Q4 Urgent Caring-Case Study 2-Pediatric Foreign Body Ingestion

Vital Signs
Blood pressure 88/58, Pulse 97, Respiratory rate 18, Oxygen saturation 98%, Temp 37.2 °C (99 °F), Weight 18.3 kg (40 lb 4 oz)

Physical Exam
Patient is not in acute distress or toxic appearing. Child is well developed. No drooling observed. Oropharynx exam is normal. Cardiovascular: Rate and rhythm: Normal rate and regular rhythm. Pulmonary: Pulmonary effort is normal. No respiratory distress or nasal flaring. Breath sounds: Normal breath sounds. No stridor. No rhonchi. No crackles, No wheezing. No intercostal or subcostal retractions. Abdominal: Bowel sounds are normal. There is no distension. Abdomen is soft. There is no mass. There is no abdominal tenderness. There is no guarding or rebounding.

Imaging
Neck and chest radiograph were normal. 

Abdominal X-ray showed a non-obstructive bowel pattern, no dilated loops. Oval radiodense foreign body projecting in the R L Q measuring 2.3 cm x 2cm. 

Discussion
Children swallowing foreign bodies is a very common chief complaint. The most common foreign body ingestion in United States are coins.¹ The populations with higher risk for foreign body ingestion are preschoolers, adolescent boys and children with mental health issues. Children aged one to three years account for the majority (61.9%) of all ingestions. ²

Most of the foreign body ingested will pass through the GI tract without any complications. In some cases, the foreign body can be too large to pass, or it can adhere or injure (sharp objects) the GI mucosa, or cause chemical/burn injury (button battery or a medication patch) requiring immediate intervention.¹

Urgent Care evaluation
The initial step after a foreign body ingestion is to promptly assess the airway.  A complete history and physical examination are crucial with specific attention to clinical presentation, details about the material ingested (type, size, number, and shape), time lapse since ingestion and last meal. ^1,2 Clinicians must obtain a detailed past medical history including preexisting GI tract abnormalities (strictures, fistulas, diverticula, or functional abnormalities), previous GI surgeries which increases the risk of complications. ³ 

Symptoms may vary based on the age of the patient and the anatomic area involved. Patients may present with throat, neck and chest pain, foreign body sensation, drooling, gagging, vomiting, irritability or refusing to eat. Cough, hematemesis, abdominal pain, or hematochezia/melena can be present. Some symptoms might be exacerbated when swallowing.^1-4

Plain radiographs are normally the initial step (anteroposterior and lateral) of the neck, chest and abdomen).^1-4

Most children with low-risk ingestions may be simply observed.  Symptomatic patients may require more advanced imaging, such as contrast-enhanced radiography or MRI or endoscopy. ¹  Unexpected foreign bodies can be found in radiographs when evaluating non-specific symptoms (cough, fevers, weight loss). 

Any symptomatic patient should be referred to the ER, especially if the airway is compromised or esophageal/intestinal obstruction is suspected.^1,4 Certain objects in the distal esophagus can be monitored to assess passage into the stomach, but foreign bodies found in the esophagus should be referred for endoscopic removal.⁴

When discharging a patient with normal GI tract after a low-risk foreign body ingestion that is expected to pass without complications, patients and caregivers should be instructed on the signs and symptoms of subsequent potential complications. 

Pearls for the Urgent Care Clinician^1,2,3,4: 

• Many foreign body ingestions by children are unwitnessed. 
• The airway should be assessed immediately. 
• Think of a foreign body when a patient complains of throat, neck and chest pain or a foreign body sensation and symptoms exacerbate when swallowing. 
• Younger children may drool, gag, vomit, or refuse food.
• Children with suspected button/disc battery ingestion should be managed urgently.
• A button/disc battery has a two-layer appearance when seen on end or a circle-within-a-circle appearance when seen front-to-back. 
• Coins, magnets, or sharp objects in the esophagus should be removed within 2 hours in symptomatic children and within 24 hours in asymptomatic children. 
• Sharp, long or large and wide objects located in the esophagus or stomach require endoscopic removal.
• Coins >23.5 mm (such as the quarter) may have difficulty passing into the stomach and are a higher risk for obstruction. 
• Most glass fragments are visible on a radiograph. 
• Radiolucent objects (large pieces of meat or plastic) may not be visible on radiographs, but edges or irregularities may still be noticeable.
• A lateral radiograph of the neck/chest is suggested to confirm the absence of a tracheal foreign body when a presumed esophageal foreign body is visualized on the AP view.
• Foreign bodies that contain nickel may cause systemic signs and symptoms in patients with nickel sensitivity (rash and pruritus).
• ER referral should be considered for any symptomatic patient. Urgent evaluation for objects impacted in esophagus and intestines.  
• Medical management, such as emetics or laxatives, after foreign body ingestion is not recommended.

References: 

1. Conners GP, Mohseni M. Pediatric Foreign Body Ingestion. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK430915/
2. Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB. Foreign-body ingestions of young children treated in US emergency departments: 1995–2015. American Academy of Pediatrics. May 1, 2019. Accessed November 27, 2023. https://doi.org/10.1542/peds.2018-1988
3. Lee JH. Foreign Body Ingestion in Children. Clin Endosc. 2018 Mar;51(2):129-136. doi: 10.5946/ce.2018.039. Epub 2018 Mar 30. PMID: 29618175; PMCID: PMC5903088.
4. Citation: Chatha H, Otero H. Approach to ingested foreign bodies in children. J Urgent Care Med. December 2017. Available at: https://www.jucm.com/approach-ingested-foreign-bodies-children/.