Introduction

Ingestion of foreign (non-food) material is common in early childhood and often goes undetected whilst the child is playing and may not prompt a physician visit. The exact frequency of reported foreign body ingestions is uncertain. The literature in this field can be divided into three areas: descriptive studies of fairly large numbers of ingestion cases; studies primarily or exclusively about coin ingestion; and studies about disc batteries.¹ Common foreign bodies ingested that come to medical attention include coins, bones (fish, chicken), other metallic objects (pins, screws, keys, batteries), and plastic and rubber foreign bodies. In one large series of 1265 reported cases of foreign-body ingestions, age ranged from 7 months to 16 years with a mean of 5.2 years.² Most foreign bodies pass through the gastrointestinal tract without complications. The emergency physician should be aware of the few instances when emergent or semi-urgent intervention is indicated. Parents need to have clear guidelines regarding the treatment plan for children who are discharged to outpatient follow up.

History

In most instances, a thorough history can be obtained from parents or caregivers before a requirement for intervention. The nature of the ingested item is obviously imperative, as is the time of ingestion. The ingestion may have been witnessed or may have been reported (by an older child) or implied by the child’s environment at the onset of symptomatology. It can be extremely useful if a replica of the foreign body can be easily obtained, especially in determining the type and size of disc batteries. Determining the immediate environment of the child at the time of ingestion can assist in revealing the possibility of any likely co-ingestants.

The symptoms experienced by the child since ingestion help determine the likely site of the foreign body but this has limitations. Many children are asymptomatic at presentation, which usually (but not always) suggests that the foreign body is lying in the stomach or more distal part of the gastrointestinal tract. Symptoms of vomiting, pain or discomfort on swallowing, drooling, irritability and refusal to take food or fluids may occur and suggest oesophageal foreign body. Several reports note that some children will be asymptomatic with foreign bodies lodged in the oesophagus, especially the distal oesophagus.^3,4 Even in the context of sharp fishbones, a prospective study found that symptoms were a poor predictor of the presence of fishbones, except for a sharp pricking sensation on swallowing.⁵ Reports of abdominal pain or blood in the bowel motions should be noted. A history of previous oesophageal or other gastrointestinal disease is significant in determining a management plan and alerting one to potential complications. Significant developmental/intellectual delay has been associated with major morbidity and mortality after foreign body ingestion.^2,6 This is often due to the vague symptomatology and delay in presentation.

Examination

For the majority of children the foreign body will have negotiated the oesophagus and general examination will be unremarkable. Vital signs should be recorded but once again are unlikely to be abnormal unless there is delayed presentation and the development of a complication.

Palpation of the abdomen will usually be normal. If the history alerts one to abdominal symptoms, the examiner may find localised tenderness or peritonism suggestive of intestinal perforation. This is rare.

Some children will have symptoms of proximal oesophageal or pharyngeal foreign body. In the older child or adolescent where this is due to bony ingestion (e.g. fish or chicken) there should be a careful examination of the oral cavity and pharynx by either indirect or direct laryngoscopy. Younger children are unlikely to co-operate with these procedures without sedation and an experienced examiner.

Investigations

All children with a history of ingestion of coins or batteries (or other radio-opaque foreign bodies) should have an X-ray performed to localise the foreign body. There is some controversy on this issue in relation to the need for X-rays in children who have ingested coins. Some authors (mainly hospital-based) note that even previously healthy children can be asymptomatic with an oesophageal coin and advocate early removal of oesophageal coins to prevent serious sequelae.^3,4 Other authors (notably in primary care) believe that routine X-rays in children having ingested a coin are unnecessary given that asymptomatic coin ingestion is rarely, if ever, associated with complications in otherwise healthy children.⁷ It has been recognised that those patients presenting to an emergency department (ED) are a selected group and would be expected to have greater severity of symptoms and higher frequency of complications.⁸ Hence the recommendation that all children with a history of coin ingestion who attend an ED, should have X-ray localisation of the coin performed. An alternative approach for coin ingestions is the use of a handheld metal detector for localisation of the coin. Several authors have confirmed the safety of this approach following a clear algorithm. Handheld metal detectors are not reliable at detecting metal foreign bodies other than coins.^9,10 If the ingestion is unwitnessed and the object looks like a coin on anteroposterior X-ray, be aware that a disc battery may have a similar appearance. In this situation, an additional lateral view will reveal an asymmetry, as the two sides of the disc battery have slightly different diameters. On the anteroposterior view one may also see the ‘double ring’ of both circumferences of the battery.