Foreign body ingestion in children : Single institutional experience in Sri Lanka

Introduction: Foreign body (FB) ingestion in children is a common problem worldwide. Peak incidence is between the ages of 6 months to 4 years and children usually pass the object spontaneously without any symptoms. Objective: To assess the pattern of FB ingestion in the Sri Lankan context. Method: A descriptive cross sectional study was conducted from April to September 2010 at a leading tertiary care hospital. Data was collected by interviewer administered questionnaire and reviewing Bed Head Tickets. Results: Peak incidence of FB ingestion occurred between one to four years of age (50.4%) with a slight male predominance (56.6%). None of the children were mentally challenged. Five of the children who presented with a history of ingestion had aspirated the FB and all of them required bronchoscopy to remove the object, one child also requiring intensive care unit admission. All the aspirated objects were food particles. Button battery (24.5%) and coins (17.0%) were the commonly ingested foreign bodies. Common source of button battery was the toys with which they were playing. More than half presented to the hospital asymptomatically. One third of children notified their parents about the ingestion. Expectant management was offered to 66% of the children and all of them recovered uneventfully without any intervention. Upper gastrointestinal endoscopy was used in 12 (22.6%) children to remove the FB. Conclusions: Commonest source of FB was button batteries from toys. Most children ingested the FB despite mother’s care. Although most FB ingestion could be managed expectantly, offering appropriate intervention at the correct time prevents complications. Patient presenting with a history of FB ingestion may have aspirated the FB. As _______________________________________ Research Assistant, Senior Lecturer, Department of Surgery, Faculty of Medicine, University of Colombo, Medical Officer, Base Hospital, Tangalle (Received on 28 August 2013: Accepted after revision on 27 September 2013) aspirated FBs are associated with significant complications, a high degree of suspicion is needed to differentiate ingestion from aspiration. (


Introduction
Foreign body (FB) ingestion among children is a common problem worldwide and a leading cause of emergency room visits.Peak incidence of FB ingestion is between the ages of six months and four to six years [1][2][3] .Unlike adults, FB ingestions mostly occur accidentally in children 4 who often swallow objects readily available to them such as coins, toy parts and batteries [3][4][5] .Studies showed that most of the time, swallowed particles will pass spontaneously without any intervention [6][7] .

Objectives
• To identify the pattern of FB ingestion among children in the Sri Lankan context.
• To describe the management pattern of FB ingestion.

Method
This is a descriptive cross sectional study conducted between April 2010 and September 2010 at a leading tertiary care children's hospital in Sri Lanka.Ethical clearance was obtained from the hospital ethical review committee.Patients who presented with a history of FB ingestion to the emergency department were recruited to this study after obtaining informed proxy consent.Data was collected by the investigator using an interviewer administered questionnaire.In addition, Bed Head Tickets (BHTs) and other patient health records were reviewed.Data was analysed with SPSS 19 statistical software.

Results
Fifty three children aged between 9 months to 11 years (mean

Discussion
FB ingestion is a commonly encountered problem among the paediatric population.Our study concludes that the peak incidence of accidental foreign body ingestion occurs between one to four years of age with a slight male predominance.Button batteries and coins were the commonly ingested foreign bodies by our children.More than half of them presented to hospital without any symptom.One third of the children informed their parents about the ingestion prior to developing any symptoms.Expectant management was offered to two thirds of the children and they recovered uneventfully.Rest of the children underwent some form of intervention while none required any surgical procedure.Five children with a history of FB ingestion had aspirated the FB and one of them needed ICU care.
Peak age for paediatric FB ingestion is reported to be between 6 months and 4 to 6 years of age [1][2][3] .Our children also adhered to that age group.Slight male predominance was noted in our study and similar pattern is described in the literature 3,8 .Literature review shows that 98% of paediatric FB ingestions are accidental 4 and all of our cases were accidental.
Coin is the commonest object ingested by children where fish does not represent a large proportion of the diet and fish bone becomes the number one object in countries where fish represent a large proportion of diet 9 .Cheng W et al from China reported that coin and fish bone were the most common particles ingested by children 1 .Button battery was the commonest object swallowed by our children followed by coins.Two cases of fish bone ingestion were reported in our study.
Management of FB ingestion depends on various factors such as nature of the FB, time since ingestion and site of FB in the gastrointestinal 3,10 .A retrospective review by Arana A et al found that 50% of the children with confirmed FB ingestion were found to be asymptomatic 11 .Expectant management with the stool inspection for suspected foreign body and serial radiography would be adequate most of the time 1,2-5.9 .Kay M et al states that 80-90% of FB ingested will usually pass spontaneously without any intervention while only 10-20% will require endoscopic removal 12 .
Only less than 1% needs surgical intervention 12 .Most of our patients were also managed expectantly while only one third of the patients needed some form of intervention.None of our children required surgical intervention.
Louie et al states that FB aspiration is less common than ingestion 13 .He also says that food particles are the most common objects identified following aspiration and that the pattern of food types varies regionally 13 .Peanuts were the commonly described food particles aspirated by children 13 .Midulla F et al also found most of the aspirated FBs were food particles 14 .Five of our children who presented to the emergency department with a history of foreign body ingestion had really aspirated the objects, mostly food particles.Suspicion of aspiration should be considered even if the patient comes with a history of FB ingestion.

Conclusions
• Major source of button batteries was toys with which children were playing.• Most children ingested the FB despite mother's care.• Though most FB ingestions could be managed expectantly, offering appropriate intervention at the correct time prevents complications.• Patients presenting with a history of FB ingestion could have aspirated the FB.A high index of suspicion is needed.

Table 1 Age groups of patients presenting with a history of FB ingestion Age group No. of children (%)
Main source for the button batteries was from toys.Majority of the FBs ingested were nonsharp (77.4%) in nature, while 18.9% contained a pointed edge.Most of the time, child was playing (69.8%) at home while swallowing the FB.
3.88 years, SD 2.72 years) presented with a history of FB ingestion.Peak incidence was noted between one to four years of age (50.4%).