{
 "topic": "Foreign Body Ingestion",
 "slug": "foreign-body-ingestion",
 "category_id": 15070,
 "summary": "Swallowed objects in young children, from coins that usually pass safely to batteries and magnets that demand urgent removal, plus how to distinguish ingestion from the more dangerous foreign body aspiration.",
 "written_by": "claude-sonnet",
 "references": [
  {
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  {
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  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    5133,
    5526
   ]
  },
  {
   "title": "Pediatric Decision-Making Strategies",
   "author": "Pomeranz, Albert J.",
   "pages": [
    48
   ]
  }
 ],
 "short": [
  {
   "title": "In short",
   "content": "- Foreign body (FB) ingestion is common, mostly in children 6 months to 3 years old; about 75-80% of accidental ingestions occur in children 5 years or younger, and half of all reported ingestions are in children under 6.\n- Coins are the most frequently ingested object in young children, followed by small toys; up to 50% of children are asymptomatic at presentation despite ingestion.\n- When symptomatic, presentation can include abdominal or chest pain, stridor, drooling, respiratory distress, fever, dysphagia, or inability to tolerate oral intake; esophageal impaction specifically can cause dysphagia, refusal to eat, a foreign-body sensation, localizing pain, drooling, gagging, and vomiting.\n- Most ingested foreign bodies pass spontaneously through an anatomically normal GI tract with a good outcome; about 10-20% require endoscopic removal, and less than 1% require surgery.\n- A foreign body lodged in the esophagus is an emergency because of the risk of perforation and sepsis; management (need for and timing of removal) depends on the object's nature, location, size, timing of ingestion, symptoms, and NPO status.\n- Batteries and multiple magnets are the ingestions most likely to cause life-threatening complications, even though coins are ingested far more often; food impactions are less common in children than adults and are strongly linked to eosinophilic esophagitis (found in 92% of children presenting with food impaction and dysphagia).\n- ED visits for foreign-body ingestion in children under 6 rose 91.5% from 1995 to 2015; the American Association of Poison Control Centers reported 67,771 foreign-body exposures in children 5 and under in 2016 alone.\n- Risk factors beyond young age include developmental delay, psychiatric disorders, GI anatomic anomalies, and motility disorders.\n- Foreign body aspiration (into the airway rather than the esophagus/GI tract) is a distinct, more acutely dangerous entity: liquids most often cause choking in infants, while small objects and foods (grapes, nuts, hot dogs, candy) are the typical airway foreign bodies in toddlers and older children; sudden-onset choking, stridor, or wheezing should be considered foreign body aspiration until proven otherwise, though the classic history is not always present, and an aspirated foreign body can mimic croup, bronchiolitis, or asthma when the event was unwitnessed."
  }
 ],
 "long": [
  {
   "title": "Definition",
   "content": "Foreign body ingestion refers to the swallowing of a nonfood object (or, in the case of food impaction, a food bolus that cannot pass) into the gastrointestinal tract. It is distinct from foreign body aspiration, in which an object or food lodges in the pharynx or respiratory tract instead."
  },
  {
   "title": "Epidemiology",
   "content": "Foreign body ingestion is common in children, with most events occurring between 6 months and 3 years of age. About 75-80% of accidental ingestions occur in children 5 years old or younger, and the American Association of Poison Control Centers reported that 50% of all ingestions in 2014 were in children under 6. Emergency room encounters for foreign-body ingestion in children under 6 rose 91.5% from 1995 to 2015, and 67,771 foreign-body exposures were reported in children 5 and under in the US in 2016. Older children and adolescents with developmental delay, psychiatric disorders, GI anatomic anomalies, or motility disorders are also at increased risk."
  },
  {
   "title": "Etiology",
   "content": "FB ingestion in young children is generally unintentional and involves small household objects \u2014 coins (by far the most common), toys, jewelry, magnets, and batteries. The incidence of food impaction, while less frequent in children than in adults, is increasing, in part related to the rising incidence of eosinophilic esophagitis and to esophageal atresia repair. Young children are prone to ingestion and aspiration because of their inquisitive nature and tendency to explore objects with their mouths; once an object or food is in the mouth, it can be swallowed or can instead lodge in the pharynx or respiratory tract."
  },
  {
   "title": "Clinical features",
   "content": "Up to 50% of children are asymptomatic at presentation despite a foreign body ingestion. When symptomatic, presentation can include abdominal or chest pain, stridor, drooling, respiratory distress, fever, dysphagia, or an inability to tolerate oral intake. Esophageal impaction specifically presents with dysphagia, refusal to eat, a foreign-body sensation, localizing pain, drooling, gagging, and vomiting \u2014 symptoms that overlap with common childhood illnesses such as acute gastroenteritis, pharyngitis, or gingivostomatitis, making diagnosis difficult without a clear ingestion history. Nasal foreign bodies present differently, with delayed diagnosis and characteristic foul odor and unilateral rhinorrhea; a nasal foreign body should be suspected in a child with persistent unilateral rhinorrhea unresponsive to routine management. A foreign body lodged in the laryngeal inlet causes acute upper airway obstruction with severe coughing, hoarseness, and significant respiratory distress; when the aspiration event was unwitnessed and the child is not acutely compromised, presenting symptoms (cough, stridor, wheezing, decreased aeration) are nonspecific and can mimic croup, bronchiolitis, or asthma."
  },
  {
   "title": "Diagnostics",
   "content": "A thorough history and clinical examination are required, evaluating for respiratory distress, oropharyngeal injury, and signs of perforation such as subcutaneous emphysema or peritoneal signs. Any patient with swallowing difficulty needs a thorough exam of the mouth, oropharynx, neck, chest, and abdomen, with radiographic evaluation as needed. Management decisions depend on patient age and anatomy; object type, location, and size; timing of ingestion; presence or absence of symptoms; NPO status; and logistical factors. A history consistent with foreign body aspiration is considered diagnostic, and any child with sudden-onset choking, stridor, or wheezing should be presumed to have aspirated a foreign body until proven otherwise \u2014 though this classic history is not always present. Suspicion for airway foreign body should be raised for any sudden-onset respiratory symptoms or a history consistent with aspiration, even when the initial presentation looks like a common respiratory illness."
  },
  {
   "title": "Differential diagnosis",
   "content": "In the absence of a clear ingestion history, esophageal foreign body symptoms can be mistaken for acute gastroenteritis, pharyngitis, or gingivostomatitis. Aspirated foreign bodies causing cough, stridor, or wheezing without a clear history can mimic croup, bronchiolitis, or asthma; food impaction with dysphagia in a child should prompt evaluation for eosinophilic esophagitis, found in 92% of children presenting with this combination."
  },
  {
   "title": "Treatment",
   "content": "Most ingested foreign bodies pass spontaneously through an anatomically normal digestive tract with a good outcome. About 10-20% require endoscopic removal, and fewer than 1% require surgical intervention. A foreign body lodged in the esophagus constitutes an emergency, given the risk of perforation and sepsis, and requires prompt attention with removal timing based on the object's nature and the patient's symptoms. Nasal foreign bodies can often be removed in an office setting with appropriate preparation and equipment; difficult cases occasionally require removal under general anesthesia. Aspirated foreign bodies causing acute, severe airway obstruction may require abdominal thrusts in a conscious, choking child."
  },
  {
   "title": "Complications",
   "content": "While coins are the most commonly ingested object, batteries and multiple magnets carry the highest risk of life-threatening complications, and this risk drives urgency of removal even though these objects are ingested less often than coins. Esophageal foreign body impaction carries significant morbidity and mortality risk from potential perforation and sepsis. Aspirated foreign bodies can cause outcomes ranging from an acute life-threatening event to a slowly evolving pneumonia; chronic, unrecognized airway foreign bodies can lead to granuloma or granulation tissue formation. Presentation of foreign body aspiration can be immediate (same-day wheezing, cough, +/- fever in about 25% of cases), delayed (indolent cough, medically refractory wheezing, dyspnea, days 2-7, in about 45%), or further delayed beyond a week (in about 30%)."
  }
 ],
 "clinical": [
  {
   "title": "Bedside assessment of a suspected ingestion",
   "content": "In any child with a suspected or witnessed foreign body ingestion, take a thorough history and perform a careful examination, evaluating for respiratory distress, oropharyngeal injury, and signs of perforation such as subcutaneous emphysema or peritoneal signs \u2014 remembering that up to 50% of children are asymptomatic despite true ingestion. Ask specifically about dysphagia, refusal to eat, drooling, gagging, vomiting, or a foreign-body sensation, which suggest esophageal impaction; examine the mouth, oropharynx, neck, chest, and abdomen in any child with swallowing difficulty. Base the urgency and approach to removal on the object's nature, location, and size, the timing of ingestion, presence of symptoms, and NPO status \u2014 coins and most small objects can often be observed for spontaneous passage, but batteries and multiple magnets require urgent attention given their higher risk of serious complications even though they are ingested less often than coins. Treat a foreign body lodged in the esophagus as an emergency because of perforation and sepsis risk."
  },
  {
   "title": "Distinguishing ingestion from aspiration, and managing each",
   "content": "If a child presents with sudden-onset choking, stridor, or wheezing, presume foreign body aspiration until proven otherwise, even though the classic witnessed-choking history is not always present \u2014 an unwitnessed aspiration can mimic croup, bronchiolitis, or asthma with nonspecific cough, stridor, or wheezing, so maintain suspicion for airway foreign body with any sudden-onset respiratory symptom. In infants, liquids are the most common cause of choking; in toddlers and older children, small objects and foods such as grapes, nuts, hot dogs, and candy are typical. For acute, severe airway obstruction in a conscious child, use abdominal thrusts. For a suspected esophageal foreign body, arrange prompt evaluation and, if needed, endoscopic removal (about 10-20% of cases) \u2014 surgery is rarely needed (under 1%). Consider a nasal foreign body in any child with persistent unilateral, foul-smelling rhinorrhea, and remove in the office with appropriate equipment when feasible, reserving general anesthesia for difficult cases. In a child with recurrent food impaction and dysphagia, evaluate for eosinophilic esophagitis, which is found in the large majority of such presentations."
  }
 ]
}