General Medical Officer (GMO) Manual: Clinical Section
Pediatric "Swallowed" Foreign Body
Department of the Navy
Bureau of Medicine and Surgery
Introduction
Young children and toddlers are at the highest risk for swallowing and/or
aspirating foreign bodies because of their normal behavior of exploring the world with
their mouths. In some instances a history to support a diagnosis of swallowed/ aspirated
foreign body may be available... either through direct observation or that of a child
playing with small things or eating suspect foods (e.g. nuts, hot dogs, popcorn). In such
cases, a parent will observe a child placing an object in the mouth, or in the case of an
aspiration, beginning to cough, choke, or gag. However, most children are not directly
observed, and a high index of suspicion is required. Prevention through safe practices is
important as 80% of aspirations occur in children less than 3 years old. There are an
estimated 500 deaths annually in the U.S. due to asphyxiation.
Aspiration
Aspiration may be of a liquid substance, but this is unusual in
the neurologically intact child. The more common emergent aspiration is that of food.
Oftentimes, small foodstuffs such as nuts or seeds are swallowed inappropriately by a
developing toddler. Small toy parts or objects are also culprits. The foreign object
lodges on the right side almost twice as often as the left. Symptoms of respiratory
difficulty may vary from absent to acute, emergent asphyxia.
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Large bodies may lodge at the level of the larynx or
trachea and cause acute obstruction. The Heimlich maneuver or back blows/ chest thrusts
may be lifesaving.
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Smaller bodies yield varied symptoms, depending on where in
the respiratory tree they lodge and how long they have been present. Complaints may
include dyspnea, chest pain, or cough, and the patient may be hypoxemic on occasion. Chest
radiographs may show an object if it is radiopaque and may also show a pneumonic process
distal to the obstruction, with associated atelectasis. Standard radiographs should
include inspiratory and expiratory films (with an eye for air trapping on the effected
side or perhaps a mediastinal shift), decubitus films, and perhaps fluoroscopy.
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Treatment consists of removal with rigid or
flexible bronchoscopy by an experienced endoscopist along with assistance from an
anesthesiologist. Antibiotics are only necessary if there are radiologic signs of
pneumonia. Humidification, oxygenation, bronchodilation, and sometimes 24-48 hours of
steroids after removal are helpful.
Swallowed Foreign Body
Swallowed foreign bodies are also more common in children. Very
common objects include coins, small batteries, and food.
As most objects are radiopaque, a chest film often locates the suspected part. If a
suspected object is radiolucent, a thin barium swallow may be performed to help locate it.
Frequently these may lodge in the esophagus at either the level of the thoracic inlet, the
area where the esophagus crosses the aorta, or the gastroesophageal junction.
Symptoms can be myriad, and may range from refusal to eat solids, drooling, vomiting
(should not be induced), dysphagia (generally, an older child can localize a
foreign body trapped above the thoracic inlet but not if trapped below), cough exacerbated
by feeds, or no symptoms may be present at all. Fewer than 20 percent will have any
abnormalities on physical examination so that the diagnosis depends on radiography.
If the object has been located in the esophagus and is causing no difficulties, it may
be observed for 24 hours. Sedation may aid in its passage.
If it has not passed into the stomach within 24 hours, it should be removed
endoscopically as mucosa may grow over the object and impede its removal over time. The
exception to this rule is the known ingestion of a button disc battery. These
should be removed as soon as possible even if asymptomatic as tissue damage has been known
to occur as quickly as 4 hours post-ingestion.
Pieces of meat or other foods may be aided with meat tenderizer after 12 hours although
this is controversial as they may damage the esophagus themselves. Disk batteries greater
than 15 mm and lodged in the stomach should be considered for removal. Otherwise,
a trial of passage should be given for 24 hours.
Other objects considered for removal in the asymptomatic patient include sharp objects
or those that are long and narrow, as these may be better removed electively rather than
risk the chance of intestinal perforation. If not removed, progress of these objects
should be noted with serial films every 3-5 days and stool straining.
Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Naval Medical
Center San Diego, San Diego,CA (1999).
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Operational Medicine 2001
Health Care in Military Settings
Bureau of Medicine and
Surgery
Department of the Navy
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Operational
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Health Care in Military Settings
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January 1, 2001 |
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