Pediatric Foreign Body Ingestion

Etiology

Pediatric foreign body ingestion often occurs accidentally. Toddlers frequently place objects in their mouths—an expected developmental behavior—as they explore their surroundings. Due to underdeveloped dentition, infants and toddlers are more likely to swallow objects compared to older children.[5] Older children with psychological or neurodevelopmental disorders face elevated risk due to behavioral patterns associated with those conditions.

Functional or structural abnormalities of the gastrointestinal tract, such as strictures, scarring, fistulas, or diverticula, increase the likelihood of complications from foreign body ingestion by creating points where objects may become lodged. Button and disc batteries can cause severe injury when trapped in the esophagus, nasal cavity, external auditory canal, or other orifices, even after brief exposure. Lithium-based batteries carry the highest risk of tissue damage.

Small, high-powered magnets, commonly found in toys and household items, may lead to gastrointestinal injury. Multiple magnets can attract across tissue planes, eroding through intervening structures.[6] Ingesting a single magnet alongside another metallic object, particularly a battery, further increases the risk of serious complications.

Epidemiology

Over 50,000 cases of foreign body ingestion in children younger than 5 years were reported to the National Poison Data System in 2022.[7] Most ingestions occur in children aged 6 months to 3 years.[8][9] The majority of cases are witnessed and occur within the home. Mortality remains low overall.[10]

Older children with foreign body ingestions often have comorbid psychiatric or developmental conditions. The incidence of foreign body ingestion in adolescent boys surpasses that in adolescent girls. In younger age groups, both sexes experience similar prevalence.

Coins are the most frequently swallowed foreign body requiring medical attention in the U.S. and many developed countries. However, the ingestion of coins has decreased as their use has declined in everyday life. Younger children typically ingest smaller coins, while older children tend to swallow larger ones.[11] Magnet ingestion has risen in the U.S. over the past 2 decades, particularly among children younger than 5 years. Other frequently ingested objects include small toys and jewelry. In some countries, fish bones are the most commonly ingested foreign objects.[12][13]

Pathophysiology

The most common complication of foreign body ingestion in children is esophageal obstruction, although foreign bodies may also become lodged in other areas of the gastrointestinal tract. Once lodged, objects may partially or completely obstruct the lumen. Some may erode through the gastrointestinal tract walls, causing perforation and migration outside the lumen. Patients with anatomically or functionally abnormal gastrointestinal tracts are at a higher risk of complications. Infants and toddlers are particularly vulnerable due to the narrower esophageal and bowel lumens. Other high-risk patients include those with a history of upper gastrointestinal surgery, gastroesophageal reflux disease, eosinophilic esophagitis, neuromuscular disorders, or congenital gastrointestinal malformations.[14][15]

Several areas in the esophagus may trap foreign bodies. The most common site of obstruction is at the level of the thoracic inlet. Approximately 10% to 15% of foreign bodies lodge in the midesophagus, where the carina and aortic arch overlap. Objects may also become trapped at the gastroesophageal junction. Once a foreign body reaches the stomach, it is more likely to pass through the rest of the gastrointestinal tract. However, some may become stuck in the bowel, particularly near the ileocecal valve.

Batteries, especially button types, can create a local circuit with adjacent tissue, leading to burns and coagulative necrosis. These injuries may result in gastrointestinal tract perforation, mediastinitis, peritonitis, fistula formation, or scarring and strictures. Additionally, batteries may cause local obstruction, similar to other ingested objects.[16] A rare but potentially fatal complication of esophageal button battery impaction involves the formation of an aortoesophageal fistula, where tissue necrosis between the esophagus and aorta leads to arterial bleeding into the esophagus.

Magnets, particularly rare-earth magnets, pose a significant danger when multiple pieces are ingested together or one is ingested with another metallic object. These magnets can attract each other or other metals across tissues, causing pressure necrosis, which may potentially result in bowel perforation, peritonitis, fistula formation, or mechanical obstruction.[17]

History and Physical

The airway must be evaluated promptly in suspected foreign body ingestion. The oropharynx should be examined for foreign bodies, and any found should be removed if possible. After addressing any airway or breathing compromise, a thorough history and physical exam can follow.

Some patients with foreign body ingestion may exhibit no symptoms, while others may experience mild, nonspecific manifestations. Given the possibility of unwitnessed ingestions, foreign body ingestion should be considered in children with respiratory or gastrointestinal complaints. In a case series, only half of the patients with confirmed foreign body ingestion exhibited symptoms upon presentation.[18]

Symptomatic infants and young children are more likely to present with respiratory symptoms, while older children tend to show gastrointestinal symptoms. Symptom severity, physical examination findings, and vital sign abnormalities largely depend on the presence and extent of complications.

A foreign body obstructing or injuring the esophagus may cause chest pain, shortness of breath, odynophagia, dysphagia, coughing, or a sensation of a foreign body. Significant esophageal injury may lead to hematemesis or signs of mediastinitis. Young children with an esophageal foreign body may drool, gag, vomit, or refuse food.

Foreign bodies lodged in or perforating the stomach or bowel can cause abdominal pain, vomiting, hematemesis, or bloody stool. Foreign bodies retained for extended periods may result in fever or weight loss. Swallowed foreign bodies containing nickel may cause systemic symptoms, including rashes or pruritus, in patients with nickel sensitivity.

Evaluation

Evaluation for airway compromise due to proximal airway or esophageal obstruction is the priority when assessing a patient with suspected foreign body ingestion. Complete esophageal occlusion may lead to significant drooling, which can indirectly compromise the airway due to the accumulation of secretions. Immediate management of such airway threats must precede further history-taking or examination.

Plain radiographs provide a useful first-line imaging modality for suspected airway, esophageal, or gastric foreign bodies. Metallic foreign bodies are readily visible and can be roughly localized on plain films.[19][20][21] Batteries, coins, and most glass fragments appear on radiographs. Radiolucent objects, such as meat or plastic toys, may not be clearly visible but can sometimes be identified by their outlines or associated irregularities. Contrast radiography, computed tomography, or magnetic resonance imaging may offer better visualization of radiolucent objects.[22][23][24]

Button batteries and coins may be differentiated radiographically. Button batteries typically display a 2-layer appearance in lateral views or a circle-within-a-circle pattern in anteroposterior views, while coins appear as single-layer disks (see Image. Button Battery in the Upper Esophagus of a Child).

Treatment / Management

Management depends on the foreign body’s location and composition. The key decision involves determining whether endoscopic or surgical removal is necessary. Approximately 10% to 25% of ingested foreign bodies require endoscopic retrieval. Magnets and batteries carry a higher likelihood of requiring endoscopic or surgical intervention and are more frequently associated with bowel resection or multiple operations.

Conservative management with serial imaging and observation may be appropriate for otherwise healthy, asymptomatic children who have ingested small, inert objects. Many of these children may be monitored at home or safely discharged from the emergency department without intervention. Observation may be less suitable for children with a history of gastrointestinal diseases or structural abnormalities, given the increased risk of obstruction and tissue injury. When managed expectantly, patients and caregivers should be advised to obtain immediate medical care at the onset of symptoms, as foreign body removal may become necessary.[25][26][27](B3)

Low-risk objects in the stomach or bowel often pass spontaneously in asymptomatic children. Expectant management may be appropriate for coins and other small, inert objects located near the gastroesophageal junction in otherwise healthy patients, as these typically enter the stomach within hours and progress through the bowel without complication. The onset of symptoms warrants prompt intervention—endoscopic retrieval for gastric foreign bodies or surgical removal for bowel obstructions. Gastroenterology or surgical consultation is necessary following ingestion of high-risk objects, such as large or pointed items, batteries, or multiple magnets.

Large or obstructive foreign bodies in the esophagus generally require endoscopic removal. Endoscopy allows for the safe extraction of sharp, pointed, or otherwise high-risk objects from the esophagus or stomach. Some specialized centers may use a bougie or balloon catheter to remove small esophageal foreign bodies, such as coins, without endoscopy. Any button battery in the esophagus demands urgent removal. When endoscopy cannot be performed immediately, oral honey administration has been proposed as a protective measure to limit tissue damage surrounding the battery.[28](B2)

Button battery ingestions require urgent management due to the risk of tissue necrosis and perforation. Depending on the location, immediate gastroenterology or surgical consultation is necessary, with most cases requiring prompt removal. Asymptomatic patients who present more than 12 hours after ingestion or in whom the battery has passed into the bowel may be monitored for spontaneous passage. In such cases, follow-up imaging after 7 to 14 days is necessary to track battery progression. Symptom development at any point warrants emergency reassessment and likely surgical intervention.[29] Institutional practices may differ, though treatment algorithms for button and disc battery ingestion are widely available.[30]

Expectant management with serial imaging may be considered for asymptomatic patients who have ingested multiple magnets. Suggested imaging intervals range from every 6 to 12 hours. Surgical intervention is typically pursued when no progression through the bowel occurs or when symptoms arise.

Medical management with emetics or laxatives is not advised. Emetics, muscle relaxants, and meat tenderizers are ineffective and may be harmful.[31] Although laxatives are sometimes used to facilitate intestinal passage, this approach remains unproven and should not be employed without specialist input.(B3)

Differential Diagnosis

Pediatric foreign body ingestion can present with nonspecific symptoms that overlap with several other conditions. Clinicians must consider a broad differential diagnosis, including the conditions below, especially when complications such as obstruction or perforation are suspected.

• Esophagitis
• Laryngitis
• Pharyngitis
• Globus sensation
• Esophageal web or stricture
• Esophageal rupture
• Pyloric stenosis
• Bowel obstruction
• Bowel perforation
• Appendicitis
• Intussusception
• Volvulus
• Gastroenteritis
• Colitis

Recognizing clinical features that differentiate these conditions from foreign body ingestion is essential for accurate diagnosis and timely intervention. A thorough history, physical examination, and clinically appropriate imaging help distinguish ingestion-related pathology from mimicking disorders.

Prognosis

Outcomes following pediatric foreign body ingestion are generally favorable, with most children tolerating spontaneous passage of ingested objects without requiring intervention. Even when removal becomes necessary, morbidity and mortality remain low when identification and extraction occur promptly. High-risk ingestions, such as those involving button batteries, magnets, or sharp objects, carry a greater risk of complications and, in some cases, may result in death.[32][33]

The prognosis depends on the severity of resulting complications. Children who pass objects spontaneously tend to recover fully without lasting effects. In contrast, cases involving severe outcomes such as mediastinitis from esophageal perforation, aortoenteric fistula, or bowel perforation with peritonitis require a cautious outlook and close follow-up.

Complications

Esophageal obstruction is the most frequently encountered complication in pediatric foreign body ingestion.[34] In rare cases, certain foreign bodies may perforate the alimentary tract or migrate into surrounding structures, resulting in life-threatening outcomes, including the following:

• Esophageal, gastric, or bowel wall perforation
• Pneumothorax
• Mediastinitis
• Mucosal erosion
• Gastrointestinal bleeding
• Aortoenteric fistula
• Esophageal or bowel wall pressure necrosis
• Failure to thrive and dehydration secondary to decreased oral intake

Prompt identification and intervention remain critical in preventing serious complications. Although severe outcomes are rare, delayed recognition may lead to devastating consequences.