REVIEW

CURRENT
OPINION Foreign body ingestion in pediatric patients
Yoseph Gurevich, Benjamin Sahn, and Toba Weinstein

Purpose of review
The purpose of this article is to review clinical manifestations and management of common pediatric
foreign body ingestions, with a particular focus on some of the current trends.
Recent findings
Foreign body ingestion (FBI) is a problem that is frequently encountered by pediatric providers. As new
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toys and products enter the marketplace, there may also be new dangers from those objects not initially
recognized. Some of the recent trends and findings in pediatric FBI include an increase in adolescent injury
from ingestion of laundry detergent pods because of a popular game where participants are encouraged
to bite or swallow the pods, and injuries associated with ingesting parts of a popular toy known as a
‘Fidget Spinner’.
Summary
Adverse events resulting from FBI range the entire gamut from nonexistent or minor symptoms to moderate
injury and rarely may be fatal. Factors such as age, type of object ingested, anatomic location of the
foreign body, and timing from ingestion to receipt of medical attention all determine the risk posed to the
child and guide management decisions. Because of the constant development of products, and the
potential for the emergence of new and dangerous trends among children, continued surveillance by the
medical community is important in monitoring and managing injuries associated with FBI.
Keywords
advocacy, button battery, fidget spinner, foreign body ingestion, laundry detergent pods

INTRODUCTION CLINICAL MANIFESTATIONS

Foreign body ingestions in pediatric patients can
present challenging clinical scenarios. In the
United States, children 5 years of age and younger
account for close to 70 000 foreign body ingestions
annually [1]. The spectrum of FBI is quite hetero-
geneous; children commonly ingest coins, small
toys, and various other objects that may be sharp or
blunt and vary in size. It is thought that 80– 90% of
FBI will pass without intervention, 10 –20% will
require endoscopic removal, and 1% will require
&&
surgical intervention [2 ,3]. Unique circumstan-
ces surround particular ingestion types such as
batteries (cylindrical and disc), magnets, and
enclosed chemical packages such as detergent
pods. Unwitnessed and radiolucent object inges-
tions can create uncertainty surrounding the
nature of ingestion and may lead to significant
delay in diagnosis and management. For example,
radiolucent objects may require contrast studies or
&&
cross sectional imaging to be appreciated [2 ,4 ].
The present review will highlight current trends
in FBI and focus on some of the more common
FBIs seen in pediatric patients and their inherent
risks.
Unless witnessed, parents and caregivers may be
unaware of a foreign body ingestion as many chil-
dren are asymptomatic, or may present with non-
specific findings such as irritability and feeding
issues. Some parents may only first become aware
of an ingestion after the foreign body is passed in the
stool. When symptoms occur, they often relate to
the anatomic location of the object or injury. For-
eign bodies in the esophagus may result in a variety
of symptoms including dysphagia, drooling, chok-
ing, and/or chest pain and may be associated with
feeding refusal. Children may also exhibit wheezing,
Division of Pediatric Gastroenterology & Nutrition, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell Steven and Alexandra
Cohen Children’s Medical Center of NY Northwell Health 1991 Marcus
Avenue, Suite M100 Lake Success, New York, USA
Correspondence to Yoseph Gurevich, Division of Pediatric Gastroenter-
ology & Nutrition, Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell Steven and Alexandra Cohen Children’s Medical
&
Center of NY Northwell Health 1991 Marcus Avenue, Suite M100 Lake
Success, NY 11042, USA. Tel: +1 516 472 3669/þ1 516 472 3650;
fax: +1 516 472 3654; e-mail: ygurevich@northwell.edu
Curr Opin Pediatr 2018, 30:677–682
DOI:10.1097/MOP.0000000000000670

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Office pediatrics
KEY POINTS
 Foreign body ingestion is a commonly seen problem
in pediatrics.
 New products are constantly entering the market,
making it impossible to fully predict the risk of each
product when it is released.
 Button batteries, neodymium magnets (a common type
of rare earth magnet), and detergent pod ingestion
may cause injury and lead to serious complications.
 The role of advocacy is important when potential
dangers are identified in new products.
cough, or other symptoms of respiratory distress [5],
often when the object is in the proximal or mid-
esophagus and closer to the airway. Objects in
the stomach or intestines are less likely to cause
symptoms in the absence of obstruction or mucosal
injury. However, common symptoms, when pres-
ent, include abdominal pain, vomiting, and
hematemesis.
COMMON TYPES OF INGESTIONS
Coins/blunt objects
Coins are the most commonly ingested foreign body
in pediatric patients, accounting for greater than
85% of pediatric esophageal foreign bodies over a
16-year period at an academic Children’s hospital in
Kansas City, MI, USA [5]. The initial evaluation of a
suspected FBI includes obtaining the appropriate
radiographic study of the neck, chest, and abdomen,
including lateral views, to correctly localize the
FIGURE 1. Chest X-ray of a 23-month old who swallowed a button battery. Note the double rim/halo which is characteristic
of a button battery.
678 www.co-pediatrics.com
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object. In the case of suspected coin ingestions, it
is imperative to clearly distinguish a coin from a
button battery, as button batteries (detailed below)
necessitate emergent removal and are distinguished
by the radiographic ‘halo’ double rim sign (see
Fig. 1).
Management of swallowed coins is largely influ-
enced by anatomic location. Esophageal coins in a
symptomatic patient should be urgently removed.
In an asymptomatic patient, the coin should be
removed within 24 h of ingestion because of
increased risk of esophageal injury beyond that
timeframe. In a retrospective study of over 100
pediatric patients, Soprano et al. found that a soli-
tary coin in the esophagus would spontaneously
pass into the stomach in approximately 30% of cases
regardless of esophageal location [6]. Coins larger
than 2.3 cm have increased risk of esophageal reten-
tion [7]. Of note, an American quarter has a diameter
of approximately 2.4 cm. A coin in the stomach of
an asymptomatic patient can be managed conserva-
tively, with anticipatory guidance given to care-
givers to check all stools for coin passage. A
radiograph should be obtained 2 weeks after inges-
tion if passage is not observed, and if the coin is
retained in the stomach 4 weeks from the ingestion,
plan for endoscopic removal should be initiated
&&
[2 ,8].
Children may swallow other blunt objects of
various shapes and sizes. Generally, objects with a
diameter more than 2.5 cm are less likely to pass
through the gastric pylorus and objects longer
than 6 cm are unlikely to traverse the duodenum
C-loop [9]. When feasible, attempts should be
made to remove these larger objects upon presen-
tation to prevent potential obstruction. Nonob-
structing smaller blunt objects typically pass the
Volume 30  Number 5  October 2018

gastrointestinal tract uneventfully without causing
significant damage to the mucosa.
Sharp objects
Sharp objects, such as toothpicks, nails, pins, and
fish bones, pose variable risk of mucosal injury.
Adverse events may include perforation, abscess,
peritonitis, and even death [10]. Radiolucent sharp
objects can be particularly challenging to manage
without the ability to track the object location using
serial X-rays. Computed tomography (CT) scan,
magnetic resonance imaging (MRI), ultrasound, or
esophagram may be considered upon initial presen-
tation in cases when there is uncertainty regarding
the ingestion of a high-risk radiolucent object [11].
Similar to blunt objects, management of sharp
objects is influenced by size and location. Sharp
objects in the esophagus, regardless of symptoms,
should be urgently removed. A sharp object in the
stomach or duodenum of an asymptomatic child
should be removed if there is increased risk for
perforation based on several factors. A long or angu-
lated sharp object may not be able to pass the
duodenal C-loop or ileocecal valve—sites at higher
risk of perforation [12]—and feasible attempts for
removal should be made. Objects with two sharp
ends, such as a toothpick or an angulated sharp end
such as an open safety pin or fish bone, are more
likely to cause injury and should be removed when-
ever possible. Conversely, most sharp straight
objects with a blunt heavier end such as an earring,
thumb tack, or screw, if less than 6 cm long and
2.5 cm in diameter, will usually traverse the gastro-
intestinal tract without causing significant injury, as
the sharp end will often trail the blunt end. There-
fore, if size is not an issue, these objects do not
require endoscopic removal as the trailing sharp
ends tend not to perforate [13]. In cases where
one is unable to endoscopically remove a higher
risk sharp object, hospital admission for observation
should be strongly considered as these patients may
require surgical intervention.
Magnets
Although many small blunt foreign bodies pose low
risk of injury once reaching the stomach, ingestion
of more than one magnet, particularly rare earth
magnets, can be devastating. As early as 2002,
increased numbers of magnet ingestions were
reported in a single center review, including a
9-year-old female who required surgical laparotomy
to heal five intestinal perforations [14]. Rare earth
magnets, typically composed of iron, boron, and
neodymium, are often used in magnetic toys and
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Foreign body ingestion in pediatric patients Gurevich et al.
are particularly dangerous, as they are up to 10 times
more powerful than traditional magnets. The attrac-
tion between magnets can cause entrapment of the
bowel wall and lead to bowel perforation [15], which
is even more concerning if mesenteric vessels are
trapped because of risk for intraperitoneal hemor-
rhage. Although patients may present with nonspe-
cific symptoms such as abdominal pain and
vomiting, because of the serious complications that
can arise when multiple magnets are ingested, these
patients should be urgently referred to an emer-
gency room for further evaluation and attempted
magnet removal even if asymptomatic.
Both a frontal and lateral radiograph should be
obtained to determine if a single or multiple mag-
nets have been ingested. If a single magnet is
ingested, patients should be instructed not to wear
magnets or metallic objects until the magnet passes.
If multiple magnets are present and within reach of
an endoscope, they should be removed urgently.
Surgical consultation is required if the ingestion was
more than 12 hours prior to time of endoscopy. If
the magnets are not amenable to removal or endo-
scopic removal was unsuccessful, the child should
be closely monitored with serial X-rays to track
progression of the magnets [16].
Button battery ingestion
An ingested button (disc) battery is particularly
dangerous, with esophageal retention representing
a true emergency requiring battery removal without
delay. A radiograph should be immediately obtained
if there is any concern over a button battery inges-
tion. Accidental ingestion in a young child often
occurs after a battery is dislodged from a household
product, game or hearing device [17]. When lodged
in the esophagus, button batteries may cause signif-
icant caustic injury secondary to release of hydrox-
ide radicals and pressure necrosis. Full thickness
injury has been reported in animal models in as
little as 15 min [18]. Button battery ingestion can
result in tracheoesophageal fistulas, esophageal per-
forations and strictures, vocal cord paralysis, and
aortoenteric fistulas [8,19]. Morbidity from button
battery ingestion in the United States has increased
over the last few decades, thought in large part to be
secondary to increased use of larger diameter and
lithium-based button batteries [17].
Therefore, emergent endoscopy must be per-
formed in any child who has an esophageal button
battery to remove the battery and assess for mucosal
injury. Any evidence of significant esophageal
injury necessitates hospital admission and treat-
ment with intravenous antibiotics and further
radiographic imaging. Endoscopic intervention in
www.co-pediatrics.com 679
Office pediatrics
children with a button battery in the stomach or
beyond is dependent on the child’s age, size of the
battery, presence of symptoms, and time since
ingestion. A battery 20 mm or larger in size, age less
than 5 years, presence of symptoms, and longer time
interval since ingestion increase risk of morbidity
and hence need for endoscopic intervention. A
recent clinical report from the North American
Society of Pediatric Gastroenterology, Hepatology,
and Nutrition (NASPGHAN) Endoscopy Committee
stress consideration of endoscopy within 24–48 h
after ingestion to assess for esophageal injury and
removal of the button battery in these young chil-
dren. In older asymptomatic children with gastric
button batteries under 20 mm in size, one can con-
sider outpatient observation with repeat radiograph
within 48 h [8].
Because of the significant dangers posed by but-
ton battery ingestion, there continues to be a strong
focus on prevention, and efforts to produce a safer
battery. In addition, much work has been done in
trying to find therapeutic approaches to decrease the
rapid tissue damage that ensues quickly after inges-
tion. Recognizing that the primary mechanism of
injury from a button battery is caustic from alkaline
pH rather than electrical, Jatana et al. [20] investi-
gated whether irrigation of piglet esophageal tissue
with an acidic solution, such as acetic acid, would
help minimize esophageal damage. The authors
found that irrigation with 0.25% acetic acid after
button battery removal helped decrease the tissue
pH from 12 to 6. In addition, they reported that
various acidic drinks, including orange juice, also
helped neutralize the pH and reduce visible injury
[20]. Other weakly acidic viscous solutions such as
honey and sucralfate have also been investigated
with promising results. Anfang et al. [21] found that
both these substances demonstrated protective
effects in cadaveric porcine models and reduced
the severity of injury. Based on these findings, the
authors suggest a benefit to administering honey or
sucralfate orally immediately after ingestion to help
minimize esophageal damage prior to emergent
endoscopic battery removal. This has potential to
be a useful adjunctive therapy in the home or transit
setting prior to endoscopic removal. However, there
are several details about this intervention that require
additional study, such as safety of giving anything by
mouth if esophageal perforation could potentially
occur, and balancing the risk of tracheal aspiration
with an object impacted in the esophagus. Also worth
noting is that honey is not appropriate for children
under age 1 year for concern of botulism.
Research to design safer button batteries is
ongoing. Laulicht et al. [22] recently described a
pressure sensing button battery coating that is
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nonconductive in the low pressure gastrointestinal
tract, but conducts in standard devices with higher
pressure. Rossi et al. described a safer button battery
called the green cell battery, which did not cause the
same degree of injury, both macroscopically and
histologically, in fresh swine esophagi as conven-
tional lithium and silver button batteries cause. The
battery is made of aluminum and carbon, has a low
capacity and is small in size [23].
Fidget spinner
One toy that has become increasingly popular is the
fidget spinner. A seemingly harmless toy with three
arms that spin around a central base, it is sold at
many venues, often without product warning labels.
Some have light sources powered by button batter-
ies. Esophageal and gastric injury from ingestion of
parts of a fidget spinner have been reported in young
children, including significant esophageal injury
following button battery ingestion from a lighted
fidget spinner [24–26]. Because of injuries related to
use of this new gadget, the Consumer Product Safety
Commission (CPSC) has issued formal public safety
tips recommending that these items not be given to
children less than 3 years of age [27].
Laundry detergent pods
Laundry detergent pods are small concentrated
packets of detergent that often contain alkaline
solution. If a pod package becomes impacted within
the esophagus, the detergent is concentrated to a
focal site of tissue and can cause severe caustic injury
by liquefaction necrosis. Detergent pod ingestion
was initially identified as a danger in younger chil-
dren who were attracted to the colorful pods, mis-
taking them for candy. Recognizing this trend, the
US CPSC issued a warning in 2013 explaining the
risk of these pods and encouraged parents to keep
them out of reach of children [28]. More recently, a
new but substantial concern has been intentional
ingestion of these pods among teenagers engaging
in a dangerous game of biting or swallowing the
pod, called the ‘Tide Pod Challenge’. The American
Association of Poison Control Centers (AAPCC)
issued a statement in January 2018 noting that there
were 86 intentional ingestions of single load laundry
packets in the first 3 weeks of 2018 [29]. Lack of oral
lesions does not negate the possibility of esophageal
injury, and if patients develop symptoms such as
vomiting, drooling, or feeding refusal, an upper
endoscopy would be reasonable for further evalua-
tion [30]. At the time of this publication, it is unclear
whether this concerning trend of intentional inges-
tion will continue or subside.
Volume 30  Number 5  October 2018
 Foreign body ingestion in pediatric patients Gurevich et al.

Table 1. Key points for commonly ingested foreign bodies

Object Key points

Coin/blunt object Coins are the most commonly ingested foreign body in pediatrics
Radiographic imaging should be obtained
An esophageal coin should be removed within 24 h of ingestion
Objects wider than 2.5 cm or longer than 6 cm are at higher risk of retention
Button battery Objects and toys including fidget spinners may contain button batteries
Radiographic imaging should be obtained
An esophageal button battery should be removed emergently
Batteries larger than 20 mm are at higher risk of retention
Morbidity from button battery ingestion in the United States has increased
Magnet Objects and toys may contain magnets
Radiographic imaging should be obtained
Multiple magnet ingestion requires removal when feasible
Morbidity increases with multiple magnet ingestion
Sharp object Radiographic imaging should be obtained which may include CT, MRI, or sonogram if radiolucent
An esophageal sharp object requires immediate removal
Gastric sharp objects may require endoscopic removal
Objects wider than 2.5 cm or longer than 6 cm are at higher risk of retention
Detergent pod Concentrated detergent packets
Endoscopy should be performed within 48 h of ingestion to assess for esophageal injury
Abnormal esophageal findings can occur in asymptomatic individuals

Consequences of caustic ingestion include stric-
ture formation and esophageal leak or perforation.
With liquid caustic ingestions, damage can be
extensive and necessitate esophagectomy in rare
circumstances. Stricture formation can occur sev-
eral weeks following ingestion and one should con-
sider a contrast study in a patient who develops
dysphagia [31].
Future directions: advocacy and possible
new dangers
A recurring theme in the arena of pediatric FBI is
that new toys and products are constantly entering
the marketplace and each new object may have
unrecognized risks. Surveillance in the medical
community is essential in order to keep track of
possible dangers associated with these objects, and
providers must be proactive in reporting injuries to
organizations such as the federal CPSC in order to
compile data [32]. Approximately a decade ago, it
was recognized that powerful rare earth magnets
sold as adult desk toys were frequently ingested by
children leading to significant injury. As a result,
members of NASPGHAN partnered with the CPSC to
advocate for removal of these magnets. Reeves et al.
[33] noted a steady decrease in ER visits related to
magnet ingestion following the recall of these
products in 2012, which was thought to be the result
of the actions of the CPSC and advocacy efforts by
pediatric organizations.
Undoubtedly, primary prevention is the most
effective way to prevent injuries from FBI. The
importance of removing potentially dangerous
items from the reach of toddlers and the need for
appropriate supervision cannot be overly stressed.
As button battery ingestion remains one of the most
concerning foreign body ingestions, one should
check and secure all battery components of house-
hold items and never leave these small items in areas
where children will access them [17].
CONCLUSION
As long as children of all ages place objects in their
mouth, foreign body ingestion will continue to be a
problem pediatric providers encounter. Depending
on the nature of ingestion, serious complications,
including death, are possible. When addressing pos-
sible foreign body ingestions in pediatric patients, it
is important to consider numerous factors, includ-
ing type of ingestion, how much time has elapsed
from the ingestion, and clinical state of the patient.
Prompt and proper management is essential because
of the numerous risks associated with some types of
FBI. See Table 1 for a detailed summary of objects.

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Office pediatrics
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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