Ingestion of foreign bodies and toxic substances is a common reason for seeking emergency care. Often, the pediatric patient is unable to describe the nature of the ingestion and/or the time of the event. This can pose significant barriers for both caregivers and the medical team.
Coins, button batteries, magnets, pointed and/or large objects, food, absorbent substances, alcohol, acidic and alkaline substances, detergents and hydrocarbons are common ingestions. Each substance or object ingested requires an individualized management approach.
| Ingestion of foreign bodies |
The most common site of foreign body entrapment is the proximal area of the esophagus at the level of the cricopharyngeus muscle. Other common locations include the middle esophagus, at the site of aortic arch compression, and the lower esophageal sphincter.
Most foreign bodies ingested by children pass spontaneously without complications; however, endoscopic removal may be necessary in some situations.
Parameters that should be considered regarding the need for endoscopic removal of ingested foreign bodies include child’s age, weight, clinical presentation, time since ingestion, type and size of foreign body, location in the gastrointestinal tract, and intestinal abnormalities. underlying. This section describes the most frequently ingested foreign bodies and their management. (1)
> Coins
Coins remain the most frequently ingested objects among children in the United States. Spontaneous coin removal occurs in approximately 30% of patients. Once a coin successfully passes through the esophagus, it is more likely to progress and pass spontaneously. Factors that influence the probability of spontaneous passage include the size and location of the coin, as well as the age of the individual.
Some American and Canadian coins are more likely to require endoscopic intervention due to their size, ranging from 23.5 to 25 mm in diameter. In general, coins larger than 25 mm pass through the pylorus more difficultly. This is especially true for children under 5 years old. (1)
Coin intake may vary in presentation. Patients may be asymptomatic or show drooling, pain, or respiratory distress secondary to tracheal compression. The initial evaluation for suspected coin ingestion should begin with abdominal radiographs to identify presence and location. Lateral x-rays are extremely useful in differentiating button batteries from coins.
Coins lodged in the esophagus should be removed within 24 hours to minimize the risk of injury and/or erosion of the esophageal tissue.
If the patient presents more than 24 hours after ingestion or if the timing is unknown, immediate endoscopic removal is recommended. An x-ray should be performed before endoscopy because spontaneous coin passage may occur in up to 25% of patients within 16 hours of ingestion. (2) After endoscopic removal, careful endoscopic examination of the esophageal mucosa is necessary to evaluate possible damage.
Mucosal damage may require treatment, including acid suppression and/or alternative feeding options, until clinical improvement is demonstrated. Coins at the gastric level can be managed without intervention unless active symptoms such as abdominal pain occur.
Radiographic imaging every 1 to 2 weeks and careful monitoring of stool until the coin has been passed is recommended. If the coin is greater than 25 mm in diameter or has not passed the pylorus in 4 weeks, elective endoscopic removal is recommended. (2)
> Button batteries
Button batteries are present in many household items, including watches, toothbrushes, toys, and musical greeting cards. Batteries are easily ingested and pose a considerable risk of mucosal damage, necrosis, and perforation.
Swallowing button batteries is considered a medical emergency.
Once in contact with the esophageal mucosa, the battery produces hydroxide radicals, which result in chemical damage. Additionally, the electrical current resulting from the battery poles coming into contact with the mucous membranes causes electrical damage to the esophageal tissue. Animal models have demonstrated necrosis of the lamina propria of the esophagus within 15 minutes of ingestion. (23)
In a national study that examined battery-related emergency visits in the United States from 1990 to 2009, approximately 3,300 visits occurred annually among children under 18 years of age, and the frequency continues to increase. (4) The increased use of the 3-V 20-mm lithium coin cell has also led to an increase in the frequency and severity of coin cell ingestion.
Children who swallow button batteries may experience pain, drooling, stridor, difficulty breathing, irritability, fever, or refusal to feed. Some children may be asymptomatic and are brought for consultation after a confirmed ingestion. Professionals should be alert to possible button battery ingestion and begin investigation as soon as possible. (3)
Simple radiographic imaging of the chest and abdomen is recommended for all suspected button battery ingestions. Clues to the presence of button batteries include the "double halo" sign, which is the 2-layer appearance of the edges of the battery in front views, and the "step off" sign, described as a central projection suggesting the presence of a battery in side views. (3)
According to national pediatric guidelines, button batteries in the esophagus should be removed immediately (<2 hours) regardless of the presence of symptoms. If the battery is located in the stomach and the child is symptomatic or has a history of structural abnormalities, emergency endoscopy is required. If the button battery has reached the duodenum, it can be expected to pass in less than 72 hours and will not require endoscopic removal. (3)
The high degree of morbidity with the ingestion of button batteries has led to research for optimal management. A recent study by Anfang et al. (5) demonstrated the benefit of using honey or sucralfate as a pH neutralizing agent to mitigate esophageal injury.
The clinical guidelines of the National Capital Poison Control Center have been updated to recommend treatment with honey or sucralfate (10 ml every 10 minutes x 6 for honey and x 3 for sucralfate) in cases of suspected ingestion of lithium batteries in children older than 12 months and in whom ingestion occurred less than 12 hours before presentation.
Serious complications from ingesting a button battery result from tissue necrosis and may include the formation of a tracheoesophageal fistula, perforation of the esophagus, development of esophageal stricture, vocal cord paralysis, mediastinitis, pneumothorax, and aortoenteric fistula. (3)
In a survey conducted by the National Electrical Injury Surveillance System, 62% of button batteries were obtained directly from the product containing the battery and 30% were found to be outside the product.
Monitoring of young children handling battery-powered products should be recommended at routine pediatric visits. The Consumer Product Safety Commission requires manufacturers to secure battery compartments in any products marketed to children under 3 years old. (23)
> Magnets
The frequency of magnet ingestion in children has been increasing, with more than 22,000 ingestions reported between 2002 and 2011. 50% of magnet ingestions include 2 or more magnets. (6) Often a single small magnet can pass spontaneously. Ingesting multiple magnets, neodymium magnets, or magnets with foreign bodies attached is associated with a higher risk of serious complications. (1)
Neodymium magnets are found in toys and small objects. These magnets have over 5 times the attractive force of standard conventional magnets. They had previously been removed from the market by the Consumer Product Safety Commission due to safety concerns, but sales of products marketed to people 14 and older have resumed since 2017.
These magnets appear like a ball bearing or rosary on x-rays and can sometimes be mistaken for a metal ball. Neodymium magnets are also used in body and facial piercings and are therefore among the most common objects ingested by older children and teenagers. (2)
In patients with suspected or confirmed magnet ingestion, timeliness of treatment is essential because ingestion symptoms may be nonspecific. The examination will require evaluation for obstruction or perforation. (7) Symptoms may appear up to 7 days after ingesting the magnet. When magnet ingestion is suspected, an x-ray should be performed to discern the number and location of magnets. (1)
In a patient who has ingested multiple magnets, emergency endoscopic removal is indicated regardless of symptoms to prevent latent perforation. Surgery should be considered when magnet ingestion occurred more than 12 hours before presentation. (7)
For patients who ingest a single magnet, conservative management, including observation and laxative therapy, is a reasonable therapeutic option. These patients should be observed in a controlled manner with serial radiographs until the magnet has run its course. (2)
Endoscopic removal may be justified when a single magnet is ingested when it is large or has an unusual shape or when the child is under 5 years of age. If there is concern that the magnet may not pass as expected, endoscopic removal may be warranted even when a single magnet has been ingested.
For magnets that are beyond the ligament of Treitz but have not yet reached the terminal ileum, management is controversial. In medical centers that have the capacity to perform small bowel enteroscopy, endoscopic removal may be considered. In centers without this highly specialized capacity, or in the case of perforation or obstruction, the intervention requires surgical laparotomy or laparoscopy. (2)
Failure to promptly or adequately dispose of ingested magnets can lead to the formation of enteroenteric fistulas, perforation, peritonitis, and intestinal ischemia/necrosis, particularly when multiple magnets have been ingested. (2)
> Sharp or large objects
In the 1900s, sharp objects were commonly ingested, probably as a result of the popularity of cloth diapers and diaper pins. The frequency and type of sharp objects ingested over time have largely depended on cultural factors and the age of the individual.
For example, the ingestion of pins is more common in cultures where they are used to fasten clothing, and the ingestion of toothpicks is more common in older people. The ingestion of long objects is more common in adolescents and adults, and is often intentional.
If sharp objects are not removed promptly, they pose a significant risk of serious complications. Perforation from sharp objects is reported in up to 30% of patients, with a mean onset of 10.4 days. (2)
As with coins, management of swallowing large objects depends on the size of the object and the age of the child. Objects larger than 25 mm in diameter are unlikely to pass the pylorus, particularly in young children. Objects larger than 6 cm frequently become trapped in the second portion of the duodenum or the ileocecal valve.
Objects lodged in the esophagus are of great concern due to the increased risk of perforation, and are also more likely to cause symptoms such as dysphagia and/or pain.
50% of patients with a history of ingesting a sharp object may remain asymptomatic for a prolonged period, even when there is intestinal perforation. (2)
If ingestion of a sharp object is suspected, radiographic images should be obtained urgently. In cases where esophageal entrapment is suspected, emergency endoscopy is recommended regardless of fasting status. (2)
Radiography, computed tomography, magnetic resonance imaging, ultrasonography, and serial imaging of the upper gastrointestinal tract can all be used to identify radiopaque foreign bodies. Objects that are not radiopaque, such as those made of plastic, bone, glass, and wood, will not be identified without oral contrast-assisted imaging techniques; therefore, a high index of suspicion should justify endoscopic evaluation. (2)(8) Radiographic images may delay treatment when oral contrast is administered.
Consultation with otorhinolaryngology, when available, should be considered for direct laryngoscopy and removal of elements lodged in or above the cricopharyngeus muscle. If a sharp object has passed into the small intestine (distal to the ligament of Treitz), surgical removal should be considered in symptomatic children. (1)
If the patient is asymptomatic and the object is beyond the duodenum, follow-up in a hospital setting with daily abdominal radiographs is warranted. If the sharp object does not run its course within the expected 4 days, the possibility of intestinal perforation or congenital anomaly should be considered and surgical removal may be indicated. (1)
Objects larger than 5 cm or larger than 2 cm wide in infants and young children (larger than 10 cm or larger than 2.5 cm wide in older children) require rapid endoscopic removal within 24 hours when located in stomach.
Complications of ingesting a sharp object may include perforation (most commonly in the ileocecal region), extraluminal migration, abscess, peritonitis, fistulas, organ penetration, common carotid artery rupture, aortoesophageal fistula formation, and death. (1)
The risk of complications increases with delay in diagnosis, particularly when more than 48 hours pass after ingestion. Ingestion of long or large objects has additional risks, such as pressure necrosis, obstruction, or perforation. (6)
> Food
Food impaction is often the presenting symptom of a pathological disorder of the esophagus. Careful history taking should be considered for evaluation of eosinophilic esophagitis, reflux esophagitis, esophageal stricture (either de novo or after esophageal surgical repair in patients with a history of tracheoesophageal fistula), achalasia, and other esophageal motility disorders. .
Meat is the most commonly impacted food. (2) Presentation can range from mild dysphagia to esophageal obstruction with associated symptoms of neck pain and/or drooling. (2)(6) If the impacted food does not pass spontaneously within 24 hours after eating or the patient shows symptoms of esophageal impaction, endoscopic removal should be performed. Esophageal obstruction presenting with drooling and neck pain requires emergency endoscopy.
Oral contrast should not be administered because it can accumulate above the impacted food and be aspirated. (2) Removal of impacted foods may require a gradual approach during endoscopy. (3) Biopsy specimens should be obtained from both the distal and proximal esophagus to evaluate underlying esophageal pathology.
These patients require appropriate follow-up to ensure that evaluation of these possible underlying diseases is performed and that preventive measures are initiated to limit the recurrence of this condition. (2)
> Absorbent objects
The most common absorbent objects are disposable diapers and feminine hygiene products.
Certain manufacturers have marketed toys with superabsorbent polymers. Examples include "magical" toys that grow in water ranging from dinosaurs to water balls and more. They can be dangerous when ingested due to the risk of rapid expansion in the gastrointestinal tract resulting in intestinal obstruction. (2)
Patients will present abdominal pain, abdominal distension and/or vomiting. The most commonly ingested absorbent objects are radiolucent, so radiographic images are probably not helpful. Contrast studies should not be performed because they may delay definitive treatment.
Patients must undergo emergency endoscopy. (2)
Timely removal of these substances is of utmost importance as continued expansion of the objects will lead to worsening of the obstruction and more complications. Even when the object has reached the stomach, urgent endoscopic removal is recommended to avoid obstructions. Complications include intestinal obstruction, perforation, sepsis, and potentially death.
| Ingestion of toxic substances |
Non-pharmaceutical household products are in every home and are commonly ingested by children. Normally these substances are not toxic if ingested in limited quantities; However, some substances have the potential to cause serious injury and even death. Involuntary exposures occur most frequently in children under 5 years of age.
The most frequently ingested non-pharmaceutical household products include cosmetics, cleaning products, pesticides, craft and art supplies, deodorants, and essential oils. The key to preventing the ingestion of household substances is to ensure that they are stored in their original labeled containers out of the reach of young children.
It can be stressful for caregivers to decide whether ingestion requires immediate medical attention. To label an ingestion as non-toxic, the product and ingredients must be clearly identified, the amount ingested must be known and must be below the toxic level, and the child must be asymptomatic.
> Alcohols
Alcohol in its various forms can be found in every home. Products that contain alcohol include perfumes, colognes, mouthwashes, and hand sanitizers. Ethanol is often used as a solvent in cough and cold medications to prolong their shelf life. Even with accidental ingestion of small amounts, young children are at risk for complications. (9)
Children exposed to alcohol may present with coma, hypothermia, hypoglycemia, or lactic acidosis. Methanol and ethylene glycol can lead to profound anion gap metabolic acidosis and cause ocular toxicity and nephrotoxicity, respectively. Ingestion of isopropyl alcohol can cause gastritis and in large quantities can depress myocardial function, resulting in hypotension and shock. (10)
Ingestion greater than or equal to 1.2 ml/kg of pure ethanol often requires hospitalization and medical treatment. Serum ethanol levels should be monitored 1 hour after ingestion, and blood glucose levels should be monitored closely and replenished as necessary. It is recommended to perform electrolytes, blood urea nitrogen, creatinine, arterial blood gases, electrocardiography, and serum toxicology tests.(9)
In case of ingestion of methanol or ethylene glycol, treatment with fomepizole, an alcohol dehydrogenase inhibitor, should be initiated, even if ingestion is not confirmed due to the exceptional risk of complications.
The current recommended intravenous loading dose of fomepizole is 15 mg/kg, followed by 10 mg/kg every 12 hours x 4 doses, then 15 mg/kg every 12 hours until ethylene glycol or methanol concentrations are less than 20 mg /dl (< 3.22 mmol/l) and the patient is asymptomatic. (eleven)
If fomepizole is not available, intravenous ethanol can substitute it because it competitively inhibits the metabolism of ethylene glycol and methanol. (9) Hemodialysis may be considered in children with significant metabolic acidosis.
Isopropyl alcohol treatment is supportive, with a focus on preventing and managing the development of multiple organ failure.
The 1995 Consumer Product Safety Commission required that all mouthwash bottles containing more than 3 g of ethanol have child-resistant closures. Clear product labeling also provides information that parents can give when contacting Poison Control and health care professionals. (9)
> Acidic and alkaline substances
Common household acidic substances include sulfuric acid (stain removers, car batteries, drain cleaners), nitric acid (cleaning agents, fertilizers), hydrochloric acid (toilet cleaners), and phosphoric acid (hair dye). (10)(12)
Injuries due to acidic substances are more common in the stomach than in the esophagus due to the decreased surface tension of acidic substances, which allows them to quickly pass into the stomach. Despite this effect, large volume ingestions can cause serious esophageal injury. Mucosal injury occurs due to superficial necrosis and intravascular thrombus formation. Connective tissue scarring may occur over time. Deeper lesions tend to be less common in these patients, but can still occur. (13)
Acidic substances cause severe oropharyngeal pain when initially swallowed. As a result, patients often ingest small volumes. Patients may develop dysphagia, odynophagia, abdominal pain, vomiting, and hematemesis. Worrying symptoms such as substernal pain may indicate a possible esophageal perforation. (13) Some patients remain asymptomatic at the time of presentation.
Alkaline substances tend to be colorless and odorless and are therefore more likely to be ingested in large volumes. (12) Strong alkaline substances may contain sodium hydroxide or potassium hydroxide and are present in disinfectants, discoid batteries, bleach, and soaps.
When ingested, alkaline substances lead to liquefactive necrosis and saponification of exposed tissue, allowing their deeper penetration into the submucosa and muscle tissue, resulting in significant tissue injury.
Alkaline fluids have higher surface tension than acidic agents, allowing the substances to remain in the tissue for a longer period. Highly caustic agents tend to have a pH greater than 12. (12)
Patients present similarly to those with ingestion of acidic substances. In addition, burns or ulcerations of the mouth, lips and tongue may occur. Upper respiratory tract symptoms, such as hoarseness and stridor, are seen in more severe injuries. (12) Perforation of the esophagus is more common in patients with alkaline intake.
Laboratory tests are often used to determine the level of follow-up and supportive care required, although the results do not always correlate with the degree of mucosal injury. (12)
Chest radiographs are recommended in all symptomatic patients to evaluate aspiration and perforation of the esophagus or stomach. (12) Computed tomography should be reserved for the minority of cases with severe injuries to avoid unnecessary radiation exposure. (13)
Airway evaluation is the initial step in all patients with caustic ingestion. Fluid resuscitation should be initiated in hypotensive patients. Supportive management includes intravenous proton pump inhibitors and opioids.
The use of activated charcoal is no longer recommended because it has been shown to lead to emesis and potential aspiration and re-exposure to the toxin. Attempts to neutralize the substance should be avoided because heat may be produced from the resulting chemical reaction and further aggravate the post-corrosive injury.
The nasogastric tube should not be inserted without endoscopic guidance because it can lead to infections, acid reflux, and an increased risk of stricture. (12)(13) A meta-analysis by Katibe et al. (14) demonstrated that there is no evidence of the usefulness of corticosteroids in the prevention of stenosis.
In symptomatic patients, urgent endoscopic evaluation should be completed within 12 to 24 hours of ingestion.(10) In asymptomatic patients, the role of endoscopy remains controversial.(15) It is generally recommended to avoid endoscopy between on days 5 and 15 after ingestion, given the increased tissue friability and risk of perforation.
Antibiotics are recommended in any child with perforation secondary to ingestion of caustic substances. In those without perforation, empiric antibiotics have not been associated with better outcomes.(10)
One of the most common sequelae of caustic injury is the formation of an esophageal stricture, which may require endoscopic dilation or surgical management. Other late complications include dysmotility of the esophagus and stomach, increased risk of esophageal cancer (adenocarcinoma and squamous cell carcinoma), and gastric outlet obstruction.(12)
> Laundry detergents, tablets and dishwasher capsules
Laundry detergent tablets or capsules were introduced to the European market in 2001 and to the US market in 2012. (16)(17) They have been associated with numerous reports of exposure and ingestion. The risk of ingestion is greater in children under 6 years of age, and more specifically in children under 3 years of age. (10)
Evidence suggests that the clinical effects of exposure to laundry detergent capsules are greater than those of other laundry formulations and dishwasher tablets. (17) The most common symptoms include emesis, cough, drooling, eye pain and conjunctivitis (from direct conjunctival contact), and lethargy. Patients may also present with oropharyngeal mucosal damage, pneumonitis, and respiratory depression. (17)
Management of exposure and ingestion of detergent capsules is largely supportive. Intubation and mechanical ventilation are indicated in cases where respiratory distress is observed. Those with ocular involvement should receive copious irrigations with isotonic saline solution. (10)
Serious complications from ingestion may include seizures, coma, respiratory failure, cardiac arrest, and death. Long-term complications have not been well studied. Esophageal lesions including strictures have been reported, and endoscopy may be warranted if the patient demonstrates symptoms of dysphagia or persistent abdominal pain.(18)
Multiple case reports have demonstrated persistent swallowing dysfunction, leading to nasogastric feeding or thickened foods upon discharge. (19) These patients will require long-term follow-up with pediatric gastroenterology and speech therapy.
> Hydrocarbons
Hydrocarbons are organic compounds made entirely of hydrogen and carbon. Common environmental hydrocarbons include gasoline additives, motor oil, lamp oil, solvents, synthetic waxes, and some household cleaning products.
Hydrocarbons can be subdivided into haliphatic (petroleum), aromatic (toluene, benzene and zylene) and halogenated. The type of substance ingested may suggest the level of toxicity present. (10) All hydrocarbons have the capacity to cause severe pulmonary toxicity.
Unintentional ingestion may cause signs of acute aspiration and/or chemical pneumonitis. Symptoms may include cough, tachypnea, hypoxia, and dyspnea. Certain hydrocarbons (derived from wood, such as pine oil) can be absorbed in the intestinal tract and cause pulmonary edema even without a history of aspiration.
Exposures to complex hydrocarbon vapors are associated with significant neurological effects, including central nervous system depression, coma, and seizures. Cardiac arrhythmias have been observed following exposure to carbon tetrachloride (lava lamps) as well as other hydrocarbon toxicities.
Chest x-rays should be performed in patients with respiratory distress. If the images are interpreted as normal, repeat imaging should be done within 4 to 6 hours to evaluate for latent lung injury. (10)
The management of these patients is mainly supportive. Gastric lavage or activated charcoal are not indicated. Patients may require supplemental oxygen, intubation, and mechanical ventilation. Bronchodilators may be used for patients with wheezing.
The use of empiric corticosteroids or prophylactic antibiotics is not recommended. (10) Admission for cardiorespiratory monitoring is recommended for those with abnormal symptoms or imaging.
| Prevention of ingestion of foreign bodies and toxic substances |
Parent education is key to ensuring the safety of young children. Parents should be advised to keep all products in their original labeled containers. This practice prevents the child from confusing the item with something less dangerous and allows for easy evaluation of the ingredients if ingested. All potentially dangerous items should be stored out of the reach of children.
Innovations for safer packaging are underway. However, these packaging modifications have not been shown to significantly reduce exposures; Therefore, parental education remains the most important factor available to ensure the safety of a child. (19)
Summary
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