One of many of a parent’s worst nightmare I suppose; having to explain to a doctor that your child has swallowed a coin, or worse a toy. The most annoying thing from the aspect of a doctor is having to deal with a highly anxious parent who is having a full blown panic attack. Laughs aside, the most important thing you can do is a) calm the parent and b) find the ingested device.
As an intern, I had numerous cases of foreign body ingestions, but coins were a pretty popular foreign body. Kids whilst playing with coins may just accidentally swallow it. I know my younger brother who was a terror swallowed his catholic holy medals and sent my mother into a meltdown. The funny thing is, it’s not just kids who turn up with foreign body ingestions, but there have been some beyond dumb adults too.
So what happened?
A 10 year old boy came to the surgical ward after accidentally ingesting a 10 rupee coin whilst playing with his sibling just 4 hours previously. He had not opened his bowels yet, nor vomited. The child had also not ingested any food or water thereafter.
A paediatric abdominal x-ray post accidental ingestion of a coin.
So what do you do?
Calm the parent! There will be breathlessness and light headedness on the part of the parent so ensure you calm the parent down first. Even though this isn’t an emergency, you still have to ensure that the child is stable. The priority with any foreign body ingestion is to make sure it was swallowed and not aspirated into the lung (unlikely with a 10 rupee lung, but very possible with peanuts!). So when you percuss/auscultate lungs, look for any difference in breath sounds and percussion note. Also take a careful history to rule out any congenital/GI anomalies.
An adult abdominal x-ray post accidental ingestion of a nail.
Investigations?
When the foreign body is a metal object it’s actually better for you because this shows up on an x-ray. An abdominal/chest x-ray is useful so you can locate the coin in the GI system, but if it’s not metal you’re in for a small situation. Plastic objects such as toys won’t show up very clearly on x-rays. In very rare circumstances, there might be a place for endoscopy in order to directly visualise and remove the foreign body.
Management
Almost always it ends up being a watch and wait situation. The key here is to try and identify where the foreign body is with the help of radiographs. If the foreign object has passed the ileo-caecal valve which is the narrowest part of the intestines, then you can be pretty sure that it’ll pass through without a problem. You can advice the parents to be on poop watch where they examine the stools passed for the foreign object and then repeat the x-ray in 24-48 hours if they don’t find the object. During the time the parents should be advised to give the child to drink and eat as normal, but be on the look out for warning signs such as haematemesis and projectile vomiting. If it’s a lithium battery or has sharp edges, you must inform your seniors because this might require extraction via a scope or surgery. Sharp objects may also cause irritation or perforation so need removal ASAP. If the foreign object is impacted around the oesophagus then it also most likely requires removal. Generally, laxatives or any other medications are not given.
As a general rule though if it’s below the diaphragm the child should be fine, but if the child has drooling or is vomiting then will need more specialised care. Remember if the object was ingested on purpose then the child may need a psychiatric referral.
These cases can provide quite a laugh, but remember the parent’s anxiety can be warranted so be nice.
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