Foreign body (FB) ingestions are an increasingly common occurrence in infants and young children. The exact incidence is unknown because many cases are not reported. In 2015, the Annual Report of the American Association of Poison Control Centers noted more than 94,000 cases of FB ingestion. More than 68,000 occurred in children ≤5 years of age. Ingestions are the fourth most common pediatric exposure reported to poison control centers. Of note, magnet ingestions have increased 8.5-fold over the past 10 years with a 75% average annual increase per year. Many centers reported an increase in foreign body ingestion during the COVID-19 pandemic. Recently, the Susy Safe project has been formed to provide a pan-European surveillance registry for injuries due to FB ingestion and aspiration. This international consortium provides a risk-analysis profile for each product causing harm, evaluates socioeconomic disparities among these patients, uses data collection to interact with consumer associations, and helps guarantee the safety of consumers.

The vast majority of ingestions in children are accidental. The most common type of ingested FB varies by geographic region. In the United States and Europe, coins are the most common. ^, Other commonly ingested objects include toys, batteries, needles, straight pins, safety pins ( Fig. 10.1 ), screws, earrings, pencils, erasers, glass, fish and chicken bones, and meat. However, in areas of the world where fish contribute a significant portion of the diet, such as in Asia, a fish bone is the most common FB ingested by children. ^, Intentional ingestions are becoming more common, especially in children suffering from psychiatric conditions or those children who are detained in the juvenile detention system.

This child accidentally ingested this open safety pin, which was able to be extracted with esophagoscopy.

FB ingestions usually present after a witnessed event or disappearance of an object. Delayed presentations are also likely. There may be heightened suspicion for ingestion by a caregiver based on the child’s description. Current data suggest a higher incidence of foreign body ingestion on weekends and holidays, with a holiday occurrence of 2.75 cases/day, a weekend occurrence of 1.46 cases/day, and a weekday occurrence of 0.91 cases/day.

The initial presentation can vary from the child being completely asymptomatic to a variety of symptoms including drooling, neck and throat pain, dysphagia, emesis, wheezing, respiratory distress, or abdominal pain/distention. Most children will have a normal physical exam; however, each child should be evaluated for signs of complications. Physical exam findings that raise suspicion of potential complications include oropharyngeal abrasions, crepitus, or signs of peritonitis.

The esophagus is the narrowest portion of the alimentary tract and is thus a common site for FB impaction. Within the esophagus itself, there are three areas of anatomical narrowing: the cricopharyngeus sling (70%), the level of the aortic arch (15%), and the lower esophageal sphincter at the gastroesophageal junction (15%). Other areas of potential impaction may be found in the esophagus of children who have underlying esophageal pathology (i.e., strictures or eosinophilic esophagitis) or prior esophageal surgery (i.e., esophageal atresia). Although usually asymptomatic, sharp foreign bodies may penetrate the mucosa at any level and cause mediastinitis, aorto-enteric fistula, or peritonitis.

Symptoms of esophageal FB impaction are often nonspecific and include drooling, poor feeding, neck and throat pain, vomiting, or wheezing. Radiopaque objects can be detected on anteroposterior (AP) and lateral neck and chest radiographs ( Fig. 10.2 ), while radiolucent objects may require further workup with a Gastrografin esophagram or esophagoscopy, depending on the symptoms and the provider’s level of suspicion ( Fig. 10.3 ).

This 3-year-old child presented with dysphagia and drooling. (A) The anteroposterior radiograph shows a coin that appears in the upper esophagus. (B) The lateral view shows that the coin is posterior to the trachea, confirming its esophageal location.

A piece of chicken became lodged in this child’s upper esophagus. The chest radiograph was normal, but the esophagram shows the foreign material ( arrow ) obstructing the esophagus.

The most common round, smooth object ingested that is amenable to extraction or advancement is a coin. Most esophageal coins will appear en face in the AP view, and from the side on the lateral radiograph (see Fig. 10.2 ). On occasion, more than one coin will have been ingested ( Fig. 10.4 ), and thus completion esophagoscopy is generally recommended following removal of the first coin. Additionally, the stomach can also be desufflated, which will decrease the risk of aspiration during anesthesia emergence and the esophageal mucosa can be inspected.

This infant was seen in the emergency department for swallowing difficulty and drooling. (A) Anteroposterior radiograph shows a coin in the upper esophagus. (B) However, on the lateral view, there are actually four coins superimposed on one another. The lateral view is very helpful for the purpose of determining whether more than one coin has been ingested.

The location of the object on the radiograph is important in determining the treatment options. Most FB impactions are in the proximal esophagus at the level of the upper esophageal sphincter or thoracic inlet. FB impactions in the upper or mid esophagus will usually remain entrapped and require retrieval. Options for retrieval include nonemergent endoscopy (rigid or flexible) ( Fig. 10.5 ) and Foley balloon extraction with fluoroscopy ( Fig. 10.6 ). The Foley balloon extraction technique should be limited to round, smooth objects in appropriately selected children without any evidence of complications. This technique was found to have a success rate of 80% while significantly lowering costs. In a 2017 study, the median total cost was $1231 for balloon retrieval versus $3615 for primary endoscopy. Objects that are impacted in the lower esophagus often spontaneously pass into the stomach. For this reason, certain lower esophageal impactions can be observed for a brief interval or attempted to advance into the stomach with bougienage or a nasogastric tube in the ED without anesthesia. Once the coin passes through the esophagus further imaging is not generally required. A Turkish study from 2023 on 773 patients noted a success rate of 94%, with 88% of coins retrieved and 6% pushed into the stomach. Depending on institutional anesthesia practices, some centers now wait for a full NPO period to pass in cases of esophageal coins. Recently, transnasal esophagoscopy has emerged as a new option. Advantages include a shortened procedure time and the need for only a local anesthetic. Rarely, a chronic esophageal coin can cause esophageal perforation, but this will usually be contained ( Fig. 10.7 ).

This coin was lodged in the esophagus of a 2-year-old child. It was unclear how long the coin had been in the esophagus. Rigid esophagoscopy was performed. (A) The coin is seen through the esophagoscope. (B) The optical graspers are being used to grasp the coin and remove it. The safety and success rate for rigid esophagoscopy and coin removal approaches 100% with minimal complications. This is usually a safe and successful way to remove a coin in the esophagus of children in whom the Foley catheter technique is not appropriate.

This radiograph shows the Foley catheter technique for removing a coin lodged in the upper esophagus. Under fluoroscopy, the Foley catheter is advanced past the coin and the balloon is filled with barium ( asterisk ). Under fluoroscopy, the catheter is then removed, bringing the coin with it. Care must be taken to ensure the patient does not aspirate the coin during its removal. This is a very cost-efficient way to remove coins in the upper esophagus in young children.

This child was found to have an esophageal leak (A) after uneventful extraction of a coin. (B) As the leak appeared to be contained, the patient was managed conservatively, and a repeat study 2 weeks later showed no evidence of a leak. A central line was placed for total parenteral nutrition.

FB ingestions that are found to be distal to the esophagus are usually asymptomatic when discovered. Signs and symptoms including significant abdominal pain, nausea, vomiting, fevers, abdominal distention, or peritonitis should alert the provider to potential complications including obstruction and/or perforation. FBs that pass into the stomach will usually pass through the remainder of the gastrointestinal (GI) tract uneventfully. These children can be managed as an outpatient. Occasionally, an FB will remain present in the bowel after a period of observation and serial radiographs ( Fig. 10.8 ). Prokinetic agents and cathartics have not been found to improve gut transit time and passage of the FB. Often parents are instructed to strain the child’s stool; however, in up to 50% of cases, the FB is not identified even with successful passage. If the child remains asymptomatic and the FB has not been identified, a repeat abdominal radiograph can be performed at 2- to 3-week intervals. Subsequent endoscopy is usually deferred for 4–6 weeks.

This child began to complain of abdominal pain and the (A) plain film was obtained. Due to the fact that it was unclear how long ago the sewing needle was ingested and because she was exhibiting new symptoms, diagnostic laparoscopy was performed. (B) At laparoscopy, the sewing needle was seen to have penetrated the proximal jejunum and (C) was able to be extracted. A water-soluble contrast study was performed a few days later. The study was unremarkable, her diet was advanced, and she recovered uneventfully.