgical intervention.

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Respiratory Foreign Body

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Respiratory Foreign Bodies

Upper Airway

• Severity: Upper airway foreign bodies can be immediately life-threatening.
• Epidemiology:
  • Choking is a leading cause of unintentional injury death in children <5 years.
  • Most children with aspirated foreign bodies are <3 years old.
• High-risk foods: Hot dogs, candy, meat, grapes.
• Common man-made objects: Balloons, small balls, beads; fatality from these is less common than from food.
• Clinical presentation:
  • Acute respiratory distress
  • Stridor
  • Partial or complete upper airway obstruction
• Emergency management (complete obstruction):
  • Initiate basic life support immediately.
  • Infants: Back blows and chest compressions.
  • Toddlers, children, adolescents (conscious): Abdominal thrusts (Heimlich maneuver).
  • Begin CPR if the patient becomes unresponsive.
  • Avoid blind finger sweeps; proceed to direct visualization and manual extraction when feasible.
  • If unsuccessful, rapid progression to an emergency airway (e.g., laryngoscopy with removal, surgical airway in extremis).

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Lower Respiratory Tract

• Diagnostic challenge: Symptoms are nonspecific (cough, wheeze, respiratory distress); many children are initially misdiagnosed with asthma, pneumonia, or bronchiolitis.
• Epidemiology:
  • More common in young children.
  • Slight right-sided predominance (~52%) in the tracheobronchial tree.
• Common aspirated materials:
  • Organic matter (~80%): nuts and seeds most common; also apples, carrots, popcorn, plants, grasses.
  • Plastics and metals are less common; coin aspiration is rare.
• Symptoms & clinical triad:
  • Classic triad (cough, focal wheeze, decreased breath sounds) present in only ~14–39%.
  • Most common symptoms:
    • Persistent cough (≈70–90%)
    • Difficulty breathing (≈60–65%)
    • Wheezing (≈50–60%)
• History:
  • Witnessed choking event is highly suggestive (sensitivity up to ~90%).
  • Parents may not volunteer choking history unless specifically asked.
  • A significant proportion have no witnessed event, increasing diagnostic difficulty.
• Complications of delayed diagnosis: Recurrent pneumonia, persistent wheeze, bronchiectasis, lung abscess.

Lower Respiratory Tract – Diagnosis

Clinical Suspicion

• Symptoms overlap with URI, bronchiolitis, pneumonia, and asthma.
• Ask specifically about choking episodes, especially with nuts, seeds, apples, carrots.
• High suspicion in children 6 months–4 years with new respiratory symptoms.

Radiographic Evaluation

• Normal radiographs do not exclude aspiration.
• Suggestive findings:
  • Air trapping
  • Atelectasis
  • Mediastinal shift
  • Consolidation
• Inspiratory/expiratory films may show unilateral air trapping.
• Lateral decubitus films useful in young/uncooperative children.
• Chest fluoroscopy may show focal air trapping or mediastinal shift.
• Chest CT has ≥91% sensitivity but higher radiation; not routine.

Diagnostic Pathway

• NPO until disposition determined.
• If films normal and suspicion low → discharge with follow‑up.
• If suspicion persists → consider fluoroscopy or CT.
• Proceed directly to bronchoscopy if:
  • Acute onset of focal findings (unilateral wheeze, decreased aeration)
  • Convincing aspiration history

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Lower Respiratory Tract – Removal

Management

• Rigid bronchoscopy under general anesthesia is the standard technique (>98% success).
• Flexible bronchoscopy may aid diagnosis but is less commonly used for removal.
• Tracheostomy or thoracotomy is rarely required.

Post‑Removal Complications

• Atelectasis
• Post‑obstructive pneumonia
• Stridor
• Bronchospasm or laryngospasm
• Retained foreign body
• Risk increases with longer retention time.