Art & science | children’s care
Ingestion or aspiration of
foreign bodies by children
Siba Prosad Paul and colleagues explain how
emergency nurses should manage children
with airway compromise or bowel obstruction
Correspondence
siba.paul@nhs.net Abstract
Siba Prosad Paul is a specialty Ingestion and aspiration of foreign bodies are
trainee year 6 in paediatric
gastroenterology at Bristol Royal
common reasons for children presenting to
Hospital for Children emergency departments. A significant proportion
of such events are often unnoticed by the children’s
Manjunath K Sanjeevaiah is
a specialty trainee year 5 in
parents or carers. Emergency nurses should become
paediatrics suspicious of foreign body ingestion or aspiration
if they see symptoms such as stridor, gagging,
Christine Routley is a matron
in paediatrics
wheeze and difference in air entry on auscultation
(Hilliard et al 2003, Paul et al 2010). If they
Meridith Kane is a consultant suspect airway compromise, or bowel problems
paediatrician
such as perforation or obstruction, the children
All at Yeovil District Hospital, concerned should be dealt with immediately.
Somerset Definitive management for foreign body removal
Date of submission
is generally available at tertiary centres and children
August 28 2013 should be transferred to specialist services as
soon as possible after stabilisation (McConnell
Date of acceptance
September 18 2013
2013). Before discharge, their parents should be
educated about possible signs of deterioration and
Peer review advised about home-safety measures (Paul and
This article has been subject
to double-blind review and
Wilkinson 2012).
has been checked using
antiplagiarism software Keywords
Author guidelines
Foreign body, aspiration, ingestion, bowel obstruction
en.rcnpublishing.com
FOREIGN BODY ingestion and aspiration are
common among children and often lead to
attendance at emergency departments (EDs) (Ilardi
2005, Paul and Wilkinson 2012). These episodes
often go unnoticed by parents and carers initially
and tend to happen in busy or disorganised
households, or when the children concerned have
been left unattended (Paul et al 2010).
In a retrospective study, Arana et al (2001)
found that half of the children with confirmed
ingestions studied were found to be asymptomatic,
32 November 2013 | Volume 21 | Number 7
while parents may fail to witness up to 40 per cent
of foreign-body ingestion (Dahshan 2001).
Children who have ingested or aspirated
foreign bodies can present with a variety of signs
and symptoms, including (Hilliard et al 2003,
Aydo du et al 2009, Paul et al 2010, Advanced Life
Support Group (ALSG) 2011, Korlacki et al 2011):
■■ Behavioural disturbances.
■■ Blood in sputum or vomit due to mucosal injury
from foreign body.
■■ Choking.
■■ Coughing.
■■ Difference in chest wall movement or air entry.
■■ Drooling of saliva due to an inability to swallow.
■■ Gagging.
■■ Heart racing.
■■ Pneumonia.
■■ Retching.
■■ Stridor.
■■ Sudden onset of breathing difficulties.
■■ Vomiting.
■■ Wheeze.
Nurses working in EDs must be aware of the
possibility of foreign body ingestion or aspiration
while triaging children. Aspiration can cause
respiratory compromise and, if suspected, should
prompt urgent medical review.
This article describes two case studies from the
authors’ clinical practice that are typical of the type
of scenario encountered by ED nurses. The case
studies, which are shown opposite and on page 34,
describe the initial presentations of children who
have ingested or aspirated foreign bodies and how ED
practitioners should manage them. The second case
also illustrates how well-meaning attempts by parents
or carers to retrieve foreign bodies manually can
compromise the health of the children concerned.
EMERGENCY NURSE
Discussion
Case study 1 Most ingested foreign bodies are
metallic objects, such as coins, keys, screws and
toy parts (Paul and Wilkinson 2012). Their ingestion
can be diagnosed reliably with hand-held metal
detectors, which reduces the need for X-rays
(Tidey et al 1996).
However, if a sharp object, such as a safety pin
or fishing hook, has been ingested or aspirated and
there is a risk that it will perforate the oesophagus
or trachea, a chest X-ray is indicated. Such X-rays are
also indicated if a foreign body is, or is suspected
to be, stuck in the oesophagus, and may be helpful
in children with neuromuscular disabilities who
present with persistent gagging, which can occur
in foreign-body ingestions (Paul et al 2010).
Clinicians working in EDs should be aware
that non-metallic foreign bodies often do not
appear on radiographs and must be alert to
symptoms, such as persistent gagging, new
onset gastro‑oesophageal reflux-type symptoms,
stridor caused by mechanical compression of
the airway or feeding difficulties, that indicate
ingestion or aspiration.
Respiratory symptoms have been reported in
more than two thirds of cases in which foreign
bodies have become lodged in the oesophagus
(Liew et al 2013). The incidence of complications
secondary to ingestion of foreign bodies, such as
oesophageal and tracheal damage, increases with the
duration of foreign-body impaction (Liew et al 2013).
Most ingested foreign bodies pass
spontaneously and uneventfully through the
gastrointestinal tract. Nevertheless, children with
histories of foreign‑body ingestion or aspiration,
and especially those with new-onset respiratory
symptoms, gagging or feeding problems, should
be medically reviewed and observed until their
signs and symptoms have resolved or have been
investigated (Paul et al 2010, Liew et al 2013).
If button batteries have been ingested and
lodged in the gastrointestinal tract, there is a risk
of poisoning after they have become corroded.
Ingested magnets, which can be found in children’s
toys, pose similar problems, and bowel perforation
or mechanical bowel obstruction can occur if many
magnets, or magnets and another metallic foreign
bodies, are opposed to each other in adjacent
areas of bowel (Paul et al 2010, Sarmast et al 2012,
McConnell 2013).
In such cases, rapid triaging and stabilisation are
necessary, followed by transfer to tertiary paediatric
services (McConnell 2013), where endoscopic
removal of the foreign bodies is usually a safe and
uncomplicated procedure (Aydo du et al 2009).
EMERGENCY NURSE November 2013 | Volume 21 | Number 7 33
Case study 1
An 11-year-old boy was brought Figure 1 Chest X-ray showing
into the emergency department (ED) 50 pence coin lodged
by his parents, having accidentally in the lower oesophagus
swallowed a 50p coin while playing
with it. The boy had initially
complained of throat and chest pain,
but this had resolved before his
attendance at the ED. He had been
given toast and a drink at home in an
attempt to push the coin down, but
this caused abdominal pain and so
his family had sought medical help.
Initial observations in the ED
showed the boy had a heart rate
of 110 beats/min, indicating mild
tachycardia, a respiratory rate of
20 breaths/min and a blood pressure paediatric surgeons at a specialist
of 110/68. An urgent medical review tertiary centre. The boy remained under
was requested. The child was fully close observation for seven hours until
conscious, with equal air entry on a repeat chest X-ray had confirmed that
both sides of the chest and normal the coin had passed into his gut, when
heart sounds. he was discharged home.
On abdominal examination, he reported Home safety advice was given to the
a mild tenderness in the epigastric boy’s parents, who were also told that
region and a chest X-ray confirmed he should re-attend urgently if his
the presence of a coin in the lower part abdominal pain recurred, his abdomen
of the oesophagus (Figure 1). became distended or he experienced
bilious vomiting. A telephone review
The boy was admitted to the children’s 48 hours later revealed that the coin
ward and advice was sought from has been passed in his stool.
Case study 2 Food-related aspiration injuries are
common events among young children, particularly
those under four years of age, and may lead to
severe complications. Nuts and seeds are the most
common food items retrieved in such injuries in
children (Hilliard et al 2003). According to data
from the Susy Safe Registry, they are implicated in
38 per cent of injuries involving food-related foreign
bodies and in almost 10 per cent of all ingestion or
aspiration-related injuries (Sih et al 2012).
Children who have aspirated foreign bodies
commonly present, after initial episodes of choking,
with respiratory symptoms such as cough, wheeze
or stridor, and with decreased or abnormal breath
sounds on examination. If these symptoms are
missed or mistaken for those of other illnesses,
diagnoses may be delayed (Hilliard et al 2003).
Aspirated foreign bodies are most often retrieved
from the trachea, bronchi and lungs. Parents and
 Art & science | children’s care

Case study 2
A 15-month-old boy with stridor
and breathing difficulties was
brought to the emergency
department (ED) by ambulance.
The boy’s mother reported that
he had put a handful of peanuts
into his mouth and had begun
to choke. She had attempted to
remove them manually but was
unsuccessful and believed that
she had inadvertently pushed
some of the nuts down his throat.
The child had become flushed and,
after calling an ambulance, his
mother had delivered some back
slaps in an attempt to dislodge the
nuts from the boy’s throat before
the ambulance arrived.
After the ambulance crew
contacted the ED, a medical and
a nursing team were requested
to remain on standby in the
resuscitation room in case the
child stopped breathing and
lost consciousness.
On arrival, the boy had an
inspiratory stridor, a heart rate
of 150 beats/min, a respiratory
rate of 28 breaths/min and
Figure 2 Peanut fragments
detected in the trachea
by bronchoscopy
pulse oximetry showed oxygen
saturations of 99 per cent in air.
On examination, audible stridor at
rest was noted, along with bilateral
wheeze and normal heart sounds.
No evidence of anaphylaxis to
peanuts, such as swelling of
lips or tongue, rash or breathing
difficulties, was detected in this
case. A chest X-ray revealed
upper airway oedema but
no radiographic evidence
of a foreign body.
The child was transferred to the
care of the paediatric ear, nose
and throat surgeons in a specialist
children’s hospital and taken to
theatre urgently. There, peanut
fragments were visualised in the
trachea and right main bronchus
with a rigid bronchoscope
(Figure 2) and were removed
with optical forceps.
After the operation, the boy was
initially administered intravenous
fluids and antibiotics, namely
co-amoxiclav at a dose of
30mg/kg three times daily (British
National Formulary for Children
2013). He was also administered
steroids for 24 hours and then
gradually normalised. His stridor
settled and he was discharged
home with a further three-day
course of oral steroids and a
five‑day course of oral antibiotics,
namely co-amoxiclav 125/31 at
a dose of 5ml three times daily.
Follow up at the local hospital a
week later revealed he had made
a full recovery. Health visitor
follow up was organised to advise
on home-safety issues and
accident prevention.

carers should be advised by healthcare professionals
to resist their natural instinct to insert their fingers
into the child’s mouth and try to retrieve foreign
bodies in case they push the objects further into the
airway (ALSG 2011).
Foreign-body aspiration should be treated as
medical and surgical emergencies, and ED triage
nurses play an important role in identifying
and escalating the care of the children involved
(Dehghani and Ludemann 2008, McConnell 2013).
Paramedic personnel retrieving such children should
try to alert ED staff of their impending arrival
while en route, so the appropriate team to manage
the child is ready to initiate immediate airway
management in a calm and planned manner.
Children in whom foreign-body aspiration is
confirmed or strongly suspected are likely to need
definitive management in the form of procedures
to retrieve foreign bodies from the airway. Effort
should be made to keep children as comfortable
as possible and unnecessary procedures, such as
examinations of the throat or retrieval of foreign
bodies with forceps, should not be undertaken in
the ED. As soon as children are considered safe and
stable, they should be transferred to tertiary ear,
nose and throat or paediatric surgical services for
removal of foreign bodies. Complete obstructions
that require surgical airway procedures to be
undertaken in the ED are rare (ALSG 2011).
It is important that nurses and professionals
update themselves on basic and advanced life
support guidelines (ALSG 2011, Resuscitation
Council UK 2011). An algorithm for the management
of suspected foreign-body aspiration and ingestion
in children, adapted from ALSG (2011) guidelines, is
shown in Figure 3.
Prevention
Emergency nurses can play an important role in
educating parents about keeping children safe at

34 November 2013 | Volume 21 | Number 7 EMERGENCY NURSE

home and preventing further accidental ingestions
or aspirations. Many toys and objects display safety
labels stating they are unsuitable for children below
three years of age, or that adult supervision is
required even for older children (Paul et al 2010).
General guidelines on choking hazards are available
from the Royal Society for the Prevention of
Accidents (2013).
The following safety advice has been devised
from the available literature (Hilliard et al 2003,
Paul et al 2010, ALSG 2011, Sarmast et al 2012,
McConnell 2013) and the authors’ own experiences:
■■ Choose age-appropriate toys, taking special care
with those containing magnets or button batteries.
■■ Keep small objects out of reach of children,
especially after they have begun crawling, and be
watchful when children are moving around.
■■ Observe children while they eat, especially
during the weaning phase, and provide them
with age-appropriate puréed or lumpy food.
Take especial care when children eat nuts
or seeds.
■■ Do not leave objects such as staple pins, safety
pins, sweet wrappers or batteries where children
can pick them up.
■■ While undertaking home-improvement work,
keep screws and nails safely out of children’s
reach. After using such objects, count them to
ensure none is missing and then put them away
immediately.
■■ Child-resistant packages and containers should
be used for all medicines.
■■ Store all medicines and chemicals in safety boxes
and out of reach of children.

Figure 3 Algorithm for the management of foreign-body aspiration or ingestion

Assess whether the child is breathing and call emergency services. Do not attempt to remove unseen foreign bodies from the child’s mouth
in case they are pushed deeper and obstruct the child’s airway

If child is conscious If child is unconscious

Encourage the child to cough up the foreign body. If this is ineffective, try back blows Call for an ambulance and, under guidance
of the paramedics, start basic life support

If foreign body is removed If foreign body is not Whether or not foreign body is removed
removed

Speak to GP and, if he or she advises it, take child Take child to ED or call for Alert ED team and take child to ED. Continue basic
to an emergency department (ED) an ambulance to do so life support en route

Keep the child under observation Alert paediatric, anaesthetic and ear, nose and throat teams

If child’s condition If child’s condition Stabilise the child by following the airway, breathing, circulation approach
remains stable deteriorates

Discharge with Seek urgent medical Transfer the child to specialist services in a tertiary hospital for the foreign body
home-safety advice review to be removed

Tasks carried out by:

Parents or carers Paramedics ED staff

EMERGENCY NURSE November 2013 | Volume 21 | Number 7 35

 Art & science | children’s care

Conclusion ■■ Request urgent medical and anaesthetic review,

Children who have ingested or aspirated foreign and initiate appropriate resuscitation of children
bodies often present to EDs and, in most cases, who are asphyxiated or who show signs of
they or their parents require only supportive care, airway compromise.
reassurance and advice on accident prevention. ■■ Review children in whom foreign-body
Children with airway compromise, oesophageal or aspiration or ingestion has been previously
bowel perforation from sharp foreign bodies, or suspected or confirmed, and in whom there
bowel-wall obstruction occasionally present and are evolving signs and symptoms such as
should be treated as emergencies involving the stridor, gastro‑oesophageal reflux disease or
appropriate team. distended abdomen, even if foreign bodies
Emergency nurses are often the first healthcare have not been detected clinically or on
professionals to assess children and they should radiological examination.
remain aware of the signs and symptoms of foreign- ■■ Help with stabilisation, medicine and fluid
body ingestion and aspiration. They should be able management, and ensure timely transfer to
to (Ayed et al 2003, Paul et al 2010, Sarmast et al specialist services for foreign-body removal. Online archive
2012, Sih et al 2012, McConnell 2013): ■■ Support parents emotionally and keep them
For related information, visit
■■ Identify children who have ingested or aspirated updated about their children’s conditions.
our online archive and search
foreign bodies. ■■ Raise child-protection concerns if children using the keywords
■■ Triage children who show signs of airway with histories of foreign-body ingestion or
compromise, or bowel perforation or obstruction, aspiration, or other concerning features, Conflict of interest
in the urgent category. present recurrently. None declared

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