Foreign body aspiration and ingestion (pediatrics): Clinical sciences

Foreign body aspiration refers to the inhalation of an object, while foreign body ingestion refers to the swallowing of an object.

Most cases require timely evaluation and treatment to prevent serious complications, like airway obstruction or gastrointestinal tract perforation.

If a pediatric patient presents with a chief concern suggesting foreign body aspiration or ingestion, start with an ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, stabilize the airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring. Finally, provide supplemental oxygen if needed.

After starting acute management, obtain a focused history and physical examination to identify potential complications, like airway obstruction or gastrointestinal perforation.

Patients may report a witnessed foreign body aspiration with acute onset of symptoms, like the inability to speak or cough, as well as gasping or blood in the sputum.

The physical exam might demonstrate signs of respiratory distress, like tachypnea, nasal flaring, and retractions.

These findings should immediately make you suspect an airway obstruction, so act quickly.

Perform rapid sequence intubation and an emergent rigid bronchoscopy to remove the foreign body. In cases where a bronchoscopy is not immediately accessible, consider cricothyroidotomy.

Here’s a clinical pearl! If a patient aspirates outside of a hospital setting, perform back blows and chest thrusts on an infant; or the Heimlich maneuver in an older child.

However, if the patient is able to speak or cough, then do not perform these maneuvers since they may convert a partial obstruction to a complete one.

Now let’s talk about different findings. Patients might report a known or suspected ingestion, typically of a sharp or magnetic object, or a button battery.

They could also report symptoms like dysphagia; blood in the saliva; and neck, chest, or abdominal pain.

The physical exam may reveal crepitus and swelling in the neck and upper chest; or abdominal tenderness with rebound pain or guarding.

With these findings, suspect esophageal or bowel perforation. Then obtain X-rays of the chest and abdomen. X-rays may demonstrate a foreign body in the chest or abdomen,

and possibly subcutaneous emphysema in the neck or chest. You might also see pneumomediastinum, which is characterized by lucent streaks or air around mediastinal structures; or pneumoperitoneum with free air under the diaphragm.

If you see these findings, diagnose a foreign body ingestion with perforation.

Next, begin broad spectrum IV antibiotics and obtain an emergent surgical consultation.

Here’s a high-yield fact! Button batteries can cause rapid mucosal damage, necrosis, and perforation. As a result, a button battery in the esophagus requires immediate removal.

In contrast, those in the stomach or beyond should be removed if the child is under 5 years old or if the battery is larger than 2 centimeters. In all other cases, you can monitor closely with serial X-rays.

Let’s go back to the ABCDE assessment and look at stable patients. First, perform a focused history and physical examination.

Here’s a clinical pearl! Several factors increase the risk of foreign body aspiration or ingestion in children less than three years of age, such as developmental curiosity, immature swallowing coordination, absence of molars and premolars, and a narrow pharynx. Additionally, children with developmental delay are at an increased risk of foreign body aspiration.

Young children are more likely to aspirate or ingest small, cylindrical, and compressible items, such as coins, batteries, magnets, small toys, and balloons; as well as specific foods, like hot dogs, raw carrots, or nuts. Keep in mind that some of these items are radiolucent, meaning that they can’t be seen on an X-ray.

Now, patients are often asymptomatic, but history might reveal witnessed foreign body aspiration, coughing, choking, dyspnea, or blood in the sputum.

The physical exam might demonstrate stridor or wheezing, as well as the unilateral absence of breath sounds. At this point, suspect a foreign body aspiration.