Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee

Unmasking a New Type of Gastrointestinal Foreign Body in the COVID-19 Era

The incidence of foreign body ingestion has increased during the coronavirus disease 2019 pandemic. As face masks became increasingly available, we report a case of accidental ingestion of the metal strip insert of a surgical mask. After initially progressing, its progress halted after 24 hours. This case highlights the challenges of timing the endoscopic removal of long objects, especially considering the reduced endoscopic availability during the pandemic. Despite only causing local trauma, the strip was impacted at the duodenojejunal flexure with the potential to cause obstruction. Limiting morbidity relies on urgent removal and prevention of similar ingestions by emphasizing the safe use and storage of masks.

Endoscopy in Pediatric Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic allergen-mediated clinicopathologic condition that currently requires esophagogastroduodenoscopy with biopsies and histologic evaluation to diagnose and monitor its progress. This state-of-the art review outlines the pathophysiology of EoE, reviews the application of endoscopy as a diagnostic and therapeutic tool, and discusses potential complications related to therapeutic endoscopic interventions. It also introduces recent innovations that can enhance the endoscopist's ability to diagnose and monitor EoE with minimally invasive procedures and perform therapeutic maneuvers more safely and effectively.

Single-Center Retrospective Review of the Presentation and Initial Care of Esophageal Button Battery Impactions 2007-2020

OBJECTIVE

The aims of this study were to characterize the patient population and initial presentation and care of esophageal button battery ingestion and provide descriptive data including factors affecting accurate diagnosis, duration of battery exposure, and battery removal.

METHODS

This was a retrospective cohort study from 2007 to 2020 at a single-center, large-volume, urban academic pediatric hospital system. Included participants were children 6 months to 18 years old who underwent removal of an esophageal button battery impaction at our institution.

RESULTS

Our cohort comprised 63 patients; ages ranged from 7 to 87 months with a median of 27 months. Median button battery size was 2.12 cm with 59% lodged in the proximal esophagus. A prolonged impaction, greater than 12 hours, occurred in 46% of patients. Risk ratio analysis demonstrated that lack of caregiver suspicion of ingestion was associated with prolonged impaction (risk ratio, 3.39; confidence interval, 2.15-5.34). Misdiagnosis of button battery ingestion occurred in 10% of cases. The majority of patients, 87%, required transfer from a referring facility with a median total distance of 37 miles (range, 1.4-160 miles) from home to facility where battery was removed.

CONCLUSION AND RELEVANCE

This study describes the initial presentation and care of a large cohort of pediatric esophageal button battery ingestion. It emphasizes the continued need for primary prevention, prompt identification, and removal of these batteries. There are many challenges in caring for these patients involving multiple pediatric disciplines, and guidelines encompassing a multidisciplinary approach would be beneficial.

Pediatric button battery ingestion: A single center experience and risk score to predict severe outcomes

PURPOSE

The purpose of this study was to analyze the management and outcomes of primary button battery ingestions and their sequelae at a single high-volume center, and to propose a risk score to predict the likelihood of a severe outcome.

METHODS

The medical record was queried for all patients under 21 years old evaluated at our institution for button battery ingestion from 2008 to 2021. A severe outcome was defined as having at least one of the following: deep/circumferential mucosal erosion, perforation, mediastinitis, vascular or airway injury/fistula, or development of esophageal stricture. From a selection of clinically relevant factors, logistic regression determined predictors of a severe outcome, which were incorporated into a risk model.

RESULTS

143 patients evaluated for button battery ingestion were analyzed. 24 (17%) had a severe outcome. The independent predictors of a severe outcome in multivariate analysis were location of battery in the esophagus on imaging (96%), battery size >/ = 2 cm (95%), and presence of any symptoms on presentation (96%), with P < 0.001 in all cases. Predicted probability of a severe outcome ranged from 88% when all three risk factors were observed, to 0.3% when none were present.

CONCLUSION

We report the presentation, management, and complication profiles of a large cohort of BB ingestions treated at a single institution. A risk score to predict severe outcomes may be used by providers initially evaluating patients with button battery ingestion in order to allocate resources and expedite transfer to a center with pediatric endoscopic and surgical capabilities.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Clinical Research Paper.

Pediatric Magnet Ingestion, Diagnosis, Management, and Prevention: A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Position Paper

Magnet ingestion is a special category of foreign body ingestion associated with high levels of morbidity and mortality worldwide, particularly if it is associated with staggered ingestion of multiple magnets or with simultaneous ingestion of other metallic foreign bodies, especially button batteries. A special category of magnet ingestion is the ingestion of earth magnets, which have higher levels of magnetism and therefore, potentially, carries a worse outcome. Legislative bodies, scientific Societies and community-led initiatives have been implemented worldwide with the aim of mitigating the effects of this growing, yet avoidable potential medical emergency. A scoping literature review summarized epidemiology, diagnosis, management, and prevention, including an algorithm for the diagnosis and management of magnet ingestion is presented and compared to previously published reviews and position papers (North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, National Poison Center, Royal College of Emergency Medicine). The main emphasis of the algorithm is on identification of staggered/multiple magnet ingestion, and early joint gastroenterology and surgical consultation and management.

Button Battery Ingestions cause the Majority of Severe Complications

BACKGROUND

Foreign body ingestion in children is a clinically important reason for presentation to the emergency department. The individual outcome ranges from benign spontaneous courses to severe complications. Fatal outcomes occur rarely and complications are related to patient's age as well as type and location of the foreign body. The aim of our present study was to evaluate the outcome of children and adolescents with foreign body ingestion with a focus on complications, which mainly occurred after button battery ingestion.

METHODS

We reviewed medical records of patients between 0 and 18 years of age who had presented to the paediatric emergency department of our hospital with suspected foreign body ingestion between January 2011 and March 2021 (123 months). Clinical, imaging, and endoscopic data as well as treatment modalities were analysed.

RESULTS

In the ten10 year period under review, a total of 1,162 children and adolescents (6 months - 18 years) presented to our emergency room with suspected foreign body ingestion. Among those, 398 ingestions (34%) could be verified radiologically and/or endoscopically, while in the remaining 764 cases (66%) the suspicion could not be confirmed. The majority of patients with verified ingestion (n=324; 81%) presented with ingestion of a metallic foreign body. We observed 55 cases with verified ingestion of a button battery. Five of these cases had severe complications, with a near-fatal course in two patients who developed an oesophageal-tracheal fistula.

CONCLUSION

In contrast to all other ingestions of foreign bodies in children, button battery ingestions lead to mucosal damage and severe complications in a significant number of children.

Sharp-Pointed Foreign Body Ingestion in Pediatric Age

OBJECTIVES

To assess the clinical complications reported after the ingestion of sharp/pointed foreign bodies (FBs) in pediatric age, their incidence among all FB ingestions, and the features and clinical presentation of children.

STUDY DESIGN

We have recruited all consecutive patients aged 0-14 years, admitted for sharp/pointed FB ingestion. Clinical data until hospital discharge were accurately recorded, including both children with esophagogastric FB retention who underwent endoscopic removal and children who were radiologically followed-up till spontaneous FB expulsion. Clinical outcomes were recorded for each patient, with special reference to possible prolonged retention and wall perforation during the intestinal passage.

RESULTS

We have enrolled 580 children (males/females: 292/288; age range: 11-180 months; mean age ± standard deviation: 50.5 ± 42 months). Sharp/pointed FBs mainly included fragments of metal 270 of 580 (46.55%) and glass 180 of 580 (31%). FBs were endoscopically removed in 79 of 580 (13.6%) children whereas the remaining FBs passed through the gastrointestinal tract over an overall mean time of 29 hours. No cases of intestinal perforation nor prolonged retention were observed. In 3 of 65 (4.6%) procedures the endoscopist faced an uncomfortable endoscopic removal due to the shape and size of the FB which hampered the retrograde passage through the esophageal sphincters.

CONCLUSIONS

Our original and extensive data emphasize that accidental ingestion of sharp/pointed FB ingestion is a current issue in pediatric age, especially in toddlers. Metal and glass objects are the most involved FBs and their endoscopic retrieval may not be easy in about 5% of cases. Fortunately, in our pediatric sample no surgical intervention was needed.

Button battery injury causing an aorto-oesophageal fistula in a 1-year-old child - Sengstaken-Blakemore tube, a life-saving bridge during surgery

ABBREVIATION

AEF: aorto-oesophageal fistula;BB: button battery;CTA: computed tomography angiography;ER: emergency room;GI: gastro-intestinal;SBT: Sengstaken-Blakemore tube.

Button Battery Ingestion in Children (PilBouTox®): A Prospective Study Describing the Clinical Course and Identifying Factors Related to Esophageal Impaction or Severe Cases

In this study, we aimed to identify the factors related to esophageal impaction following button battery (BB) ingestion in children. PilBouTox, a prospective multicentric observational cohort study, was conducted from French Poison Control Centers between June 1, 2016 and May 31, 2018. Children (0-12 years old) with BB ingestion were included. After ingestion, patients were monitored for 21 days or more if they remained symptomatic (maximum 1 year). Causes of ingestion, clinical manifestations, medical management, and the outcomes were recorded. In total, 415 patients were included; among them, 35 had esophageal impaction and 14 had severe complications or died. Seven symptoms were closely related (relative risk (RR) > 30) to esophageal impaction: anorexia, drooling, dyspnea, fever, hemodynamic instability, pallor, and pain. Furthermore, BBs > 15 mm were related to esophageal impaction (RR = 19, CI_95% [4.1; 88]). The absence of initial symptoms was a protective factor for esophageal impaction (RR = 0.013, CI_95% [0.002; 0.1]). Nine symptoms were closely related (RR > 30) to major effects and death: dyspnea, cough, dysphagia, drooling, fever, hemodynamic instability, pain, pallor, and vomiting. Seven symptoms were related to esophageal impaction and their rapid recognition could help to ensure that the patient is taken to a health care facility. Nine factors were related to the major effects of BB ingestion. We recommended an X-ray as soon as possible to determine the position of the BB.Trial Registry: Clinical Trial ID: NCT03708250, https://clinicaltrials.gov/ct2/show/NCT03708250.

Impacted esophageal foreign bodies in children

PURPOSE

Foreign body (FB) ingestion in children has varied presentation. When unwitnessed, it poses therapeutic and diagnostic challenges especially in the presence of pre-existing anatomical pathology. We aim to analyze the clinical course, management, and outcome of children with impacted esophageal FBs.

METHODS

Retrospective chart review (Jan 2000-Feb 2018) recruiting children with impacted esophageal FBs. FBs in cricopharynx and those that moved to stomach were excluded. Investigations/management were based on underlying anatomical pathology, duration of impaction, and difficult FBs. Clinical details, management, and outcomes were collated.

RESULTS

Of 86 children, N1 = 31 had identifiable predisposing anatomic pathology and N2 = 55 had impactions in normal esophagus or difficult FBs. N1 group presented early (42 months), had recurrent impactions (1-6), and needed multiple dilatations (0-8) and longer follow-up (avg 35 months). Food matter was commonest impaction. Many had persistent symptoms. N2 group had commonly coin impactions and strictures developed in long standing or corrosive FBs. Most were asymptomatic.

CONCLUSION

Abnormal esophageal anatomy predisposes to impaction with organic food bolus. Age of presentation is earlier with recurrent impactions requiring multiple dilatations/surgery and longer follow-up. Metallic FBs commonly impact in normal esophagus and are often innocuous. Atypical/multiple FBs may mirror an underlying psychiatric illness.

Clinical Experiences and Selection of Accessory Devices for Pediatric Endoscopic Foreign Body Removal: A Retrospective Multicenter Study in Korea

BACKGROUND

Swallowing of foreign bodies (FBs) is the most common indication of therapeutic endoscopy in children. Endoscopic removal may be necessary depending on the type of FB, age of the child, and location of the FB. We attempted to analyze the characteristics of each device used for the endoscopic removal of FBs in children.

METHODS

Medical records of the patient's age, sex, weight, type, location, size, shape, type of device used for endoscopic removal, and endoscopic time were retrospectively collected.

RESULTS

A total of 424 FB removal procedures were analyzed. The average age of the patients at the time of FB removal was 4.1 ± 3.7 years. Coins were the most common FBs (192, 45.3%). The most common locations of the FBs were the esophagus (45.7%) and the stomach (48.3%), respectively. For a total of 371 cases, forceps were used in 96 cases (25.9%) for esophageal FBs and in 25 cases for gastric FBs (6.7%), while nets were used in 250 cases (67.4%) for gastric FBs retrieval; the average durations of the procedures were 7.2 ± 7.4 minutes, 8.5 ± 7.2 minutes, and 5.7 ± 7.3 minutes, respectively (P = 0.003). The procedure time was significantly shorter, in the group of patients with low body weights, when nets were used than when forceps were used to remove gastric FBs (P = 0.001).

CONCLUSION

The endoscopic procedure duration, in low-weight children, was shorter when retrieval nets were used than that with forceps.

MANAGEMENT OF COMPLICATIONS FOLLOWING BUTTON BATTERY INGESTION

Ingestion of button batteries by children is increasing every year, which is becoming a clinical problem for pediatricians. The number of complications and mortality when using batteries exceeds similar indicators when accidentally swallowing other foreign bodies. This is due to the electrochemical and mechanical effect of the battery on the mucous membrane of the gastrointestinal tract and especially the esophagus. With a late diagnosis, an ordinary battery leads to the development of fatal complications. In modern literature, there are no protocols that would relate to the treatment of similar situations, in particular, in the development of a tracheoesophageal fistula. The article describes a case of successful treatment of a tracheoesophageal fistula due to a long-term stay of a battery in the esophagus. This condition was also complicated by the development of bilateral tension pneumothorax. The dilemma in such cases is always difficult: to choose operative or conservative treatment. Both methods have their advantages and disadvantages. In this clinical case, preference was given to conservative treatment, which ended quite successfully. But the main goal is to prevent such situations. This can be achieved by raising parents' awareness of the risks of battery ingestion. Also, the efforts of a doctor who is faced with a similar situation should be directed to the fastest possible diagnosis and removal of such a foreign body as a battery.

Advantages of Fluoroscopy for Accidental Ingestion of Multiple Magnets

Foreign body ingestion is one of the common problems among children. A three-year-old girl presented to the emergency department 2 h after ingesting three small disk-type neodymium magnets. She had no gastrointestinal symptoms. Abdominal radiography revealed a foreign body in the left upper quadrant, which was the three circular magnets. Fluoroscopy was performed. She was placed in the right lateral decubitus position for 3 min and slowly returned to the supine position. Abdominal fluoroscopy revealed a foreign body migrating near the middle of the spine. Similarly, when she was placed in the left lateral decubitus position for 3 min and slowly returned to the supine position, the foreign body migrated to the outermost part of her left upper quadrant. Thus, we anticipated that the magnets could be excreted spontaneously. The patient did not develop any gastrointestinal symptoms after returning home, and two days later, three overlapping magnets were finally found in her stool. During accidental ingestion of single or multiple desk-type neodymium magnets, endoscopic removal may not be necessary if they are mobile and clump together in the stomach. Regarding the ingestion of multiple desk-type neodymium magnets, fluoroscopy is useful to determine the extent of endoscopic intervention.

Management of Gastrointestinal Foreign Bodies with Brief Review of the Guidelines

Foreign body (FB) ingestion is a common health problem that affects children more than adults. According to gastroenterologists' guidelines, the management of FB ingestion differs slightly between adult and children. This review aimed to compile adult and children guidelines and establish an understandable association to reveal the requirements and timing of the endoscopic procedure, which is the most effective and least complicated technique for gastrointestinal FBs. Coins, pins, and chicken and fish bones have been the most commonly ingested FBs. However, with their increasing use in recent years, large batteries with lithium-ion conversion, stronger magnets composed of rare earth metals, such as neodymium, and superabsorbent objects have become the most morbid and mortal, necessitating new management strategies. Although the approach to gastrointestinal FBs is controversial, with different treatment options available in different disciplines, many studies have demonstrated the efficacy and safety of endoscopic procedures. Many factors influence the timing of endoscopy, including the nature, size, and location of the ingested object and the patient's clinical condition.

The Effect of COVID-19 Stay-At-Home Orders on the Rate of Pediatric Foreign Body Ingestions

BACKGROUND

Foreign body ingestions are a common presentation in the emergency department (ED), particularly in young children.

OBJECTIVE

We sought to determine whether the COVID-19 pandemic lockdowns had an effect on the proportion of foreign body ingestions.

METHODS

We performed a retrospective review of the Pediatric Health Information System for patients younger than 19 years who were identified by International Classification of Diseases, Tenth Revision codes for foreign body ingestion. We analyzed patients in the following three groups: young children (younger than 5 years), school-aged children (5-12 years), and adolescents (13 years and older), using an interrupted time series analysis. Our primary outcome was the difference in proportion of foreign body ingestions. We compared 1 year after the declaration of the COVID-19 pandemic (March 13, 2020 to March 31, 2021) with the previous 3 years (March 1, 2017 to March 12, 2020).

RESULTS

Total pediatric ED encounters decreased in the post period (p < 0.01); 4902 patients per year presented for foreign body ingestion pre-COVID-19 shutdown vs. 5235 patients per year post-COVID-19 shutdown. In all three age groups (young children, school-age children, and adolescents), there was a higher proportion of foreign body ingestions post-COVID-19 shutdown (p < 0.01, p < 0.01, and p = 0.028, respectively), driven primarily by the decrease in total ED encounters. In the youngest age group (younger than 5 years), there was also a significant increase in slope for foreign body ingestions post-COVID-19 (p = 0.010).

CONCLUSIONS

The proportion of foreign body ingestions increased after the declaration of the COVID-19 pandemic, primarily driven by an overall decrease in total ED volume.

Management of oesophageal foreign bodies in children: a 10-year retrospective analysis from a tertiary care center

OBJECTIVE

Oesophageal foreign bodies (EFBs) are a common emergency issue in paediatrics, and few studies have revealed its clinical features and treatment methods. We conducted this retrospective study to provide our 10-year clinical evidence for the diagnosis and treatment of EFB and reduce the incidence of complications.

METHODS

We retrospectively reviewed all paediatric cases diagnosed with EFB from January 2012 to December 2021 at Shenzhen Children's Hospital. The age and sex of the patients, types of foreign bodies (FBs), preoperative examination, location and duration of FB impaction, clinical symptoms, surgical methods, therapeutic effects and complications were analysed.

RESULTS

Among the 1355 cases, 759 were boys and 596 were girls, with a median age of 2.9 years (4 months to 16 years). The shortest FB lodged time was 1 hour, while the longest time was 3 months. The types of foreign bodies included coins and blunt objects (812,59.9%), bones and sharp objects (278,20.5%), button batteries (86,6.3%), food impactions (84,6.2%), toys (51,3.8%) and plastic objects (44,3.2%). A total of 720 of 812 cases impacted by coins and blunt subjects were successfully treated with a Foley catheter without any complications. A total of 558 patients underwent rigid oesophageal endoscopy under general anaesthesia, and foreign bodies were successfully removed in 525 cases. No FB was found in 33 cases, and FBs pushed into the lower digestive tract during operation in 5 cases. Oesophageal injury was found in 130 cases (23.3%). Our study showed that the age of the patient, time of foreign body incarceration, type of foreign body, location of the lodged foreign body, and fever or cough were risk factors leading to oesophageal foreign body complications, and the differences were statistically significant (P < 0.05).

CONCLUSION

Children with EFB have a risk of complications, especially if the FB is a button battery. The appropriate surgical method should be selected through the analysis of the clinical characteristics of the foreign body in the oesophagus and the risk factors for complications to reduce the incidence of complications. Health education and effective care are the keys to the prevention of EFB.

Diagnosis and Management of Button Battery Ingestion Complicated by Tracheo-Esophageal and Aorto-Esophageal Fistulas

Button battery ingestion (BBI) is common in children and its prevalence has increased in the last decades. BBI can be responsible for very severe and potentially fatal complications if not promptly detected. We describe the successful management of two cases of BBI that occurred in two previously healthy infants. Both patients presented with vague symptoms and no witness of foreign body ingestion. The prolonged time of exposure to the corrosive effects of disk batteries was responsible for the development of tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). We demonstrate how prompt diagnosis and management are crucial for the infants’ survival.

Contained Jejunal Perforation Secondary to Ingestion of Magnet Balls in a Nonfatal Drowning Child

Most ingested foreign bodies often pass through the gastrointestinal tract uneventfully; however, complications such as perforation do occur. Jejunal perforation is a known complication of abdominal trauma. While gastrointestinal tract injury due to the ingested foreign body such as a toothpick, fishbone, and battery among others are common, jejunal perforation is not very common in pediatrics.

We report an unusual case of jejunal perforation that was diagnosed after a child was admitted to the pediatric intensive care unit for nonfatal drowning. A 15-month-old girl presented to our emergency room after she was found submerged in a swimming pool. She was unwitnessed for about ten minutes. At the scene, she was apneic, and cyanotic but had a pulse. Cardiopulmonary resuscitation was started and she was brought to our emergency room. She was managed for her drowning injuries and was accidentally found to have a foreign body on her abdomen by x-ray. She had no signs or symptoms of perforation, however, after questioning the parents they told us that they brought her a toy containing magnet balls about one month ago. After stabilizing her respiratory status and correcting her acidosis, an upper gastrointestinal (GI) endoscopy was done that showed jejunal perforation and multiple magnets. A consultation was done immediately for the pediatric surgery team then the perforation was repaired. High-powered magnets represent a serious health hazard if ingested due to risks of gastrointestinal perforation. It is important to have a high index of suspicion for potential injuries, especially silent ones. One of the rare complications is contained jejunal perforation.

Multicentre study of magnet ingestion in Spanish paediatric emergency departments

INTRODUCTION

The ingestion of magnetic objects can cause complications in children, and there are no epidemiological or clinical data on the subject in Spain.

OBJECTIVES

To determine the incidence, epidemiological characteristics and management of magnet ingestion in paediatric emergency departments in Spain.

MATERIAL AND METHODS

Prospective observational multicentre study conducted over a 3-year period. The study universe consisted of patients aged less than 14 years.

RESULTS

The incidence was 4.8 cases per 100 000 emergency care episodes. Of the 72 patients included (mean age, 7.2 years), 54% were male. Seven percent had neuropsychiatric disorders. Sixty-one percent of the magnets were spherical and 69% came from toys. The size was variable, most frequently between 5 and 10 mm (50%), and ranging from 3 to 30 mm. Eighty-six percent of patients were asymptomatic. The most frequent symptom was abdominal pain. Eighty-three percent of the patients sought medical care within 6 h of ingestion and 92% within 24 h. Thirty-one percent of the cases were of multiple ingestion. Endoscopy was required for extraction in 15% of cases, a proportion that rose to 36% in the group of cases of multiple ingestion. None of the patients required surgery. We did not observe any gastrointestinal complications of magnet ingestion.

CONCLUSIONS

The ingestion of multiple magnets is less frequent than single magnet ingestion, and we did not observe any complications despite the lower frequency of procedures compared to other studies.

Management of Magnet Ingestions at a Large Tertiary Care Children's Hospital

OBJECTIVES

To review the clinical management and outcomes of magnet ingestions at a large tertiary children's hospital. To determine the association of frequency of high-powered magnet ingestion with the regulation of these magnets.

METHODS

Children <18 years who presented to the emergency room and were admitted to the Children's Hospital of Philadelphia for ingestion of single or multiple magnets from January 2008 to December 2020 were included. Demographics, symptoms, management, and outcomes were analyzed. The frequency of magnet ingestion was compared over 3 eras: (1) pre-ban (2008-2012), (2) intra-ban (2013-2016), and (3) post-ban (2017-2020).

RESULTS

There were 167 magnet ingestions, including 99 with multiple magnets. Most patients (59%) were male and median age was 6 (interquartile range, 3-9) years. Most single magnet ingestions (86%) were discharged with outpatient monitoring, and none experienced severe outcomes. Multiple magnet ingestions led to significant morbidity including hospitalizations (68%), endoscopic procedures (48%), surgical procedures (14%), and severe outcomes (12%). Most patients (75%) were asymptomatic, however, there was a higher risk of surgery and severe complications based on the presence of symptoms ( P = 0.003). The rate of surgical intervention was higher with ≥3 magnets (31.7%) compared to 2 magnets (2.4%) ( P < 0.003). Additionally, we found an 160% increase in children with magnet ingestions in the post-ban period ( P = 0.021).

CONCLUSIONS

Multiple magnet ingestion is associated with high morbidity and rate of severe outcomes. There is a relationship between public policy of magnet sale and frequency of magnet ingestion.

Protocol of care for foreign-body ingestion in children: a qualitative study

OBJECTIVE:

This study aimed to suggest a care protocol for foreign-body ingestion, address the clinical aspects, and identify the ingested object, severity, and professional conduct.

METHODS:

This is a qualitative study. We used books and original articles published in national and international journals (BIREME, SCIELO, LILACS, and MEDLINE/PubMed) in Portuguese, Spanish, and English.

RESULTS:

The ingestion of a radiolucent object should be evaluated radiographically and with endoscopy for cases with symptoms of impaction and radiolucent objects. Coins are the most commonly involved foreign bodies. In asymptomatic patients, it often requires only a conservative form of management. Ingestion of batteries, magnets, and sharp objects carries a high risk of serious clinical complications and should have an endoscopic or surgical approach. In view of this, each pediatric emergency service, based on these recommendations, has the possibility to develop an individual protocol to identify and remove the ingested foreign body.

CONCLUSIONS:

Protocol of care for foreign-body ingestion in children depends on the object ingested, time of ingestion, symptoms, and local epidemiological context. This study provides some suggestions for decision-making in the conduct of health professionals.

Role of Nose to Pelvis Imaging in the Evaluation of Foreign Body Ingestion: A Case of Magnet Ingestion in a 2-Year-Old

Foreign body ingestion (FBI) of small-rare-earth-magnets (SREM) sets are associated with high morbidity and mortality, as these tend to cause significant mucosal injury. Current clinical guidelines for the evaluation of FBI do not include imaging of the nose and neck. A 2-year-old patient presented with known SREM ingestion, with location confirmed in the right lower quadrant on imaging at the time of initial evaluation. Subsequent imaging involving the neck revealed additional magnets lodged in the patient's hypopharynx, which were missed on initial evaluation. This case highlights the importance of considering advanced imaging of the nose and neck to uncover extraintestinal foreign bodies.

Management of multiple magnetic foreign body ingestion in pediatric patients

Background

Multiple magnetic foreign body ingestion in children is increasingly common and can cause serious injury. The present study aimed to analyze the clinical features of such cases and summarize treatment experiences.

Methods

A retrospective survey of 91 patients in the Children’s Hospital, Zhejiang University School of Medicine with magnetic foreign body ingestion from October 2018 to October 2021 was performed, the data were collected including the clinical information of the patients, treatment details, and prognosis.

Results

Twenty-two (24.2%) patients were conservatively treated, with the foreign bodies discharged through the anus, 31 (34.1%) underwent laparoscopic surgery, including 18 cases converting from laparoscopic surgery to laparotomy, and 38 (41.8%) underwent laparotomy. In 13 (14.3%) patients, the foreign bodies were partially removed by gastroscope. The remaining foreign bodies were removed by laparoscopy in six patients, including three cases converting from laparoscopy to laparotomy, by laparotomy in four patients, and by conservative treatment in three patients.

Conclusions

Multiple magnetic foreign body ingestion can cause significant harm to patients and different clinical techniques must be used for patients in different situations to reduce the harm to children.

Delayed Endoscopic Management of Esophageal Sharp-Pointed Food Impaction: An Analysis of 829 Cases in China

BACKGROUND

Esophageal foreign body impaction is the most common cause of endoscopic emergency. However, there are limited available data on delayed endoscopic management of esophageal sharp-pointed food impaction.

AIMS

To investigate cases of esophageal sharp-pointed food impaction with endoscopic removal findings.

METHODS

This single-center retrospective study collected medical records to identify patients with esophageal sharp-pointed food impaction who underwent endoscopic removal between April 2018 and April 2020. The patients were divided into the early (endoscopic removal <12 h) and delayed intervention (>12 h) cohorts.

RESULTS

Overall, 133 and 696 patients received early and delayed intervention, respectively. The success rate of endoscopic foreign body removal was 96.45%. The most common foreign body was fish bone (66.90%), and the most common shape was "I" (56.26%). Patients from the delayed intervention cohort received general anesthesia with a higher risk for perforation, and no foreign body was identified. The duration of endoscopy, distance between the foreign body/wound and the incisor, and longest diameter of the foreign body were not different between the groups. In multivariate analysis, male sex (odds ratio = 1.792 [1.159, 2.771]; P = 0.009), longer duration of impaction (odds ratio = 2.212 [1.121, 4.365]; P = 0.022) and endoscopy (odds ratio = 1.502 [1.253, 1.800]; P < 0.001), and longest diameter of the foreign body (odds ratio = 1.632 [1.329, 2.003]; P < 0.001) were associated with a higher incidence of perforation in patients with foreign body impaction.

CONCLUSIONS

Endoscopic removal is a safe and effective treatment method for sharp-pointed food impaction. Delayed endoscopic removal can increase the risk of esophageal perforation.

Button batteries in the ear, nose and throat: a novel survey of knowledge of UK advanced nurse practitioners

BACKGROUND

Button battery (BB) impaction in the ear, nose and throat can result in significant morbidity. Advanced nurse practitioners (ANPs) are increasingly responsible for initial patient assessment and prompt escalation to otolaryngologists for definitive management.

AIM

Our novel national study aimed to assess ANPs' knowledge with respect to the assessment and management of patients with BBs in the ear, nose and throat.

METHOD

A national 13-point survey was disseminated among ANPs over a 2-week period. Knowledge was assessed through eight multiple choice questions with a maximum attainable score of 21.

FINDINGS

A total of 242 responses were analysed. Knowledge deficits were identified in all domains (mean overall score 8.5/21), including presenting clinical features, preliminary investigations and intervention strategies. The overwhelming majority of respondents (97%; n=234) advocated for further training.

CONCLUSION

A need for further education has been highlighted by this surveyed cohort of ANPs. Implementation of standardised protocols, virtual resources and simulation platforms may address knowledge deficits.

Pediatric Multiple High-Powered Magnetic Buckyballs Ingestion—Experience From Six Tertiary Medical Centers

Multiple high-powered magnetic Buckyball ingestions may lead to a high risk of severe complications. Great concerns have been raised by public health workers, and it remains challenging for clinicians to solve this troublesome problem. We report a large case series of children with Buckyball ingestion from six tertiary medical centers. The clinical data, including demographics, medical history, diagnosis tools, management options, intraoperative or endoscopic findings, and outcomes, were retrospectively analyzed. Seventy-one children aged 1–13 years ingested 2–41 Buckyballs. Among them, Buckyballs passed spontaneously on 2–10 days post-ingestion in seven cases; gastroscopic removal was performed in 14 cases; laparoscopic removal in 13 cases; laparoscopic-assisted surgical removal in 6 cases; and open surgical removal in 31 cases. Surgical indications included small bowel obstruction, perforation, peritonitis, acute abdominal pain, or along with ingestion of other metallic foreign bodies. Among those who underwent a surgical procedure, primary intestinal repair was performed in 44 cases, enterectomy with primary anastomosis in 6 cases. The postoperative hospital stay ranged from 5 to 28 days. No major complications occurred. In unwitnessed cases, a vague medical history and nonspecific symptoms usually make the diagnosis difficult. The treatment options should include the watch-and-wait approach, endoscopic, laparoscopic-assisted, or open surgical removal of Buckyballs, with primary intestinal repair or anastomosis. Preventive measures, including children's not having access to Buckyballs, are essential to protect children from this kind of unintentional injury.

Bilateral Vocal Cord Fibrosis: A Delayed Complication of Button Battery Ingestion

A 14-month-old girl initially presented to the Accident and Emergency (A&E) department following a choking episode and subsequent vomiting. The child left the department before being seen but re-presented the following morning with stridor, drooling, and increased work of breathing. A chest and lateral neck soft tissue X-ray performed in the A&E department revealed an ingested button battery in the oesophagus. Emergency oesophagoscopy was performed and a 22 mm button battery was removed from the oesophagus at the level of the cricopharyngeus muscle, with no immediate complications. Following extubation, the patient was initially well but later required a prolonged hospital stay due to recurrent episodes of stridor, voice changes and aspiration pneumonia. Follow-up microlaryngoscopy and laryngeal electromyography (EMG) diagnosed bilateral vocal cord palsy and cricoarytenoid fibrosis. This case highlights the need for increased public awareness, urgent diagnosis and standardised management of battery ingestion, and discusses the potential for the development of serious latent complications.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review

Importance

Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions.

Objective

To review airway injuries, including long-term sequelae, after BB ingestion in children.

Evidence Review

For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis.

Conclusions and Relevance

Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Pediatric Foreign Body Ingestion: Complications and Patient and Foreign Body Factors

Background: Management of the child who has swallowed a foreign body should be guided by the risk of complication. Objective of the Review: This review discusses the patient and foreign body characteristics most likely to be associated with complications. Discussion: Most swallowed foreign bodies will pass through the GI tract without complication. Children with pre-existing GI tract abnormalities of any sort, or those who swallow higher-risk foreign bodies, are at higher risk. Higher-risk foreign bodies include long, sharp, or pointed objects, button batteries, and small magnets. Nearly any child who presents to an Emergency Department or other acute care setting after foreign body ingestion should undergo plain radiography; other forms of imaging may also be appropriate. Primary care providers may opt for an initial observation period when there is lower risk of complication. Esophageal button batteries should be emergently removed; other esophageal objects should be promptly removed or, if low risk, allowed a brief period to pass spontaneously. Most lower GI tract foreign bodies will pass spontaneously. Prevention, while not always possible, is preferable to management of foreign body ingestion. Conclusions: Management strategies for children who have swallowed foreign bodies can be optimized by considering relevant patient and foreign body factors, and how they contribute to the risk of complication.

Decade of the dangers of multiple magnet ingestion in children: A retrospective review

AIM

Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre.

METHODS

Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant.

RESULTS

A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention.

CONCLUSION

This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards.

Endoscopic management of magnet ingestion and its adverse events in children

Background and Aims

Magnet ingestion has recently increased among children. Multiple magnets can lead to serious adverse events owing to pressure necrosis of trapped bowel wall; therefore, urgent removal of the magnet is recommended. However, awareness of magnet ingestion and adverse events associated with it are lacking among the general population and some healthcare professionals. Herein, we demonstrate the adverse events associated with prolonged retention of ingested magnets and endoscopic management of ingested magnets in children.

Methods

We present a case series of 3 patients with magnet ingestion. Foreign body ingestion was confirmed on fluoroscopy. After fluoroscopy, all children underwent EGD under propofol sedation in a left lateral position. A Roth net was used to remove magnets.

Results

Three patients (median age 5 years), each with ingestion of 2 magnets of different shapes and sizes and with variable periods of ingestion, underwent EGD. In 2 patients, both magnets were Successfully removed. In 1 patient, 1 magnet could not be removed because it became dislodged deep in the jejunum. All 3 patients had developed magnet-related fistula (gastroduodenal: 1 patient; duodenojejunal: 2 patients). Patients with duodenojejunal fistula were managed conservatively. There was mild self-limited bleeding during magnet removal in 1 patient. There were no major adverse events related to endoscopic removal.

Conclusions

Endoscopic removal of magnets is feasible and safe in children. Few patients with fistulas can be managed conservatively. There is an unmet need to increase societal awareness of magnet ingestions and adverse events associated with it.

[Treatment of complications following esophageal electrochemical burns by batteries in children]

OBJECTIVE

To determine the optimal treatment of patients with complications of esophageal electrochemical burns by batteries.

MATERIAL AND METHODS

There were 75 children with esophageal electrochemical burns by batteries between 2010 and 2019. All children underwent X-ray of the cervical spine, chest and abdomen, esophagoscopy with removal of the battery, tracheoscopy. Complications occurred in 39 children: TEF - 21, esophageal stenosis - 19, laryngeal paresis - 14, esophageal perforation - 3. Patients with TEF were divided into 2 groups: clinically stable children without respiratory failure and severe illness with respiratory failure including mechanical ventilation. Group I consisted of 6 children, four of them underwent laparoscopic Nissen fundoplication and gastrostomy. Group II consisted of 15 children. In acute period, 3 children underwent laparoscopic fundoplication and gastrostomy, 8 ones - TEF ligation, 4 patients - tracheal repair with esophageal flap and esophageal extirpation. Patients with esophageal stenosis underwent bougienage. Patients with esophageal perforation required therapy. Tracheostomy was necessary for respiratory failure and bilateral laryngeal paresis. Lateralization procedures were performed in patients with negative course of disease.

RESULTS

In the 1st group, spontaneous closure of TEF was found in 3 children after fundoplication and gastrostomy. One child underwent thoracoscopic disconnection of TEF after reduction of fistula. In the 2nd group, fundoplication resulted spontaneous closure of fistula after 2-5 months. In 4 children, recanalization of the fistula or esophageal failure were observed in acute period after TEF ligation.

CONCLUSION

Laparoscopic fundoplication and gastrostomy are optimal for TEF and can result complete or partial spontaneous closure of TEF. If radical procedure is necessary in acute period, tracheal repair with esophageal flap and extirpation of the esophagus with subsequent coloesophagoplasty should be considered.

“Jingle All the Way!”: Sharp Foreign Bodies Embedded Within the Esophageal Mucosa During the Holiday Season

Sharp pointed objects in the esophagus are extremely hazardous and can lead to complications such as mucosal ulcerations, perforations, obstruction, abscess, and fistula formation. Patients exhibit symptomatology based on the location within the proximal or distal esophagus. Ingestion of a sharp foreign object warrants emergent endoscopic removal, particularly when lodged in the esophagus. We present two young children, a 30-month-old male and a 10-month-old male, who underwent emergent endoscopic evaluation following the ingestion of a jingle bell and a Christmas ornament hanger, respectively. Types of ingested sharp foreign bodies may vary during the holiday season and present unique diagnostic and therapeutic challenges for pediatric physicians. Additionally, foreign body ingestions are not limited to children including teenagers and should also be considered in infants. Here, we report two young patients who ingested unique holiday ornaments and describe the management of these impacted esophageal foreign bodies.

Disc battery ingestion in paediatric age

AIM

The aim of the present study was to analyse clinical data of children referred for disc battery ingestion in order to assess short- and long-term reported injuries and to identify outcome predictors and trends, define the urgency of intervention and refine treatment guidelines.

METHODS

The records of all children admitted to Santobono-Pausilipon Children's Hospital, Naples, Italy for disc battery ingestion from January 2016 to December 2020 were retrospectively reviewed. Odds ratio were computed to assess the association between the different study variables and the rate of complications.

RESULTS

We enrolled 118 children. Mild to major complications related to the ingested disc batteries were reported in 12/118 (10.2%) patients. Disc battery oesophageal retention, disc battery diameter >20 mm, together with age below 1 year and symptomatic presentation were the most important factors associated with poor clinical outcome.

CONCLUSION

Our data confirm that ingested disc batteries are a serious health hazard and require a timely and qualified medical evaluation. We have identified three predictors of outcome severity: oesophageal retention, large-diameter cells and symptom onset. Disc batteries lodged beyond the oesophagus appear substantially harmless and we may support a more conservative approach.

Evolving Trends of Button Battery Ingestion in Indian Children at a Tertiary Care Hospital

INTRODUCTION

Foreign body ingestion is a common problem encountered in the pediatric age group. Impaction of lithium batteries of greater than 20-mm diameter in the esophagus is associated with severe complications. This study aimed at analyzing the evolving trends of button battery ingestion in pediatric age groups at our tertiary care center in terms of clinical presentation, intraoperative findings, and the correlation of various clinical variables.

METHODS

A retrospective observational study was done. All children younger than 18 years with impaction of a button battery of size greater than 20 mm in the esophagus between January 2015 and December 2018 were included in the study. All children underwent removal of the battery using direct laryngoscopy/rigid esophagoscopy under general anesthesia.

RESULTS

There were 100 children included in the study with a mean age of 29.92 months having 93 children (93%) younger than 6 years. The mean duration of impaction was 34.7 hours. Increased duration of impaction was associated with an increased risk of complications and an increased difficulty in removal. There was a significant correlation between the site of impaction and the age of the patient. Complications were seen in 10% of cases with severe complications in 6 cases. No fatalities were reported in this study.

CONCLUSIONS

Button batteries impacted in the esophagus can lead to severe complications including death. There has been an increasing trend in the ingestion of button batteries over the last 4 years. A prompt diagnosis and emergent removal of the battery are crucial to minimize the rate of complications. Symptoms of stridor and dysphagia must be given more attention, and these children are prioritized because they are more prone to have complications. Furthermore, primary prevention and caregiver education should be emphasized, and the need for a legislation to change the policies for securing the batteries in their products must be endorsed.