See also

Foreign bodies inhaled
Acute upper airway obstruction
Poisoning - acute guidelines for initial management
High risk - low dose paediatric ingestions

Key Points  

1. The majority of ingested foreign bodies (FBs) are low risk objects and can be managed without imaging or intervention
2. High-risk foreign bodies can be associated with significant harm and even death, and require discussion with senior clinician or specialist
3. Oesophageal button batteries require removal within two hours to avoid serious complications including death
4. Large sized objects, magnets and objects impacted in the oropharynx require surgical review
5. Ingested objects may be toxic. Consider consulting Poisons Information Centre, phone 13 11 26

Background

• Children of all ages may ingest a FB, however the highest incidence is between the ages of 6 months and 3 years
• Children with developmental concerns, behavioural problems or Pica (eating of non-nutritive substances such as paper, wood and soil) are at increased risk of ingesting a FB
• Older children with underlying psychiatric problems may intentionally ingest FBs and require a mental health review
• Gastrointestinal tract obstruction or impaction by a FB depends on the physical properties of the object, including its size, shape and composition
• It is rare for sharp objects to penetrate the mucosal wall of the lower GI tract, and these may not require intervention if the child is otherwise well

Assessment

History

• Clarify type of object and timing of ingestion
• GIT symptoms: Coughing, drooling, pain on swallowing, reduced oral intake, abdominal pain or vomiting, melaena or GI bleeding
• Respiratory symptoms: coughing, choking, respiratory distress, consider inhalation. See Foreign bodies inhaled

Red Flags

High-risk FBs include:

• Button batteries lodged in the oesophagus
• Magnet + a metal object or >1 magnet
• Sharp objects in the oesophagus eg fish bone, pins or needles
• Lead based objects that fail to transit through the stomach
• Large objects (>6 cm long and/or >2 cm wide)
• Expandable foreign bodies eg superabsorbent polymers (water beads)
• Multi-component objects eg toys with lights, motors and batteries
• Objects impacted in the oropharynx require urgent ENT evaluation 

Children with higher risk of impaction/obstruction include those with:

• pre-existing gastrointestinal tract abnormalities (eg strictures) or congenital malformations (repaired or unrepaired)
• eosinophilic oesophagitis 
• neuromuscular disease

Examination

• Signs of airway compromise, see Acute upper airway obstruction
• Inspection of the oropharynx for excessive drooling, abrasions, ulcers or lacerations
• Respiratory distress, see Foreign bodies inhaled
• Tender abdomen on palpation, signs of peritonitis or obstruction

Management

Investigations

Imaging is required in

• suspected or known button battery ingestion
• magnet/s or other high-risk radio-opaque object
• unknown object
• high risk or unwell child

In smaller children

• a single X-ray to include neck, chest and abdomen

Imaging may not be required for children who meet ALL of the following criteria

• asymptomatic
• normal clinical examination
• no known gastrointestinal abnormalities
• reassuring period of observation
• able to eat and drink
• history of ingesting an object that is ALL of the following
• less than 2 cm diameter and less than 6 cm in length
• not a magnet or battery
• non-expandable
• non-toxic

Treatment

Critically unwell children or certain high risk FBs (button battery, magnets, sharp or lead containing objects) require time critical care

The appropriate specialist team for referral varies depending on local service and may include ENT, General Surgery or Gastroentrology services. Referral will be guided by type of ingested object and anatomical site and should be discussed with senior clinician

Button batteries

Management is directed by the location of the ingested battery

*Administer honey to children >1 year with an oesophageal button battery within 12 hours of ingestion whilst awaiting theatre. Dose 10 mL every 10 minutes up to 6 doses

Magnets
One magnet seen on X-ray may still be high risk, as two may have been swallowed which give the appearance of one

Expandable Foreign bodies - superabsorbent polymers

• May pass easily through proximal gastrointestinal tract and pylorus, then expand large enough to cause bowel obstruction
• Early discussion with Poisons Information Centre who can advise on growth potential of object and need for endoscopic removal by gastroenterology

 
Objects impacted in the oropharynx

• Require urgent ENT evaluation
• Fish bones may lodge in tonsils and require removal

Oesophageal Food Bolus

• Children with food bolus that does not spontaneously resolve should be discussed with a paediatric gastroenterology team
• Acutely symptomatic children (drooling, neck or chest pain) require urgent endoscopy
• Children able to manage their secretions should be discussed early with paediatric gastroenterology service regarding planning for endoscopic retrieval within 12-24 hours
• Carbonated drinks are low cost, safe and may be effective in mobilising food bolus, however can result in vomiting
• The use of glucagon and hyoscine butylbromide lacks evidence and is not recommended in children
• Children with a history of food bolus obstruction that has spontaneously cleared should be discussed with paediatric gastroenterology outpatient service for further investigation

Coins and blunt objects

• Acutely symptomatic children (drooling, neck or chest pain) require urgent endoscopy
• Asymptomatic children with an oesophageal object require endoscopic removal within 24 hours
• Larger objects >6 cm long require gastroenterology or surgical opinion due to increased risk of obstruction
• An object with a diameter >2 cm (Australian 20c, 50c and $1 coin) is unlikely to pass through the pylorus of younger children

Consider consultation with relevant specialty team when

• Child is symptomatic
• Immediate FB removal needs to be facilitated
• The FB is lodged in the oesophagus
• Concern that the FB is toxic
• Child has significant past medical history and/or behavioural issues leading to ingestion

Consider transfer when

Child requiring care (including surgical services) above the level of comfort for the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Child meets following criteria:

• Looks well
• Is pain free
• Has no respiratory distress
• Is able to eat and drink
• Has a reliable history and a low risk FB has been ingested

Discharge advice should be given, and the child/parents should be instructed to seek medical advice or return to ED if any of the following symptoms occur:

• breathing problems
• abdominal pain
• fever
• vomiting
• unable to tolerate food and drink
• melaena or haematemesis

Parent information

Swallowed (ingested) foreign bodies

Last updated February 2024