Foreign Bodies

Children often swallow things. The management pretty much depends on what they have swallowed, and whether they have symptoms or not. If the child is coughing, consider that they may have inhaled the foreign body instead - the inhaled FB can act as a ball-valve and air can enter but not leave.

The Object
Button batteries, objects >5mm and sharp, and razor blades are considered dangerous. Button batteries are toxic, and have a slow but deep action, and can also cause direct pressure necrosis. Their effects may be seen after they have been removed. Open safety pins might be dangerous - sharp objects have a 15 - 35% risk of perforation.

Imaging
1. X-ray if likely to be radio-opaque or "dangerous".  Request a neck and chest x-ray- an abdomen is not needed, and irradiates the gonads un-necessarily.
Look at the x-ray carefully- common points that get stuck are:
- C6 is cricopharyngeal sling and upper oesophageal sphincter
- 15% get stuck in the midoesophagus where the aortic arch and carina push on the oesophagus.
- 15% get stuck in the lower oesophageal sphincter / oesophagogastric junction
Check carefully it is a coin and not a button battery. If you are not sure if the coin is in the oesophagus or not, do a lateral film. If the coin is in the oesophagus, it appears coronal. Tracheal objects appear in a sagittal orientation.

2. Dangerous Object - refer to surgeons where ever the object is. There is some debate about button batteries if they are below the diaphragm. Above the diaphragm - in the oesophagus, nose or throat, they need to come out ASAP.

3. Above diaphragm, symptomatic, - refer to the surgeons. Most (75%) objects impact in the upper oesophagus.
b. Mild or no symptoms - home, repeat x-ray 24 hours.

4. Below diaphragm
Reassure, return if symptoms develop

5. Asymptomatic, not seen - reassure and return if symptoms develop.
b. Symptomatic - refer to surgeons

There is no need to search the poo. It might take six weeks for the foreign body to come out.

Metal Detector
The metal detector can help prove whether a FB is above the diaphragm or not. They can confirm whether the coin has reached the stomach.

(flowchart from the amazing and well worth buying http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X

References

http://dontforgetthebubbles.com/the-magic-coin/
http://dontforgetthebubbles.com/podcast-week-button-batteries/
http://lifeinthefastlane.com/ccc/inhaled-foreign-body/
http://lifeinthefastlane.com/top-ten-foreign-bodies/
http://wikem.org/wiki/Esophageal_foreign_body
http://www.annemergmed.com/article/S0196-0644(84)80573-9/abstract
http://lifeinthefastlane.com/paediatric-quiz-017/
http://emedicine.medscape.com/article/801821-treatment
http://www.ncbi.nlm.nih.gov/pubmed/15913481
http://learnpediatrics.com/body-systems/gastrointestinal/suspected-foreign-body-ingestion/
http://www.sciencedirect.com/science/article/pii/S0165587612006519
http://blog.clinicalmonster.com/2015/03/foreign-body-ingestions-in-children-by-abi-iyanone/
http://pediatriceducation.org/2005/03/28/
http://www.sinaiem.org/pearls/2015/05/26/fool-me-once/
http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X
http://www.amazon.co.uk/books/dp/0199589569