Abstract
Objectives: To improve the local data and demographics of foreign body (FB) ingestion in the Makkah, Saudi Arabia and to provide basic statistics for future studies in the local community.
Methods: We carried out a record-based retrospective epidemiological study of 153 pediatric patients with FB ingestion who presented to our center in Makkah, Saudi Arabia, between December 2014 and December 2019. Adult age, impacted FB at other sites, and chemical ingestion were excluded.
Results: Descriptive statistical analyses were performed. There has been an alarming increase in the number of children admitted to hospitals following FB ingestion. Approximately 41.8% of these patients were under the age of 4 years, with boys (63.4%) accounting for the majority. Most of the ingested FB were coins (60.8%), and 96.7% of the patients remained under 24 hours of observation at the hospital. The results showed a highly statistically significant relationship between the FB type, age, length of hospital stay, and esophagoscopic findings.
Conclusion: A large number of children presented with ingested FB, especially those younger than 4 years of age, whose clinical presentation varied from asymptomatic to severe complications, and urgent endoscopic intervention might have decreased serious complications. Further preventive measures are necessary within homes in addition to increasing caregivers’ awareness of the different circumstances of FB ingestion and the time required for urgent admission.
Foreign body (FB) ingestion is the accidental or intentional swallowing of an object that can affect the esophagus.1 The presentation differs depending on the location, size, and nature of the FB. Coughing, difficulty in breathing, nausea, vomiting, chest pain, and fever are possible symptoms.2
Foreign body impaction in the esophagus is a common and serious health problem worldwide, with 2.5 million cases reported each year in the United States; in most cases the patients are younger than 5 years old.2 Esophageal FB is commonly observed in children, as their lack of molars and curiosity may lead to the placement of the FBs in the mouth.1,2 According to Abualenain et al,1 most FB ingestion occurs in children aged 0–4 years. Moreover, variations in incidence have been observed between male and female patients.1
The diagnosis of FB ingestion can be challenging for clinicians, especially when the event is not witnessed or when the child is asymptomatic.3 Children who complain of sore throat or have trouble swallowing saliva or meals for no obvious reasons should be suspected of having esophageal FBs. If an esophageal FB does not pass naturally within 24 hour (h), it must be removed to prevent esophageal anatomical injury (such as erythema, edema, ulceration, or perforation) that can lead to serious complications.2,4,5
In one literature review, the reported FBs included coins, batteries, safety pins, food boluses, buttons, magnets, and toys of which coins were the most common FBs ingested by children.1,2 Abualenain et al1 found that approximately 74% of swallowed FBs were coins, and 49% of all FB types were managed with upper endoscopy. Coins in the esophagus must be removed as quickly as possible because they can lead to serious complications if left untreated. Early detection of foreign materials is crucial to avoid catastrophic issues, such as atelectasis, pneumonia, bronchiectasis, suffocation, and mortality.2
Our literature search did not find any studies of the prevalence of FB ingestion among children in the Makkah region. In this study, we explored the prevalence of FB ingestion in pediatric patients at the Otolaryngology Head and Neck (ORL-H&N) department of Al-Noor Specialist Hospital (NSH), the only hospital in Makkah that receives and manages such cases, as well as to enhance the local data for different types of FB ingestion, management, and outcomes and to increase awareness of the hazards of FB ingestion with an exhortation to keep such items out of reach of children. This can be implemented through educational programs on social media, in nurseries, and in schools.
Methods
This was a record-based retrospective review of a prospectively maintained demographic and clinical database of 153 patients with FB ingestion, including all pediatric patients who presented to the emergency department with FB ingestion and were admitted to the ORL-H&N department at NSH, Makkah, between December 2014 and December 2019.
Inclusion criteria of the study included all pediatric patients (neonates to 14 years old) admitted because of an FB impact on the esophagus who underwent chest radiography (CXR). While the exclusion criteria were patients older than 14 years with FB ingestion or impacted FB at other sites (such as the ear, trachea, nose, and bronchial tree) and chemical ingestion were excluded.
This study was approved by the Institutional Review Board of the Ministry of Health in Makkah (registration number: H-02-K-076-0320-282).
Two authors collected data by reviewing the electronic records of the Al-Noor Specialist Hospital database system, including admissions data such as patient demographic characteristics (age, gender, and nationality) and clinical presentation (duration of hospital stay, symptoms, previous history of FB ingestion, and CXR findings). Details of the hospital course, including the need for rigid upper endoscopy, intra-operative upper endoscopy findings, and FB type, were also recorded.
Statistical analysis
The data were analyzed using the Statistical Package for Social Sciences, version 26 (IBM Corp., Armonk, NY, USA). Participant variables were estimated using descriptive statistics, including frequency counts and percentages of categorical variables. To detect relationships between different categorical qualitative variables, a Chi-square (χ2) test was used. Results were considered statistically significant when the significance (p-value) was <0.05. A p-value <0.001 was considered highly statistically significant (HS), and a p-value of 0.05 was considered statistically non-significant (NS).
Results
This study included 155 patients admitted to NSH with FB ingestion. Two patients without FB were also identified. Therefore, a final total of 153 patients were included in this study.
Of the patients presenting with FB, 41.8% were between the ages of 1 and 4 years, and 38.6% were between the ages of 5 and 8 years. Most patients with FB (71.2%) were Saudi Arabian, and more than half (63.4%) were male. The results are presented in Table 1 and Figure 1.
- Patients’ basic characteristics in the studied group.
- Age distribution of the patients in the studied group.
Approximately 94.8% of the patients had no symptoms. None of the patients had a history of FB ingestion. Most patients (96.7%) remained under 24-h observation at the hospital (Table 2).
- linical presentations of the studied group.
Regarding the CXR findings, 96.1% of the FB appeared in the CXR from C1 to T4. Most patients (95.4%) required a rigid upper endoscopy. More than half of the patients (60.1%) experienced no complications. Most cases involved metallic FB (60.8%) in the form of coins (Table 2 & Figure 2).
- Types of foreign bodies ingested in the studied group.
Our results showed a highly statistically significant (p<0.001) relationship between the types of FB and age, as the highest incidence of coin ingestion (44.1%) was observed in the age group of 5-9 years, whereas 81% of the cases of battery ingestion were in patients aged 1-4 years. There was a highly significant (p<0.001) relationship between the type of FB and hospital stay, with 1% of coin FB and 19% of battery FB ingestion cases needing to stay in the hospital for >24 h. There was a statistically significant (p<0.001) relationship between the types of FB and the need for rigid upper endoscopy. Regarding esophagoscopy findings, 71.4% of the cases showed that the ingestion of batteries was associated with complications such as esophageal injury. The other parameters and different foreign body-type relationships are listed in Table 3.
- Relationship between types of foreign body and different parameters.
Discussion
Foreign body ingestion is considered a common health concern and mostly occurs in children between the ages of 6 months and 3 years. However, the majority (80%-90%) of FBs pass through the gastrointestinal tract (GIT) without complications, and only 10%-20% require upper rigid endoscopic removal. Age, body weight, clinical findings, shape, type, and time of FB ingestion are essential parameters for the timing of endoscopic removal.6 In this study, we analyzed the data collected from the ORL-H&N departments of patients who had ingested FB. Most of the 153 children were aged 1-4 (41.8%) years. This is consistent with the findings of Navia-López et al,7 who carried out a cross-sectional study of the prevalence of FB ingestion between 2013 and 2018 in 85 patients with a median age of 4 years. Foreign body ingestion was high in this age group, owing to their exploratory habits. Another study by Al Lawati et al8 showed that 50.9% of patients with FB were below 3 years of age. A slight male predominance (63.4%) was seen in the gender distribution, similar to the finding that 58.4% of children diagnosed with FB ingestion in Oman between 2011 and 2014 were boys.8
Of the various FBs ingested by the children, coins were the most common in this study (60.8%). The same finding was reported by a study carried out at King Abdulaziz University, Jeddah, Saudi Arabia which included 117 pediatric patients who ingested FBs between 2011 and 2020. Coins were the most frequent FBs (48.2%), and most FBs (63.6%) affected the upper esophagus.9 Similarly, a study from the Jazan region showed that 68.5% of FBs ingested were coins. They also found that the incidence of removal of coin FB ingestion markedly increased after coin currency implementation from 16.1% of all cases to 83.9%.10 Moreover, Orsagh-Yentis et al11 reported a significant increase in the incidence of FB ingestion to 91.5% per 10000 children in the United States between 1995 and 2015.
Button batteries are frequently used in electronic devices; therefore, the incidence of their accidental ingestion has increased.5 Because button batteries are of the same size and shape as coins and the 2 types of FB are frequently difficult to distinguish, x-ray screening is required to prevent delays in diagnosis.12 However, it is difficult to identify the magnetitic FB single or multiple only by radiological methods such as x-ray and computed tomography (CT) scans.4 Moreover, battery size is a deciding factor in complications. Lee et al12 reported that children who ingested batteries <15 mm in size were asymptomatic and passed them without complications, whereas those who ingested >15 mm batteries showed moderate to severe complications.
Gatto et al13 reported a significant relationship between the morphology of ingested FBs and presence of symptoms. Approximately 47% of cases with sharp FBs were symptomatic, whereas coins were associated with symptoms in only 20%. However, morphology was not significantly associated with the length of hospital stay or endoscopic removal. In a study by Speidel et al,14 38.1% of patients who ingested batteries needed a 24-hour hospital stay. Similarly, the current study observed a statistically significant relationship between the types of FB and length of the hospital stay.
Recent guidelines recommend performing 2-projection radiography (lateral and anteroposterior) in all patients who ingest FBs, including asymptomatic cases.13,15 However, some sharp objects are radiolucent, which reduces the positive predictive value of radiographic findings.13 In the current study, 2-projection radiography was performed in all patients. Most FB were visualized at the C1–C6 (53.6%) and C7–T4 (42.5%) sites. Coins are commonly located at C1–C6, thereby confirming a highly statistically significant relationship between FB type and CXR characteristic findings, as the sensitivity to detecting coins in x-rays was 100%, which is consistent with the findings of other studies.9,16 In other studies, the FB was not visualized by x-ray in 43% of cases, and this was related to the different characteristics of the FB.13
The need for intervention depends on the characteristics of the ingested FB, time of impaction to decrease complications, and location. According to the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines for endoscopic intervention in FB cases, ingested batteries should be removed within 2 h even if the patient is asymptomatic. The same time frame applies to the other types of FBs in children with excessive and unmanageable oral secretions. Asymptomatic children may be observed for up to 24 h. However, esophageal impaction of long FBs should be removed within 24 h, regardless of the presence or absence of symptoms.5
In this study, examination findings of rigid upper endoscopy showed a highly statistically significant relationship between complications and the type of FB. Intra-operative esophagoscopy findings reported that 71.4% of battery ingestion cases were associated with different grades of esophageal injury (such as erythema, edema, abrasion, and ulceration) as complications, whereas a low incidence of complications was observed with the ingestion of coins. This may be due to differences in the type, size, and location of FB; variable time until hospital admission (as many parents try to manage at home first and others require time to reach the hospital); median time between consultation and extraction; clinical presentation; and presence of other morbidities, as discussed in the literature.7,9 Others have reported esophageal perforation as a complication from sharp FB ingestion in one patient (among 76) who underwent upper endoscopy.7 Practical and rapid management strategies are advised to reduce the possibility of complications.4
Study limitations
The current study contributes retrospective epidemiological data on the characteristics of pediatric patients admitted with FB ingestion and provides information regarding the location and type of FB. In addition, diagnostic and therapeutic endoscopy plays an important role in the emergency management of FB ingestion. However, as our results depended on retrospective data, one of the limitations of this study is that some key statistics could not be obtained, significant biases might have affected the selection of participants, and the researchers could not control for exposure or outcome assessment. Another limitation is that as the sample was convenience-selected, the results cannot be generalized.
In conclusion, this study showed that FB ingestion is a common problem in children, especially in those under 4 years of age and male. Most cases were asymptomatic, and clinical presentations varied depending on the type of FB, patient age, and duration of hospital referral. Urgent endoscopy performed within 24 h of exposure can reduce the incidence of complications and unnecessary stress, highlighting the importance of prompt medical attention. Caregivers should be educated on the different circumstances of FB ingestion and the urgency of seeking medical attention. By doing so, patient outcomes can be improved and resource utilization can be optimized.
Acknowledgment
The authors express their deep appreciation to their supervisor and adviser Dr. Tariq Alaydaroos. We would also like to thank Editage (www.editage.com) for the English language editing.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received February 5, 2023.
- Accepted May 11, 2023.
- Copyright: © Saudi Medical Journal
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