Incidence of Foreign Body Ingestion in Children

Majed Alahmad, the man who’s every action helped me become the person that I am today, to you I dedicate all my success. And to my amazing mother Fatima Saleh who is a living proof of “If there is a will, there is a way” as she continues to lead me towards success by being the best example, May ALLAH bless you now and always. I would like to express my gratitude to Dr. Sarmad Al Hamdani, Consultant general pediatrician in Dubai Hospital and Dr. Mahera Amirad for their unlimited support and guidance throughout the research period. Finally, most of the patients do not experience any complication as the rate of complication was at 9%. Conclusion: FB ingestion among children is dangerous as it may result in serious morbidity and mortality.

Since most of FB ingestions are asymptomatic, parents and guardians should remain vigilant and seek immediate medical attention in case of any suspected ingestion. Table of Contents List of Tables and Figures 1 List of Abbreviations 2 Introduction 3 Materials and Methods 4 Results 6 Discussion 22 Conclusion 39 References 40 Appendix 43 List of Tables and Figures Figure 1: Incidence of FB Ingestion 6 Figure 2: Age Distribution of Kids Studied 7 Figure 3: Incidence of FB Ingestion with Age 8 Figure 4: Gender Distribution 8 Figure 5: Presentation on FB Ingestion 10 Figure 6: Type of FB Ingested 11 Figure 7: Foreign Bodies Located in the Esophagus 12 Figure 8: Foreign Bodies Located in the Stomach 13 Figure 9: Foreign Bodies Located in the Small Intestines 14 Figure 10: Foreign Bodies Located in the Colon 15 Figure 11: Location of Foreign Bodies 16 Figure 12: Type and Location of Foreign Body 16 Figure 13: Management Techniques Adopted 18 Figure 14: Radiological Findings 19 Figure 15: Colonoscopy Findings 20 Figure 16: Complications Experienced 21 List of Abbreviations EGD - Esophagogastroduodenoscopy ERCP - Endoscopic Retrograde Cholangiopancreatography FB – Foreign Body GI - Gastrointestinal KSA - Kingdom of Saudi Arabia SPSS - Statistical Package for the Social Sciences UAE - United Arab Emirates Introduction Foreign body ingestion is a common problem encountered in pediatric age group.

It is indeed the most common pediatric gastrointestinal emergencies in the department in Dubai hospital. Materials and Methods This research was conducted as a descriptive retrospective study over a period of 5 years (2011–2016) in order to assess the particular aspects of foreign body ingestions in children admitted in a pediatric gastroenterology unit in a tertiary care hospital in Dubai – UAE. The paper concentrates on data from the pediatric department which deals with emergency cases involving children from various parts of the world, however, it is notable that most cases come from the Asian countries as well as locally. The data was collected in tailored excel sheet and analyzed by SPSS. Data is displayed using descriptive statistics such as bar graphs and pie chart for better easier understanding.

Comparison to other similar studies continentally and internationally auditing the existing protocol in management in discussions. It is also notable that patients who did not have adequate notes that would enable us to achieve our variables and objectives were also excluded. Further, it is notable that the study did not involve the collection of tissue/fluid samples and there were no any risks to the participants of the study. The study does not reveal any form of identifications to the children or their families that imply taking any sort of permission from them. Results The aim of this study was to determine the incidence of incidence of foreign body ingestion in children attending Dubai hospital pediatric gastrointestinal unit from 2011 to 2016. This study collected data from 246 children between the ages of 0 to 12.

The incidence of ingestion for one-year-old kids stood at 25. At age two, the figure sharply rose and more than doubled to 58. Subsequently, the number sharply dropped (but not to the original position) to 36 at age three which remained constant at age 4 and continued to drop from age 5 (30), age 6 (19) age 7 (15) age 8 (9) and age 10 (3). The number then remained constant from age 9 through age 12. Therefore, the highest number of foreign bodies is ingested at age two and gradually drops as the kids grow. 5 M 131 53. 5 Total 245 99. 0 Missing System 1. 4 Total 246 100. 0 Figure 4: Gender Distribution The data collected from the population shown diversity as the children came from various countries around the world namely Antigua, Australia, Bangladesh, Canada, Chile, Comoros, Cote d'Ivoire, Egypt, India, Iran, Iraq, Jordan, Saudi Arabia, Lebanon, Liechtenstein, Nepal, Oman, Pakistan, Palestine, Philippines, Romania, Saudi Arabia, Sri Lanka, Sudan, Syria, Togo, UAE, Uganda, United Kingdom, USA, and Yemen.

The most common symptom was an abdominal pain at 7. 3% followed by drooling with dysphagia 4. 4% and then vomiting at 3. Note that some of the kids presented multiple symptoms. For instance, 4. 4 Mild Chest Pain 1 0. 4 Oral burn/Drooling 1 0. 4 Cough 1 0. 4 Vomiting blood streaked & chest pain 1 0. 4 Swelling of the lower lip, oral mucosa inflamed 1 0. 8%) were located in the middle esophagus, while 86 (72. 9%) were located in the upper esophagus. This indicates that most of the foreign bodies ingested normally did not pass upper esophagus into the lower esophagus. Note that of the 118 foreign bodies located in the esophagus, 99 were coins, 8 were batteries, 6 were nails or pins related, 3 were toy parts, while 2 were chemicals. Interestingly, all the 2 chemical ingested were located in the lower esophagus. See figure 8 below for details Figure 8: Foreign Bodies Located in the Stomach Further, 27 of the foreign bodies were found located in the small intestine.

Of these 27, 14 (52%) were battery ingestions, 7 (28%) were toy-related objects, and lastly, 6 (20%) were pin or nail-related objects. Note that no chemical or magnet-related foreign bodies were found located within the small intestines. Therefore, unlike the esophagus, most of the foreign bodies located in small intestines were batteries, just like in the stomach. See figure 9 below for more details. As shown in figure 12 below, a large part of the foreign bodies in the esophagus relates to coins. For batteries and pins or nails, a majority of the objects were located in the stomach rather than the esophagus. In fact, for batteries, the esophagus had the least number of objects. Foreign Body Chemical Battery Coin Toy Pin/Nail Magnet Total Esophagus 2 8 99 3 6 0 118 Stomach 0 30 24 2 14 2 72 Small intestine 0 14 7 0 6 0 27 Colon 0 13 7 0 5 0 25 Total 2 65 137 5 31 2 242 Figure 12: Type and Location of Foreign Body With regards to the management, there were three commonly adopted techniques namely upper Gastrointestinal (GI) Endoscopy, colonoscopy under General Anesthesia (GA) and simply observation.

Since most of the objects were located in the upper esophagus, the most commonly used approach was upper GI endoscopy. Figure 13: Management Techniques Adopted Note that the mentioned management methods were not the only one. These methods were used in conjunction with other techniques such as esomeprazole, sucralfate, and follow up x-ray. Follow up x-ray was most used to monitor the progress of the kids after application of other management techniques such as GI endoscopy under GA. Radiological evaluation was used to determine the location of the foreign bodies in the kids. Studies suggest that prompt treatment of kids with suspected foreign body ingestion is crucial because of the potential for severe complications. For the abnormal colonoscopy findings, some of these findings included inflammation of the mucosa with severe bleeding, erosion, and ulceration.

Grade 1 and grade 2 burns were also observed. Note that the most severe findings such as inflammation of the mucosa and grade 1 and grade 2 burns were common for chemical, magnet, and battery ingestions. To put this into perspective, see figure 15 below. From the table, it is clear that 100% of chemical and magnet ingestion revealed abnormal colonoscopy findings. Some of this objects may be swallowed accidentally and sometimes on purpose (9). Some of the most commonly ingested foreign bodies include coins, pins, nails, toy parts and button batteries. Surprisingly, most of the kids who ingest foreign bodies including those that seem to be very dangerous such as razor blades, nails, and pins naturally pass them through their systems. However, parents need to be vigilant and seek immediate medical attention as soon as there is suspected ingestion of foreign objects.

This is because any symptom warranty emergency medical attention. Therefore, the number incidence of 2% may be highly understated when you factor in the unreported cases. However, an incidence of 2% is still significant care should be taken to limit the exposure of dangerous objects to the kids. The incidence of foreign bodies ingestion can also be locked at from the age perspective. Although studies recognize that foreign body ingestion can be observed at all ages, the phenomenon is more common in children. However, researchers do not fully agree on the age with the highest incidence of FB with some arguing it is between 6 months and 6, year 6 months and years while others argue that it is 1 to 3 years (1, 9, 21). This therefore explains why the number of foreign bodies ingested significantly rise at age 2.

Note that age 3 and older, the number of foreign bodies gradually reduces. This is because as kids grow, they become more aware of their environment and know can identify that some objects are dangerous and should not be inserted in the mouth. Simply, kids stop inserting objects into the mouth and as such the incidence of foreign bodies ingested greatly reduce. Thus this explains the big variance between the number of foreign bodies ingested at say age 1 through age 6 (a total of 204 kids making up 83%) and age 7 through age 8 (a total of 41 kids making up 17%). The study also indicated that even though there was diversity in the kids who ingest foreign objects, most of the kids (34%) were from the UAE. Note that this does not necessarily mean that UAE kids are more prone to ingesting foreign bodies than kids from the other countries.

This study was carried out for kids admitted at the Dubai hospital pediatric gastrointestinal unit. As such, it is expected that most of the kids who visit the hospital are UAE citizens and that is why UAE was highly represented. India came in next with 22 percent. For instance, children from the Far East are more likely to have reported cases of fish-borne ingestion that those in the Middle East. However, despite regional differences, one thing that comes out on top of the list is always coins. Some studies revealed that coins, toys, magnets, and batteries respectively are the most ingested foreign bodies (15, 16). In studies conducted in China and Belgian, the rate of coin ingestion was found to be 47% and 27% respectively (1). Similarly, a study conducted by in the United States revealed that “coins are the most common ingested objects among children in the United States with >250,000 ingestions and 20 deaths reported in the United States during a 10-year period.

Therefore, the composition of swallowed batteries has shifted towards the larger diameter lithium batteries as they are now conspicuously available in many households. Similarly, from this study alkali batteries was only reported once out of the 62 patients with battery ingestion. This study, however, went against that of Waltzman study which stated that toys and magnets ingestions were more prevalent than batteries (16). Note that for most of the children (82%) who ingested batteries, there were no complications. However, a considerable number reported complications including inflammation, erosion, and ulceration of the mucosa, erosion of the stomach, erythema, and corrosive burn at cervical esophagus. From this study, the most common sharp object ingested was scarf pin followed by hairpins and nails. However, the data collected was not enough to help make conclusions on the relationship between the type of sharp objects ingested and the cultural background of the children.

There was also an important observation with regards to the location of the foreign bodies. Most of the bodies got stuck in the esophagus and the number kept on decreasing all the way from the esophagus, stomach, small intestine and into the colon. In fact, there were 188 (49%) foreign bodies located in the esophagus, 72 (30%) located in the stomach, 27 (11%) located in the small intestines, and 25 (10%) located in the colon. It is not clear why most of the coins ingested stuck in the esophagus but then it may be due to the fact that they have a larger diameter and therefore they are the hardest to pass the esophagus once ingested. In addition, with the rise of the button batteries with a relatively smaller diameter than alkaline batteries, it has become increasingly easy for the batteries to pass the esophagus and land in the stomach, another reason to why there might be a large number of battery-related objected located in the stomach.

Studies suggest different methods of management depending on the type and location of the foreign body (6). As a rule of thumb, the coins visualized in the sagittal plane on anteroposterior radiographs are in the trachea, while coins in the esophagus will normally have a coronal orientation on the frontal chest radiographs (3, 20). In addition, one other important alternative one need to consider while assessing the coin-like foreign bodies is the button batteries. The technique is very efficient because it yielded an almost perfect result. In fact, in the 6 cases where the FB was not seen through radiological imaging, in 5 cases the foreign body spontaneously passed out of the kid's system. Therefore, it is accurate to conclude that radiological images should be used in cases of foreign body ingestion in kids be it symptomatic or asymptomatic.

With regards to colonoscopy findings, it became clear that despite the abnormally large number of coins being ingested, they are relatively less fatal when compared to the other bodies. Further chemical, magnets, and batteries are very lethal to the kids’ body and they should be given close attention in case of any suspicion of ingestion (13). Forceps with a “rat tooth” may be used to grasp the battery for removal. Alternatively, the physician can use the retrieval net. However, in those kids that adherence to the mucosa does not allow flexible endoscopy removal, rigid endoscope by surgery is necessary although this method substantially increases the perforation risk (17). However, gastric endoscopic intervention for battery ingestion remains controversial. There is evidence of fatalities from batteries that had caused injury before reaching the stomach.

However, chemical ingestion may prove to be more dangerous as they react fast with the body fluids and thus increasing acidity in the stomach. Further, chemical ingestions may not be removable through endoscopy as they may dissolve in the stomach. Thus, in this study, some of the complications associated with chemical ingestion included grade 1 oesophageal mucosal injury, grade 1 burn in the esophagus, grade 1-2A burn in the esophagus, and inflamed oral oesophageal mucosa. Thus, these findings reveal exactly how dangerous chemical ingestions are and that parents should always take care great care to ensure that kids are not exposed to chemical substances. Magnets are another commonly ingested objects. In other cases such as large magnet size, failure to pass as expected, unusual shape of the magnet, and age of the child, the endoscopic removal may be necessary.

Some studies have revealed that 52% of magnet ingestion patients result in endoscopic intervention alone, 20% result in endoscopy and surgery, and 8% result in surgery alone. Only 15% are managed with observation alone. In addition, of those patients who undergo surgery, 41% had repair of a perforation or fistula while 22% required bowel resection. Note that in this study, only two magnets were ingested. Studies indicated that there is 100% predictive value of radiographs for the metallic sharp objects, but the much lower around 43% for glass, and further 26% for fish bones and zero percent for wood. If the x-ray shows negative result but then there is still suspicion of foreign body, then it is prudent to undertake the endoscopic evaluation. A sharp object that is located in the esophagus is always an emergency due to the high perforation risk and should be promptly removed.

Once the sharp object has been identified, then the optimal management depends on the location as well as the type of the FB. The success rate would then depend on the level of endoscopy and experience of the doctor. Also note that the FB was removed in only 45% of the cases while in 55% of the cases, the FB spontaneously passed from the system. However, most of the kids did not experience any complications, since the complication rate was only at 15%. Therefore, the results of this study agree with other studies that as much as sharp objects are dangerous, most of the time there will be no complications. However, physicians should carefully assess the risk of the sharp object before deciding to use observation over the removal of the FB.

Coins are the most ingested foreign bodies among children. However, endoscopic removal may be necessary if the coin does not leave the body after about 4 weeks of observation This study revealed that in the cases of coin ingestion, the GI endoscopy was performed and the coin removed in 85% of the cases. This may seem to go against the literature findings that coins spontaneously pass the body at a rate of 60%. However, special attention should be placed on the fact that most (75%) of the foreign bodies were located in the esophagus. Studies suggest that coins lodged in the esophagus warranty removal within 24 hours and therefore this may explain why endoscopy rather than observation was preferred for the management of coin ingestion in this study (11).

Note that for toy parts ingestion, the management technique will largely depend on the size and shape of the objects. The most frequently performed endoscopies are Endoscopic Retrograde Cholangiopancreatography (ERCP), Colposcopy, and Esophagogastroduodenoscopy (EGD) (23). The therapeutic interventions of GI endoscopy include percutaneous endoscopic gastrostomy, variceal bleeding ligation, and foreign body retrieval. Upper GI endoscopy is commonly used in children who have ingested foreign bodies. An upper GI endoscopy is a way for the physician to examine the inside lining of the esophagus, stomach, and the duodenum. A thin and flexible viewing (fixed with a camera at the tip) instrument (endoscope) is used for this purpose. However, this is extremely rare and occur in about 0. 1% of the kids that undergo the procedure (23).

If the child is at a higher risk of infection then preventive antibiotics may be administered before the endoscopy is performed. However, the likelihood of all these complications are remote and if they occur they will be identified before the child is discharged. Parents or guardians should however immediately contact a doctor if they observe symptoms such as increased vomiting, fever, severe pain in the chest or abdomen, shortness of breath, difficulty in swallowing, black stools, or blood in stools (22). In addition, male children ingest more foreign bodies than female children at a ratio of 1. Further, FB ingestion among children is dangerous and may result in complications especially for objects with chemical composition and sharp ends. Also upper GI endoscopy is safe method in managing FB ingestion among children as none of the patients’ experienced any complication with regards to endoscopy.

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