ECH Chung, TYW Hon, KP Leung, FL Lau

Abstract

A prospective 4-month survey was conducted at our hospital to look into paediatric patients presenting with suspected lodgement of swallowed foreign bodies. Eighty-eight consecutive cases were collected and 93% of accidents were meal-related with fish bone representing the single most common variety of foreign bodies swallowed. Presentation was uniformly early and the foreign body confirmation rate was 54.5%. The clinical picture generally paralleled that seen in local adults but differed markedly from paediatric series reported elsewhere. Prevention here should emphasize more on educating parents! guardians in food preparation than on play supervision. Discharge against medical advice rate was found to be high (18%) and it should be cut down. The means of achieving this were briefly discussed.

Introduction

In Hong Kong, suspected lodgement of foreign bodies (FB) accidentally swallowed is a fairly common complaint among adults attending the Accident and Emergency Department of acute hospitals. Several recent series have been reported^1-5 but coverage is essentially on adults. In order to elucidate the nature and extent of this problem in children a prospective survey was conducted between 1 August 1994 and 30 November 1994. It is hoped that data gained from this survey can improve our understanding of this problem and its management.

Patients and Method

All children (aged up to 12 years) presenting with this complaint to our Accident & Emergency Department within the 4-month period were candidates for this study. Data collection was by means of questionnaire filling upon presentation and case-notes review.

Subjects generally had a lateral neck x-ray taken in addition to throat examination using a direct laryngoscope under local anaesthesia. Additional x-rays (chest, abdomen) were ordered only on a need basis. Those with FB successfully removed were discharged while the rest were generally offered admission following which upper digestive tract endoscopy was selectively performed based on clinical-radiological findings. Only a small number of cases - those with low suspicious for retained FB and trivial symptoms - were directly discharged from the Accident & Emergency Department when no FB was found.

For patients in whom the FB had already reached the stomach or intestine (radiologically) at the time of presentation, the choice between observation and operative removal was made based on the nature and size of the FB, presence/absence of sharp edges and rate of progression down the alimentary canal.

Result

Eighty-eight consecutive cases were recruited, their age-sex characteristics were as shown in Table I and management-outcome in Figure.

DL=direct larygngoscopy OGD=oesophage-gastro-duodenoscopy * not our regular practice!

Fig. Management and outcome of patients

Our patients presented remarkably early. Eighty of them came on the day FB swallowing took place, seven came the next day and only one sought treatment after four days. This lone late-coiner was a 11-year-old boy who had allegedly swallowed a piece of pig bone and no FB was found following the standard clinical-radiological examination. Eighty-three patients presented directly to our Accident & Emergency Department and only five were referrals from general practitioners.

In 82 instances the FB swallowing was meal-related, and the FB allegedly swallowed included 76 fish bones, two livestock bones, three poultry bones, and one piece of glass fragment. The remaining six were accidents not related to meal and details were provided in Table II.

Of the 88 complaints of alleged FB lodgement, 48 were proven cases with 49 FB found. Details of these were provided in Table III.

All patients were stable at presentation with none in distress. There was no morbidity, mortality arising from patient management and none of the 88 children had re-presented for the same or related complaints. All cases had been genuine accidents and an underlying predisposing pharyngo-oesophageal disorder was not present in any of them. There were altogether 16 DAMA (discharge against medical advice) cases, six were aged above six years and the rest were younger.

Discussion

Paediatric accidental FB ingestion seemingly is not uncommon in Hong Kong for we already had 88 cases within four months. Since overseas series generally contain far fewer cases than ours, e.g. 126 from three years of Simpson & Lloyd⁶, 141 from seven years of Suita et al⁷, and 13 from 18 months of Phillipps & Patel⁸, there is ground to suspect that accidental FB ingestion in children is more prevalent here than elsewhere.

The more striking difference between this series and those from overseas lies in the nature of FB allegedly swallowed. Although the range of FB swallowed by children is well known to be vast on account of their propensity for exploring objects with the mouth, coins, toy bits, and of late button batteries almost always represent the majority.^7,9 This is clearly not the case here since 93% of the instances were meal-related with few occurring during play or mishap. Not surprisingly, fish bone constituted an overwhelming majority among FB swallowed (a situation not unlike that of adults in this locality^1-3) and no button battery ingestion had occurred within those four months. In view of this, most of our cases of FB ingestion should be potentially preventable and unlike elsewhere prevention rests more on proper preparation of child food than on supervision of children at play. The Chinese culinary practice of cooking fish/meat without deboning or similar processing for its supposed merit of flavour and essence retention should probably be abandoned whenever the dish is one to be shared between adults and children.

From our study there is evidence to indicate that parents in Hong Kong are generally very concerned about the welfare of their offsprings. Suspected FB lodgement was perceived as an emergency and there was minimal delay in seeking medical care. The child was either brought to the Accident & Emergency Department or taken to a general practitioner (because of immediate availability of service at both settings no doubt) and none came in as a referral from Government Outpatient Clinics. Nearly all cases in this series presented within 24 hours and this FB ingestion - presentation interval was considerably shorter than what had been noted in local adults with the same complaint.^1-3 Furthermore, a large percentage of alleged lodgement was not subsequently substantiated (FB confirmation rate being only 54.5%) and in more than a few cases FB ingestion was suspected merely because of the disappearance of an object, e.g. the safety-pin, rather than by the presence of symptoms in the child.

While most parents/guardians were very apprehensive, many would rather choose the risky option of DAMA than leaving their children in hospital, probably for fear of separation and of invasive procedures that may befall the child once admission is accepted. The DAMA rate in this study was 18%, which was much higher than those of adults with the same complaint managed in our hospital (6.5% in a 1993 study and 5% in a 1994 study¹⁰). Insofar as DAMA constitutes a breakdown of doctor-patient relationship it is a management option best not evoked. A clear, detailed, explanation by a sympathetic A&E doctor would go a long way in dispelling fear and suspicion, and doctors in the ward proposing invasive procedures should do likewise. The hospital can also help by making available overnight accommodation for parents/guardians so that the child can be accompanied if that is desired.

Although the selective ambulatory management approach is the established practice at our hospital for adults with the complaint of alleged lodgement of ingested we have not yet considered the scheme suitable for use in children. Nevertheless, 4 cases were unexpectedly selected for home observation with pharyngoscopy review at the Accident & Emergency Department with no apparent harm done even though one patient subsequently turned out to be FB positive. In retrospect, selective ambulatory management perhaps is not a bad option since the scheme has worked well in adults and the pictures we gained of FB lodgement from this and our other adult series^1-3,10 are remarkably similar. The extension of this management scheme to children no doubt would allow anxiety-ridden parents/guardians an alternative to DAMA. New selection criteria, however, have to be set, and probably an age limit too, in order for home observation cum interval re-examination to be safe.

References

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6. Simpson ET, Lloyd DA. The management of swallowed oesophageal foreign bodies in children. S Afr J Surg 1982;20:311:5.

7. Suita 5, Ohgami H, Nagasaki A, Yakabe S. Management of Paediatric patients who have swallowed foreign objects. Am Surg 1989;55:585-90.

8. Phillipps JJ, Patel P Swallowed foreign bodies. J Laryngol Otol 1988;102:235-41.

9. Malone BN. Foreign body ingestion. In: Reisdorff EJ, Robert MR, Wiegenstein JG (ed). Paediatric Emergency Medicine. WB Saunders Co. 1993;347-50.

10. Chung ECH, Leung KP, Hon TYM, Lau FL. Selective ambulatory management of adults with alleged lodgement of swallowed foreign bodies. Hong Kong Practitioner 1995;17:593-6.