International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

Contents lists available at SciVerse ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Review article

A systematic review of paediatric foreign body ingestion: Presentation,

complications, and management
Shruti Jayachandra, Guy D. Eslick *
The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 27 September 2012
Received in revised form 13 November 2012
Accepted 17 November 2012
Available online 20 December 2012

Background: Foreign body ingestion is a common problem among paediatric populations. A variety of foreign
bodies are ingested, some of which are particularly harmful and life threatening such as button batteries,
magnets and bones. Common household items such as small toys, marbles, batteries and erasers are often
ingested. The aim of this systematic review is to study the problem of foreign body ingestion among paediatric
populations in terms of commonly ingested objects, and attempt to identify the link between location of
impaction, associated symptoms, complications, spontaneous passage, methods and timing of removal.
Methods: A literature search of multiple databases including PubMed, Embase, Current Contents
Connect and Medline were conducted for studies on foreign body ingestions. Based on strict inclusion
and exclusion criteria, 17 studies were selected. A qualitative review of these studies was then
performed to identify commonly ingested foreign bodies, symptoms, signs and complications of foreign
body ingestion, rates of spontaneous passage and methods of retrieval of the ingested objects.
Results: Coins are the most commonly ingested foreign body. A variety of gastrointestinal symptoms
such vomiting and drooling as well as respiratory symptoms such as coughing and stridor are associated
with foreign body ingestion. The oesophagus, in particular the upper third, is the common site of foreign
body obstruction. Objects in the stomach and intestine were spontaneously passed more frequently than
at any other sites in the gastrointestinal system. Complications such as bowel perforations, infection and
death are more commonly associated with ingestion of objects such as batteries and sharp objects such
as bones and needles. Ingested objects are most commonly removed by endoscopic means.
Conclusion: Foreign body ingestion is a common paediatric problem. Batteries and sharp objects should
be removed immediately to avoid complications while others can be observed for spontaneous passage.
Endoscopy has a high success rate in removing ingested foreign bodies.
Crown Copyright 2012 Published by Elsevier Ireland Ltd. All rights reserved.

Keywords:
Systematic review
Paediatric
Foreign body ingestion
Children

Contents
1.
2.

3.

4.

Introduction . . . . . . . . . . . . . .
Aim of this review . . .
1.1.
Methods . . . . . . . . . . . . . . . . .
Search strategy . . . . . .
2.1.
Study selection . . . . . .
2.2.
Data extraction . . . . . .
2.3.
Results . . . . . . . . . . . . . . . . . .
Study characteristics. .
3.1.
Presenting symptoms .
3.2.
Anatomical location . .
3.3.
Complications . . . . . . .
3.4.
Spontaneous passage .
3.5.
Method of extraction .
3.6.
Discussion . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . .

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312
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317

* Corresponding author at: The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Level 5, South Block, P.O. Box 63,
Penrith, NSW 2751, Australia. Tel.: +61 2 47 341 373; fax: +61 2 47 343 432.
E-mail address: guy.eslick@sydney.edu.au (G.D. Eslick).
0165-5876/$ see front matter . Crown Copyright 2012 Published by Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijporl.2012.11.025

312

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

1. Introduction
Foreign body ingestion is a common problem in paediatric
populations with up to 75% of cases occurring in children under 4
years of age [14]. A variety of foreign bodies are ingested by
children, some more harmful and life threatening than others.
Typically, ingested foreign bodies include common household
items such as small toys, marbles, batteries, erasers, etc. However,
coins are reported to be the commonest type of object ingested by
children, accounting for up to 70% cases of paediatric foreign body
ingestion [59].
Most ingested foreign bodies either pass through the gastrointestinal system spontaneously [10,11] and without complication,
or they may become impacted, most commonly at one of the sites
of anatomic constriction in the oesophagus [12]. The commonest
site of impaction is in the upper oesophagus, at the level of the
cricopharyngeus muscle, accounting for over 75% of all cases of
foreign body impaction [13]. Less frequently, objects may become
impacted in the mid oesophagus at the level of the aortic arch or
left main bronchus, or in the lower oesophagus at the gastrooesophageal junction [14]. Foreign bodies that pass beyond the
gastro-oesophageal junction usually pass through the alimentary
tract without complications [14]. In fewer than 10% of cases,
foreign bodies may impact within the intestines [15].
Foreign body impaction may result in complications such as
mucosal abrasions within the gastrointestinal tract, bleeding,
gastric outlet obstruction, oesophageal or gastrointestinal perforation and secondary mediastinitis, peritonitis, abscess or stula
formation [1619]. Therefore, impaction is generally a strong
indication for foreign body removal.
A variety of methods for identication and removal of an
impacted coin have been studied and described such as the use of
rigid and exible oesophagoscopy, McGills forceps, Foley catheter
extraction and oesophageal bougienage [1,6,20,21].
1.1. Aim of this review
This systematic review is aimed at determining the signicance
of foreign body ingestion among paediatric populations in terms of
location of impaction, associated symptoms or complications and
methods of removal.
2. Methods
2.1. Search strategy
We followed the Preferred Reporting Items for Systematic
reviews and Meta-Analyses PRISMA guidelines in performing our
systematic review. A systematic search of the databases MEDLINE
(from 1950), PubMed (from 1946), EMBASE (from 1949) and
Current Contents Connect (from 1980) was conducted through to
September 20, 2012, to identify relevant articles for the systematic
review. The search used the terms oesophageal, gastric,
intestinal, ingested, foreign body, child and paediatric which
were searched as keywords. The reference lists of relevant articles
were also searched for appropriate studies. No language restrictions were used in either the search selection or study selection.
2.2. Study selection
We included studies that met the following inclusion criteria:
(1) cases related specically to ingestion of foreign bodies; (2)
studies that assessed presenting symptoms, complications, anatomical locations, spontaneous passage and management; and (3)
the total sample size of the study exceeded 100 patients. We
excluded studies that did not meet the inclusion criteria. Fig. 1

shows our study selection strategy based on the extensive

literature search.
2.3. Data extraction
The data extraction was performed using a standardized data
extraction form, collecting information on the publication year,
study design, temporal direction, total sample size, population
type, country, age range, location of foreign body impaction,
presenting symptoms, complications, spontaneous passage rates
and extraction methods. Authors were not contacted for missing
data (Table 1).
3. Results
3.1. Study characteristics
Seventeen studies were selected for our systematic review
based on the inclusion and exclusion criteria applied. There were
ve studies from USA, three from Turkey, two from Hong Kong, two
from Brussels and one each from Canada, United Kingdom, Greece,
South Korea and South Africa. Fourteen of the 17 studies were
retrospective case series and the remaining 3 were designed as a
prospective cohort study. Only 2 of the 17 studies exclusively
studied coin ingestion. Of the remaining 15, coins were identied
as the most frequently ingested foreign body in 10 studies. Among
these studies, sample sizes varied from a minimum of 101 to a
maximum of 675. The summation of sample sizes from all included
studies was 5559 children aged between one month and 18 years.
For each study, information on the three most common foreign
bodies ingested with details of percentages (if available), the three
main symptoms encountered, any complications from ingesting
the foreign body, location of impaction of the foreign body,
spontaneous passage rates and methods of removal of ingested
foreign body were sought. Due to the breadth of topics on foreign
body ingestion, not all papers provided all of the above
information.
3.2. Presenting symptoms
Symptoms associated with foreign body ingestion varied
between studies. They varied from gastrointestinal symptoms of
vomiting, drooling, dysphagia, odynophagia, globus sensation to
respiratory symptoms of coughing, stridor and choking to being
completely asymptomatic. Of the 10 studies where coins were
most frequently ingested and the 2 exclusively coin ingestion
studies [22,23], vomiting and drooling were the predominant
symptoms in 9 studies [15,2230].
3.3. Anatomical location
The location of impaction of the ingested foreign body was
recorded in 14 studies. Five studies found the foreign body most
commonly impacted in the oesophagus [24,26,3133] and 4
studies [15,27,29,30] reported the stomach as the most common
site. In addition, where the study stated location of impaction
within the oesophagus, the upper oesophagus was the most
frequent site of impaction of foreign bodies in 5 studies
[25,26,28,31,33].
3.4. Complications
Complications associated with the ingested foreign body were
only discussed by under half (5/17) the studies [22,27,28,31,35] in
our review. There was a wide variety of complications ranging
from 1 case of mortality due to coin ingestion as described by

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

313

Fig. 1. Flowchart depicting study selection criteria for qualitative systematic review.

Cheng and Tam [28], to mucosal abrasions and lacerations [27,31]

and bowel perforations [28,31,35].
3.5. Spontaneous passage
Spontaneous passage rates were only described in just over a
third (7/17) of the studies [15,24,28,3234,36]. In 4 of these 6
studies it was found that spontaneous passage rates were higher
when the foreign body was in the stomach and intestine
[15,32,33,36]. Within the oesophagus the lower third had the
highest spontaneous passage rates [15].
3.6. Method of extraction
Methods of extraction were documented for most studies (14/
17). Of operative methods employed to extract ingested foreign
body, exible and rigid endoscopy were mainly used
[15,24,25,28,3032,34,36]. Foley catheter extraction [26], oesophageal bougienage [22], extraction with McGill forceps [23] and
magnet catheters [27] were primarily used in 1 study each.
4. Discussion
A variety of foreign bodies are ingested by children, of which
coins appear to be the most common. In some instances, where
coin ingestion is witnessed or self-reported, the child may be
asymptomatic on presentation. However among symptomatic
children, a wide variety of clinical manifestations are reported.
They vary from gastrointestinal symptoms such as dysphagia,
vomiting and drooling, and respiratory symptoms such as

coughing, choking and wheezing. Airway symptoms are less

common with oesophageal foreign bodies. In general, it appears
that symptoms are dictated by the type and location of impaction
of the foreign body and the duration of impaction.
Our review found that complications are likely to occur when
the foreign body remains impacted for an extended period of time.
In addition, the type of foreign body ingested also affects
complication rates. Certain foreign bodies such as button batteries
are known to cause complications if not removed immediately [31]
and sharp objects such as open safety pins can cause perforations
[28]. In the case of button batteries, injury was believed to occur
primarily from leakage of alkaline material. However, more
recently, studies have suggested that the main issue with button
batteries relates to the development of an external circuit when
button batteries are placed in a conductive medium, causing the
passage of current through gastrointestinal tissues leading to
hydrolysis of tissue uids and production of hydroxide ions at the
negative pole of the battery [37,38]. Furthermore, 20 mm lithium
batteries cause greater damage than other button batteries due to
the increased voltage and therefore current passing through them
[38]. Blunt objects such as coins which are not considered as
dangerous can also occasionally be associated with severe
morbidity and mortality. For instance, Cheng and Tam [28] noted
a case of bowel perforation from an impacted coin. In our review,
although only 5 of the 17 studies described complications from
foreign body ingestion, the actual complication rates with ingested
foreign bodies may be higher. Not all studies focused on
symptomatology and complications of foreign body ingestions
and instead studied other aspects such as investigation and
management of ingested foreign bodies.

314

Table 1
Study characteristics. UO- upper oesophagus, MO- mid oesophagus, LO-lower oesophagus, HP- hypopharynx.
Author, date &
country

Patient group

Study type

Sample
size

Commonest foreign body

ingested (with % where
available)

Symptoms

Complication

Pak et al., 2001,

Hong Kong

4 months12
years

Prospective
cohort

311

Fish bones

Pricking sensation

Tonsils 72%

Chicken bones

Globus sensation
Dysphagia

Tongue base 13%

Yalcin et al., 2007,

Turkey

1 month14
years

Retrospective
case series

112

Pins

Spitz, 1971,
England

Under 16 years

Prospective
cohort

410

Rounded & cuboidal

objects (coins, marble,
buttons etc.)
Sharp pointed objects

Spontaneous
passage (% where
available)

Direct vision using

tongue depressor/
Mackintosh
laryngoscope (107)
Endoscopy (8)

Cricopharyngeus 7%
Pharyngeal wall 4%
Unknown/dislodged 4%
Vomiting Dysphagia
Cough

Oesophagus 71%,
Stomach 11%,
Duodenum 6%,
Intestine 5%

Spontaneous
passage 30%

Endoscopy (84)

Oesophagus 56%

Oesophagus 10%

Endoscopy:

Stomach &
duodenum 23%
Intestine 7%

Stomach &
dudodenum 80%
Intestine 100%

Oesophagus (205)

UO 69%,

Spontaneous
passage 3%

Coins

Macpherson et al.,
1996, USA

6 months to
17 years

Retrospective
case series

118

Coins 69%,

Surgery (4)

Gastrointestinal
symptoms
Respiratory
symptoms

Other metallic foreign

bodies 11%
Non opaque foreign
bodies 3%
Popel et al., 2011,
Canada

4 months to
16.9 years

Retrospective
case series

140

Management

Stomach &
duodenum (43)
Laparotomy:
Oesophagus (2)
Stomach &
duodenum (2)
Surgery (2)

MO 21%,

Endoscopy (72)

LO 10%

Foley catheter
extraction (53)
Flexible endoscopy
(89)
Rigid endoscopy (49)
Both (2)

Coins 78%

Drooling

UO 66%

Food bolus 13%

Jewellery, safety pins,
school supplies, batteries
& stones 9%

Vomiting Dysphagia

LO 19%
MO 14%

Surgery (2)
Arms et al., 2008,
USA

Children, average
age 3.7 years

Retrospective
case series

620

Only coins studied

Asymptomatic

Drooling gagging
& vomiting
Pain

Stridor post
endoscopy
due to subglottic
oedema (1)

Oesophageal
bougienage (355)

Endoscopy (265)
Authors recommend
bougienage

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

Coins

Location (with %
where available)

Table 1 (Continued )
Author, date &
country

Patient group

Study type

Sample
size

Commonest foreign body

ingested (with % where
available)

Symptoms

Complication

Location (with %
where available)

Tokar et al., 2006,

Turkey

26 days to 16
years

Retrospective
cohort

161

Group 1:

Group 1:

Duodenal
perforations(7)

HP & UO 63%
(Group 169%,
Group 235%)

Group 1 = no
complications
group

Coins

Dysphagia

Group 2:
complications
present

Group 2:

Fluid intolerance

Complete
oesophageal
obstruction and
aspiration
pneumonia (10)
Layngeal
oedema (2)

Radio-opaque metal
objects
Food bolus

Group 2:
Fluid intolerance

Coins 88%

All other foreign

bodies 12%

Management

Group 1:

Rigid and exible

endoscopy 64%

McGills forceps 36%

MO & LO 30%
(Group 129%,
Group 234.6%)

Group 2:
Below oesophagus
7% (Group 12%,
Group 231%)

Open surgery

Dysphagia

UO 88%

Drooling

MO 14%

Balloon extraction
with uoroscopy
88%
Rigid endoscopy 12%

Choking

LO 12%

Dysphagia
Little et al., 2006,
USA

Hachimi-Idrissi et al.,
1998, Belgium

Panieri & Bass, 1995,

South Africa

2 months to 19
years

7 months to 14
years

6 weeks to 13
years

Retrospective
case series

Restrospective
case series

Restrospective
case series

555

174

663

7 months to 16
years

Retrospective
case series

552

Magnet tube (48)

Choking &
gagging
Retrosternal
pain

Oesophagus (30)

Endoscopy (26)

Small intestine (25)

McGill forceps (9)

Dysphagia &
vomiting
Stridor

Stomach 37%

UO (1)

Rigid endoscopy (76)

Oesophagus18%
Oropharynx 6%

MO (2)
LO (5)
Stomach &
bowel (224)

Balloon catheter (27)

McGill forceps (6)

Specic to coins:

Coins 35%

Specic to coins:

Vomiting

Sharp objects
Batteries

Coins
Bones
Sharp objects

Cheng & Tam, 1999,

Hong Kong

Stomach (102)

Coins

Coins 49%

Specic to coins:

Fish bones 29%

No symptom 50%

Metallic objects 14%

Vomiting 31%

Mucosal
abnormalities
(13)

Mortality 5days
post impacted
oesophageal
chicken bone (1)
Bowel perforations
(2) from ingested
toothpick &
impacted coin
Cervical abscess
from sh bone (1)

Odynophagia 13%

Paul et al., 2012,

USA

5 months to 14
years

Prospective
cohort

217

Coins 46%

Endoscopy 76%

MO (52)

Direct laryngoscopy

LO (22)
Stomach (62)
Bowels (17)
Trapping in
oesophagus (35)
Aspiration (10)

315

Food items 9%

UO (118)

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

Mucosal
laceration (3)
Caustic injury
from battery
alkali (3)

Spontaneous
passage (% where
available)

Stomach (7)

Endoscopy (61)
61%
Stomach 24%
Oesophagus15%

Small bowel 11%

Oropharynx 9%
Vomiting

Small bowel (108)

Oesophagus 20%
Drooling

Sharp objects (needles,

pins)
Batteries

Stomach 60%
Pain
Coins

Cultural blue beads

with safety pin 39%
Coins 28%
Turban pins 18%
176
9 months to 17
years
Aydogdu et al.,
2009, Turkey

Retrospective
case series

Only coins studied

101
4 months to
12.8 years
Bhargava, 2011,
USA

Retrospective
case series

5 months to 18
years

Toy parts 8%

Arana et al., 2001,

Brussels

Retrospective
case series

325

Infection (3)
Penetration (2)
Obstruction (2)
Perforation (1)

Small intestine

Management
Spontaneous
passage (% where
available)
Location (with %
where available)
Complication
Symptoms
Commonest foreign body
ingested (with % where
available)
Sample
size
Study type
Patient group
Author, date &
country

Table 1 (Continued )

Foley catheter and

forceps (45)

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

McGill forceps (56)

316

In keeping with widely understood aspects of foreign body

ingestion, objects identied in the stomach and bowels were
managed conservatively and objects in these sites passed
spontaneously more than in any other part of the gastrointestinal
tract. Importantly, such patients were often not admitted and
safely discharged home. In contrast, foreign bodies impacted in the
upper part of the oesophagus, often requires medical intervention
to remove.
Timing of medical intervention to remove ingested foreign
bodies appears to be largely dictated by the type and location of
foreign body, duration of impaction and patient symptoms.
Ingested bones for instance call for urgent removal, due to the
high likelihood of complications such as gastrointestinal perforation and mediastinitis, as noted in the studies we reviewed [28,35].
Based on our review, we recommend early removal of impacted
foreign bodies in symptomatic patients, particularly with airway
compromise or where there is an indication of gastrointestinal
obstruction or inammation, or where patients have ingested
sharp, penetrating foreign bodies such as chicken bones or pins.
Button batteries are a special case that requires urgent removal
[27]. Cases of magnet ingestion were not present in studies
included in our review. However, ingestion of magnets particularly
with other metallic objects or ingestion of more than one magnet
can create strong magnetic elds and is associated with severe
complications such as pressure necrosis, stula formation and
bowel perforation, therefore warranting urgent removal [39,40]. In
our review we noted that most asymptomatic blunt foreign body
ingestion cases were safely observed for some hours before
attempts were made to remove the ingested object.
A variety of methods for removal of oesophageal foreign bodies
have been described in the literature. As discussed, studies in our
review utilised extraction with McGill forceps to rigid and exible
oesophagoscopy, Foley catheters, oesophageal bougienage, laparotomy and open surgery [27,31,32]. Predominantly however,
endoscopy is used and of the non-surgical techniques, oesophageal
bougienage where a dilator is used to push the foreign body into
the oesophagus, as well as Foley catheter where a deated catheter
is passed beyond the oesophagus, inated and removed under
uoroscopy were used successfully. Of note, no unied approaches
are noted for removal of different types of foreign bodies. In regard
to ingested coins, again a variety of techniques have been used:
Arms et al. [22] recommended bougienage while Bhargava and
Brown [23] only used McGill forceps and Foley catheters to
successfully extract coins. A limitation is that not all studies in our
review shed light on the success and complication rates of rigid
versus exible endoscopy techniques. However, a recent study by
Popel et al. [25] found that both rigid and exible endoscopy
techniques had similar success rates although exible endoscopy
was associated with a lower rate of severe complications, greater
patient comfort and avoided the need for general anaesthesia.
Our systematic review has highlighted that foreign body
ingestion is a common paediatric problem and coins are the
commonest type of ingested foreign bodies. By simply limiting our
selection criteria to sample sizes over 100 patients, it is apparent
that there are only a few large sample sized studies conducted thus
far. There is limited data in the literature studying coin ingestion in
particular. This is in regard to presenting symptoms, complications, predictors of spontaneous passage as well as timing and
techniques of surgical and non-surgical interventions associated
with coin ingestion. Although most swallowed coins pass through
the gastrointestinal tract uneventfully, there are occasions when it
has caused serious harm to the patient and even death. Therefore
coin ingestion is an important paediatric problem and must not be
overlooked.
Foreign body ingestion is common among children. Patients
may present asymptomatically or may be symptomatic with a

S. Jayachandra, G.D. Eslick / International Journal of Pediatric Otorhinolaryngology 77 (2013) 311317

wide variety of symptoms, depending on the type of foreign body,

location and duration of impaction. Most often foreign bodies
become impacted at the level of the cricopharyngeus in the upper
third of the oesophagus. Spontaneous passage is more likely to
occur when the object is located beyond the distal oesophagus.
Indications for urgent foreign body removal are a threatened
airway, ingestion of sharp objects, button batteries, multiple
magnets, and animal bones, prolonged duration of impaction (over
24 h). Certain types of foreign bodies such as button batteries and
magnets carry high complication rates and require urgent removal
while others such as coins often do not cause complications.
However, severe morbidity and mortality still occurs with coin
ingestion. There have been limited large scale studies researching
coin ingestion, particularly in regard to coin denomination and
spontaneous passage.
Finally, a variety of extraction techniques are used to extract
foreign bodies and no single method is used consistently among
different care centres. However it appears that endoscopy is the
most commonly used technique with high rates of success and
exible endoscopy in particular appears to have lower complication rates and increased patient comfort in removing ingested
foreign bodies.
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