by Michelle Place, CRNP-P
A foreign body ingestion (FBI) occurs when an object that is not food is swallowed. Most FBIs occur in children between the ages of six months and three years. Fortunately, most foreign bodies that reach the gastrointestinal tract pass spontaneously. Only 10 to 20 percent require removal with a flexible tool with a light on the end of it known as an endoscope, and less than 1 percent require surgical intervention.
If your child ever ingests anything that is not food do not hesitate to call the Poison Control Center at 1-800-222-1222 for advice. Every parent should have this number pre-programmed into their phone.
Below find a list of the most commonly ingested foreign bodies and when medical intervention is recommended.
Of any foreign body that can be ingested, button batteries are most likely to cause dangerous or fatal injury. A button battery lodged in the esophagus forms a closed circuit which will discharge its electrical current causing severe tissue injury that can occur within 2-3 hours of ingestion. This is a medical emergency and button battery removal should not be delayed under any circumstance.
- Any person with witnessed or suspected button battery ingestion should be taken to the nearest emergency department for rapid evaluation regardless of symptoms.
- The size of the battery is a major determining risk factor for severe injury. Any battery 15 mm in diameter is associated with much higher risk, and batteries as large as 20 mm are the cause of most button battery-related injuries and deaths.
- Medications to induce vomiting (such as ipecac) should never be given regardless of battery location.
These batteries do not typically discharge electrical current the way button batteries do, but they have the potential to leak caustic fluid if the outer casing is breached.
- For single cylindrical battery ingestions endoscopic removal is recommended in <24 hours if it is in the esophagus.
- If in the stomach, x-ray evaluation within 1 week if the battery is not observed to pass in the stool is sufficient. If not passed in 1 week removal by endoscopy will be considered
- Once these batteries pass into the small intestine, they almost universally pass the remaining gastrointestinal (GI) tract without incident.
Coins and similar objects are the most common FBIs in small children
- Coins, blunt screws, bolts, and similar hardware, while potentially anxiety provoking, are highly likely to pass the GI tract uneventfully if swallowed as a single object.
- For blunt foreign bodies that are lodged in the esophagus in a child without symptoms, observation for 12 to 24 hours is reasonable because spontaneous passage often occurs.
- Objects lodged in the esophagus for more than 24 hours or for an unknown amount of time should be removed promptly. Any longer and complications are more likely to occur.
- Coins do not have sharp edges and the metal is not toxic, so, most coins that reach the stomach will pass out uneventfully within 1-2 weeks.
- In an asymptomatic child, an x-ray 2-3 weeks after ingestion should be checked if the object is not observed to pass in the stool.
- Endoscopic removal can be considered if the object is still retained for around 4 weeks
- If the child develops any signs or symptoms of obstruction: abdominal pain, vomiting, or fever, then an x-ray should be checked and the coin removed endoscopically.
- On initial evaluation, if the object is in the small bowel or colon, a follow-up x-ray is not needed routinely because spontaneous passage is very likely.
In 2009 sales of adult desk toy magnet sets became very popular. Since then the danger of high-powered magnet ingestion has increased exponentially.
Single Magnet Ingestion
- Ingestion of a single magnet is typically of little danger once it passes into the stomach, as long as further ingestions do not occur.
- Other magnets or metallic objects should not be worn on the body or clothes until the magnet has completely passed.
- A trip to the emergency department is essential if there is even the smallest chance that more than one magnet was ingested. Neck, chest, and abdominal x-rays are recommended.
- If a single magnet is found in the esophagus, endoscopic removal within 24 hours is recommended if it does not pass into the stomach.
- If the magnet travels beyond the esophagus, spontaneous passage is likely.
Multiple Magnet Ingestion
- Multiple magnets can attract each other across tissues causing pressure which can lead to decreased blood supply and even death to the bowel wall.
- Any patient suspected of multiple magnet ingestion should be immediately taken to the emergency department for evaluation regardless of symptoms.
- Urgent endoscopic removal is indicated in all cases when the magnets are within reach.
- If the magnets cannot be retrieved the child should be admitted to the hospital for monitoring, serial x-rays, and potential surgical removal if the magnets are not progressing through the GI tract or if the child develops symptoms such as pain, vomiting, or increased heart rate.
- Sharp objects in the esophagus or in the symptomatic patient should be removed emergently
- Sites of highest risk for perforation include the esophagus, the first part of the small intestine (the duodenum), and particularly at the junction between the small and large intestines. As a result, passage beyond the small intestine does not eliminate the need for follow-up, as is the case in other ingestions.
- In general, straight pins and like objects with a heavier weighted blunt-end and lighter sharp-end, have a fairly good track record of passing spontaneously without complication, as long as it passes beyond the esophagus and is a length that can travel through the duodenum.
- Non-straight sharps such as open safety pins and dual-ended sharp objects, like toothpicks or food bones, should be urgently removed if possible, with close inpatient observation if not retrieved.
- An ingested object that is made of a material that does not show up on x-ray poses an additional challenge because identifying its location is not possible. Proceeding directly to endoscopic removal is a common practice.
- If the object is in the stomach or just past the stomach in the duodenum, it also should be removed promptly using a flexible endoscope. The risk of a complication caused by a sharp-pointed object passing through the gastrointestinal tract is 4-35%.
- Sharp objects that pass beyond the reach of a flexible endoscope and then cause symptoms will require surgical intervention. The most common site of intestinal perforation are the areas between the small and large intestines and between the large intestine and the rectum.
- If the object has passed into the small intestine and the patient has no symptoms, it may be followed with serial x-rays to follow its passage.
- Surgical intervention should be considered for objects that do not progress for three consecutive days. Parents should immediately report symptoms of abdominal pain, vomiting, fever, and blood in vomit or stool.
Long and Large Objects
- Foreign bodies that are long and blunt include toothbrushes, batteries, and spoons.
- Objects longer than 6 to 10 cm generally cannot pass beyond the stomach and should be removed.
- Objects of intermediate length (5 to 6 cm) may pass through the stomach, but up to half become stuck in the region between the small and large intestines so, they should be removed if they are in the stomach.
- If they pass into the small intestine they should be followed by serial x-rays, and surgical removal should be considered if they fail to progress.
- Toys and household products made of superabsorbent polymers, like tiny dinosaurs which grow when placed in water, present a risk for bowel obstruction if swallowed.
- These objects can expand 30 to 60 times their original size when hydrated.
- If ingestion of a superabsorbent object is suspected, it should be removed immediately.
- The superabsorbent polymer is radiolucent, so x-rays are generally not helpful. The object can sometimes be identified by administering a small amount of contrast material.
- If the object has passed beyond the stomach, the child should be monitored closely for symptoms of intestinal obstruction.
(Most information in this post taken from: B. Sahn et al. / Journal of Adolescent Health 55 (2014) 260-266 and Up-to-Date)
If you are worried that your child has ingested a foreign object and have questions after talking to Poison Control, do not hesitate to call our triage nurses at (301) 279-6750.