Foreign body ingestion

Key points

• Most swallowed foreign bodies in children are low-risk objects that can be managed without imaging or intervention.
• High-risk foreign bodies can cause significant harm and even death and need discussion with a senior clinician or specialist.
• A button battery in the oesophagus must be removed within two hours to avoid serious complications, including death.
• Large objects, magnets and objects impacted in the oropharynx require surgical review.
• Ingested objects may be toxic, so consider consulting the Poisons Information Centre.

Overview

This Royal Children's Hospital Melbourne guideline explains how to assess and manage a child who has swallowed a foreign body. Most objects are low risk, but button batteries, magnets and sharp, lead-based, large or expandable objects need imaging, time-critical care and specialist input. Ingestion is most common between 6 months and 3 years of age.

Who is at risk

Children with developmental concerns, behavioural problems or pica (eating non-nutritive substances such as paper, wood or soil) are more likely to swallow a foreign body, and older children with psychiatric problems may do so intentionally and need a mental health review. Impaction or obstruction depends on the size, shape and composition of the object and is more likely in children with gastrointestinal abnormalities such as strictures or congenital malformations, eosinophilic oesophagitis or neuromuscular disease.

Assessment and red flags

History covers the type of object, timing, gastrointestinal symptoms (drooling, pain on swallowing, reduced intake, abdominal pain, vomiting, melaena or bleeding) and respiratory symptoms that suggest inhalation. Examination looks for airway compromise, oropharyngeal injury, abdominal tenderness and signs of peritonitis or obstruction. High-risk objects include oesophageal button batteries, more than one magnet or a magnet with a metal object, sharp objects in the oesophagus, lead-based objects that fail to pass the stomach, objects over 6 cm long and/or over 2 cm wide, expandable objects such as water beads, multi-component toys and objects impacted in the oropharynx, which need urgent ENT evaluation.

Imaging

Imaging is required for a suspected button battery, magnets or other high-risk radio-opaque objects, an unknown object and a high-risk or unwell child; in smaller children a single X-ray should include the neck, chest and abdomen. It may not be needed if the child is asymptomatic with a normal examination, has no known gastrointestinal abnormality, has had a reassuring observation period and can eat and drink, and the object is under 2 cm in diameter and under 6 cm long, not a magnet or battery, non-expandable and non-toxic.

Treatment

A button battery in the oesophagus needs endoscopy within 2 hours; a battery in the stomach of a symptomatic child needs emergency endoscopy, while batteries in the stomach or beyond without signs of injury are discussed with a specialist. While awaiting theatre, children over 1 year with an oesophageal button battery swallowed within the previous 12 hours are given honey, 10 mL every 10 minutes up to 6 doses. Multiple magnets or a magnet with a metal object anywhere in the gut need urgent referral. Symptomatic children with a coin, blunt object or food bolus in the oesophagus need urgent endoscopy; asymptomatic children with an oesophageal object need endoscopic removal within 24 hours, and coins over 2 cm in diameter are unlikely to pass the pylorus of younger children. For a food bolus, carbonated drinks may help but can cause vomiting, and glucagon and hyoscine butylbromide are not recommended.

Discharge

Discharge can be considered when the child looks well, is pain free, has no respiratory distress, can eat and drink and has a reliable history of a low-risk object. Parents should return if breathing problems, abdominal pain, fever, vomiting, inability to tolerate food and drink, melaena or haematemesis occur.

Frequently asked questions

Does every swallowed object need an X-ray?

No. A well child with a normal examination who swallowed a small object that is not a magnet or battery, non-expandable and non-toxic may not need imaging if all the guideline criteria are met.

Is a single magnet on X-ray reassuring?

Not always. One magnet seen on X-ray may still be high risk, because two swallowed magnets can look like one.

Why is a button battery in the oesophagus an emergency?

It must be removed within two hours to avoid serious complications, including death, so it needs time-critical endoscopy.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Foreign body ingestion. Last updated February 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). This summary was prepared by Medpresso from the original guideline and is not a substitute for the full text or for medical advice.