Foreign body ingestion (FB) is a common ER complaint for young children, especially toddlers. Sometimes a FB makes its way all the way in and out of the body and other times it gets stuck. Common sites of impaction are sternal notch, aortic knob, GE junction and ileocecal valve. Depending on the FB, size and location it could be a serious emergency to pick up right away and treat and other times the FB can be allowed to pass on its own. But what’s what? The esophagus is particularly narrow near the cricopharyngeus muscle, at the site of the aortic crossover, and at the lower esophageal sphincter. Review these locations here: https://www.ebmedicine.net/topics/gastrointestinal/emergency-medicine-foreign-bodies
1. Button Batteries: EMERGENCY! Poison Control in the U.S. gets 3300 calls/year related to button battery ingestions in kids.
a. Consider battery ingestion if: drooling, gagging, vomiting, coughing with trying to PO, refusing PO, difficulty swallowing, Chest pain, new airway obstruction or wheezing, or family concerned it was a button battery.
b. Battery ingestion known or suspected: immediately start honey 10ml q10 minutes >12 month old, or Carafate in hospital 10ml q 10 minutes until removal, otherwise remain NPO
c. ID battery from parent/package
d. Neck/Chest PA and Lateral, abdomen XR immediately for localization and delineation of battery vs other. Button batteries will demonstrate a “double halo” on AP view, step off on lateral view. Check out these articles to view a button battery lodged in the esophagus: https://www.ohniww.org/pediatric-otolaryngologist-la/
https://appliedradiology.com/articles/button-battery-ingestions-and-diagnostic-imaging
e. Esophageal location: EMERGENT removal within 2 hours.
f. Complications: esophageal burn/injury/perforation, stricture, aortic bleeding and death
g. Stomach location: Depends on age of child/size of battery
h. Large child/smaller battery could be left to pass on own with repeat XR in 7 days
i. Consult Ped Surg vs Peds GI even/odd days for button batteries in stomach to help determine treatment/follow-up
j. Beyond stomach: Asymptomatic? Monitor closely for abdominal pain, GI bleeding, fever, vomitingàif this develops, consult Peds Surgery for removal
Questions or concerns about Button Battery ingestion: Call National Battery Ingestion Hotline (NBIH; 1-800-498-8666) or a regional Poison Control Center.
2. Coins: Urgent (unless not sure if coin, then emergent)
a. XR neck/chest/abdomen ASAP and assess location/double halo/lateral step offà if concerns for battery in esophagus, immediately consult specialist and start Carafate
b. Location
i. Esophagus-NPO, urgent removal (12 hours) unless severe symptoms-vomiting/respiratory distress
ii. Stomach or beyond
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- Symptomatic: vomiting, pain, not eating/not drinking: consult/admit/removal
- Asymptomatic: Discharge home, strict return precautions discussion, start MiraLAX 1 cap dissolved in apple juice/water twice daily to speed expulsion, check stools, if it hasn’t been seen in 2 weeks, repeat XR with PCP. If not moved from stomach in 4 weeks, consult Peds GI for removal.
- Any time if symptoms develop, return to ER, repeat imaging and consult specialist.
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3. Sharp objects:
a. Symptomatic: Removal at any time or location
b. Asymptomatic:
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- Stomach and 3cm X 2cm needs removal
- Stomach and less than 3cm X 2cm can allow to pass, repeat XR in 2-3 days
- Beyond stomach without symptoms-Repeat XR in 2-3 days
- At any time if symptoms develop or if Fb stops moving, will require removal
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4. Expanding objects:
Superabsorbent polymer beads-Water beads: start out small, when around water expand in size and can block pyloric outflow tract or cecal valve and lead to bowel obstruction. For kids, if known to be in stomach normally would remove, otherwise if asymptomatic would allow to pass. Newer research showing Golytely may decrease the size of expanded water beads and it helps FBs pass faster thru the gastric tract. If any vomiting, refusal to eat, fever, distension of the abdomen may require laparoscopic or open removal of beads from bowel. Visit these articles to see photos of water-beads in the digestive tract: https://pmc.ncbi.nlm.nih.gov/articles/PMC10848886/
5. Magnets: Biggest concern is with multiple magnets, or magnet plus, other metal FB leading to entero-enteric fistula across two loops of bowel, peritonitis, and bowel necrosis.
a. Stomach:
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- One only magnet—could pass if asymptomatic but keep away from other magnets/ingesting metals. Return for symptoms
- Multiple magnets-high risk to entrap bowel loops, typically remove
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b. Beyond stomach:
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- Symptomatic-consult Peds Surg
- Asymptomatic multiple: get repeat XRs in 4-6 hours, if progressing together, less likely to cause fistula between two bowel loops, repeat imaging in 7 days, return for symptoms, if not progressing on imaging, removal
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Visit this article to see a radiograph of ingested magnets: https://sciencefeatured.com/2024/06/13/magnets-and-kids-a-playtime-hazard-turns-serious/
References:
- https://www.ebmedicine.net/topics/gastrointestinal/emergency-medicine-foreign-bodies
- https://www.ncbi.nlm.nih.gov/books/NBK470298/
- https://espghan.info/files/EM011875_ESPGHAN_Button_Battery_Advice_Guide_211126_v3_NMA.pdf
- https://www.ohniww.org/pediatric-otolaryngologist-la/
- https://appliedradiology.com/articles/button-battery-ingestions-and-diagnostic-imaging
- https://naspghan.org/files/documents/pdfs/cme/jpgn/Management_of_Ingested_Foreign_Bodies_in_Children_.28.pdf
- https://pmc.ncbi.nlm.nih.gov/articles/PMC10848886/
- https://pathways.chop.edu/clinical-pathway/foreign-body-ingestion-ingestion-sharp-object
- https://www.aap.org/en/news-room/news-releases-from-aap-conferences/water-absorbing-beads-pose-increasing-hazard-for-young-children-researchers-test-methods-on-how-to-shrink-them/?srsltid=AfmBOoqzWgIm2OTeVdgq79ECB0qVUcvZfPLNQFXTGVZhDYNt0S0cmb9Z
- https://sciencefeatured.com/2024/06/13/magnets-and-kids-a-playtime-hazard-turns-serious/