When a child swallows a foreign object

• Parents can tell if their child has swallowed a foreign object from the following symptoms: coughing, choking, difficulty breathing, sore throat, increased saliva production, bloody saliva, difficulty swallowing food or drink, refusing to eat, stomach pain, vomiting or passing blood. However, some children may not display any symptoms whatsoever.
• Do not attempt to dislodge the object with fingers or induce vomiting because it could result in that object moving from the esophagus into the airway, which can be very dangerous.
• Some foreign objects, including plastics, wood and small fish bones, will be undetectable on an x-ray image, so it is crucial that the symptoms be communicated, and that examples or suspected objects which may have been swallowed are provided to medical staff, who will use the information to determine treatment.

Parents and guardians should be especially careful of their children carelessly playing with objects which they may easily swallow. The most common objects swallowed by small children are coins, particularly among children aged 6 months to 3 years. Although most objects—between 80 to 90%—will pass harmlessly through the digestive system causing no health issues at all, around 10 to 20% of objects swallowed by infants will not be able to pass through the digestive system successfully, or they may become lodged so deep as to require endoscopic removal. Approximately 1% of cases will require open surgery to remove the offending article. The method used to remove foreign objects depends on what they are made from, size of the objects, where they are lodged, the child’s age, and the amount of time passed since the object was initially swallowed. Some objects, including plastics, wood and small fish bones, may not appear on x-ray images. It is crucial that all symptoms be communicated to medical staff, and that an example of the object or something of a similar shape and size to that which may have been swallowed be given to medical staff to help them determine their choice of treatment.

Symptoms include coughing, choking, difficulty breathing, sore throat, increased saliva production, bloody saliva, difficulty swallowing food or drink, refusing to eat, stomach pain, vomiting and passing blood. However, some children may not display any symptoms at all.

• Ensure they refrain from eating or drinking before they are taken to a hospital.
• Respiratory symptoms such as coughing, choking, or difficulty breathing could mean the object has become lodged in their airway, which is dangerous enough to require urgent hospital treatment.
• In cases where the child is not suffering with any obvious symptoms, do not try to remove the object with fingers or induce vomiting because the object could become dislodged from the esophagus and lodge itself in the airway, which is extremely dangerous.
• Bring an example of the object or something of a similar shape and size to that which was swallowed for the medical staff to see.
• Seek medical attention to undergo a chest and stomach x-ray, which will be able to accurately locate the object.

The following sizes of object are recommended for removal via endoscopic procedures:

• Objects measuring > 2cm in width and > 4-5cm in length for newborns and small children aged less than 3 years
• Objects measuring > 2.5cm in width and > 6-10 cm in length for children aged 3 and above.

Objects lodged in the esophagus

• For disc-batteries or similarly shaped objects, small batteries and sharp objects, it is recommended that children be taken to seek urgent medical attention—whether or not they are displaying symptoms—so that medical staff can perform an endoscopic removal of the item at the earliest opportunity.
• Magnets should be removed endoscopically within 12–24 hours.
• Impacted coins or food lodged in the esophagus in the esophagus should be removed immediately if they are causing any symptoms; even in less urgent cases it is still recommended that the object be removed within 24 hours of being swallowed.
• Blunt objects measuring > 6cm in length should be removed within 24 hours regardless of symptoms.
• Fish bones usually (over 60% of cases) become lodged in the upper throat region but, should they become lodged in the esophagus and an x-ray image shows that the bone is large enough to cause issues, it is recommended that it be removed endoscopically. This is because such bones can pierce the esophagus walls, resulting in a perforated or infected dangerous wound. Nevertheless, if these bones are invisible on an x-ray image, an endoscopy would be recommended when symptoms appear.

Objects lodged in the stomach

• Disc-batteries
  • Any size resulting in symptoms: It is recommended that they be removed endoscopically at the earliest opportunity.
  • Asymptomatic cases measuring > 2cm in length among children aged under 5 years: It is recommended that they be removed via endoscopy within 24-48 hours.
  • Asymptomatic cases measuring < 2cm in length or for children aged over 5 years: The urgency is reduced and x-rays can be taken every 3–4 days to assess whether the offending article is able to pass through the child’s digestive system. If the battery cannot be passed, medical staff may consider an endoscopy, although if medical staff deem it possible to pass the article naturally, all parties should wait for this process to play out naturally.
• Magnets
  • Any size resulting in symptoms: It is recommended that they be removed endoscopically at the earliest opportunity.
  • Asymptomatic cases whereby a single magnet measuring < 2.5cm in length has been swallowed: Periodic x-rays should be taken to assess whether it can be passed naturally. If it cannot be passed naturally within 24 hours, medical staff may consider an endoscopy to remove the article. However, if it can be passed naturally, all parties should await that result, during which time the child should be kept away from other magnetic objects and avoid wearing clothing with metal buttons, including belts with metal buckles, which could attract the article lodged in their stomach.
  • Asymptomatic cases whereby a single magnet measuring > 2.5cm in length has been swallowed: Such objects cannot be passed naturally, so an endoscopy should be performed to remove the offending item.
  • Asymptomatic cases whereby several magnets have been swallowed:
    • Where the magnets are not bundled together or where the magnets have been swallowed alongside other metal objects, an endoscopy of the stomach should take place within 12–24 hours as there is a risk of the objects becoming bundled together. Such an occurrence is particularly dangerous owing to the objects attracting to one another once already inside the stomach, which could involve stomach or intestinal tissues becoming pinched in between the objects, leading to the affected tissue rotting and coming loose. This is especially risky in cases where the magnet consists of neodymium, a material that has up to 5–10 times greater attraction than other types of magnets.
    • Magnets that are bundled together should be considered like a single magnet, and assessed according to the total size of the magnets that are bundled together, meaning an x-ray should be performed every 4–6 hours to monitor the situation.
• Coins
  • Any size resulting in symptoms: It is recommended that they be removed endoscopically at the earliest opportunity.
  • Asymptomatic cases should be assessed according to the size of the coin swallowed, as follows:
    • Coins measuring < 25mm (about the size of 1- or 2-baht coins) are not so urgent, but x-rays should be taken on a weekly basis to check whether they can be passed naturally. If they remain in the stomach after a period of 4 weeks, an endoscopy should be undertaken to remove the coin(s).
    • Coins measuring > 25mm (about the size of 5-baht coins) are not usually able to pass through the digestive system naturally, meaning an endoscopy would be necessary to remove the coin.
    • Larger objects measuring > 2.5cm: It is recommended that an endoscopy take place within 24 hours of the object being swallowed.
• Sharp objects: It is recommended that an endoscopy take place within 24 hours of the object being swallowed due to the risk such objects pose to the digestive tract.
• Blunt, benign objects: Should these objects measure less than 2.5cm in length, all parties can wait for it to be passed naturally within 2–4 weeks. However, if the object is not passed after 4 weeks, an endoscopy should be undertaken to remove the object.

Objects lodged in the small/large intestines

• Small, disc-shaped batteries, coins, blunt and benign objects: If such objects can be passed naturally, they usually exit the body within 1–2 weeks without any complications. The likelihood of tearing to the intestinal walls or other complications is less than 1%. It is recommended that parents check their child’s stools each time they visit the bathroom until they find the foreign object. Should the object not pass within a week, a doctor should be consulted to take an x-ray aimed at detecting the object’s location. In cases where the child suffers from stomach pain, vomiting, or a fever, or where x-rays show that the object has not moved at all for a week, open surgery may be considered as an endoscopy would no longer be suitable.
• Magnets: If a single magnet or several magnets bundled together are present in the intestine, it is possible that the object(s) may be passed naturally. As such, an x-ray should be taken every 4–6 hours to monitor the situation. Nevertheless, should a child have swallowed several magnets which have not bundled together, or the magnets have been swallowed alongside other metal objects, open surgery to remove them is recommended due to the risk that the objects may become bundled together while in the stomach, thus placing the stomach and intestinal tissue at risk of being pinched, rotting and becoming loose.
• Sharp objects: There is a 15–35% chance of intestinal damage in these cases. If symptoms are apparent, open surgery is required. However, if the child is asymptomatic, they should be admitted to hospital in order to have their progress monitored and to undergo daily x-rays aimed at locating the object at each stage of its journey through the digestive system. Should the object become lodged in one place for more than 3 days, or it is not passed within 4 days, open surgery to remove the object will be considered.

Young children are at high risk of picking up and swallowing foreign objects as they are not yet aware of the dangers inherent in their actions. Therefore, parents and guardians should ensure that their children’s toys are large enough so as not to pose a choking risk and that any small objects are kept out of the reach of young children. Parents should also be sure to keep an eye on their child at all times at this young, vulnerable stage of their lives.