PREVENTION AND MANAGEMENT OF AERODIGESTIVE FOREIGN BODY INJURIES IN CHILDHOOD

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Pediatricians always strongly have endorsed the concept of anticipatory guidance and, therefore, have led the medical specialties in the field of public health. Among their accomplishments in childhood safety, accidental deaths and injuries from foreign body ingestion or aspiration have been drastically reduced. Less than a century ago, death and injuries were an almost certainty for all children with persistent foreign bodies lodged in the airway or esophagus, whereas, now, about six deaths per 100,000 of these children, or about 150 deaths per year, occur in the United States.2

These significant advances, which include a 40% decrease in fatality rates just in the last 10 years, have come through the cooperative efforts of many individuals.7 Starting with the technologic advances in endoscopic foreign body removal by Jackson, the availability of safer pediatric anesthesia, more and improved antibiotics, better radiologic imaging, in concert with direct public health efforts by the American Academy of Pediatrics, the Federal Government through its Consumer Product Safety Commission (CPSC), and the cooperation of responsible manufacturers of products for children have made safety a priority that now should be built into every product and food that could be anticipated to cause harm for young children.

Despite these advances, choking remains the cause of 40% of accidental deaths of children under 1 year of age in the United States.2 Also, a larger number of children suffer anoxic brain damage from foreign body aspiration, which tragically shortens the productivity of their young lives. Physicians and parents worry about and must evaluate children who cough or choke as they curiously explore their expanding environment. What can be done? What should pediatricians do to inform and protect young families from this devastating event?

The peak incidence of all foreign body ingestions and aspirations for children is between the ages of 9 and 24 months and the risk remains until age 6 years (Fig. 1).1, 3, 6, 13 Young boys are more at risk, and at an even younger age. Deaths from choking accidents most often occur in the home environment in more than 95% of children, and the mean age for a fatal outcome is approximately 14 months.10

Causative factors include increased mobility of the toddler child and access to new objects within his or her environment. The introduction to adult foods, which require proper dentition for chewing, shows a distinct rise in frequency at approximately 20 months of age (Fig. 1). Children's behavior illustrates the natural curiosity of toddlers to explore by oral examination and stimulation of their gums during “teething” stages. Unfortunately, developing young children also are not sufficiently mature to appreciate risk and to distinguish food from nonfood items.

A second group of older children (average age, 10 years) also has been shown to be at risk, and boys are more often at risk. Older children represent approximately 20% of children who injure themselves from aspiration or ingestion. Aspiration of nonfood objects occurs more frequently, and often the children are “acting out” and inhale a pen cap or tack that was being held in the mouth.5

Injuries follow a simple formula. Risk is the result of the hazard of the product multiplied by the exposure. The risk to the child must take into account the foreseeable use of the object by the child and any defects of the product, whether it is a manufacturing or design defect. The exposure to the child is modified by the accessibility and vigilance of the parent or caretaker. The exposure is also affected by the quantity in the child's environment and the density of the object over a population area.

Numerous studies confirm that coins and food constitute approximately 80% of the aggregate objects that cause injury in young children. Pennies have a higher circulation in the United States than any other coin, and are also the most common offender in children.8 Coins generally are lodged in the upper esophagus and are large enough in diameter to persist in the cricopharyngeus muscle. Coins that enter the stomach are generally passed along the digestive tract without any medical sequelae.

Toddlers are particularly at risk for choking on certain foods and are vulnerable because the larger and more posterior teeth (e.g., molars) develop 12 to 24 months after the incisors. Incomplete deciduous dentition makes proper chewing of hot dogs, grapes, carrots, peanuts, pinto beans, and other hard foods difficult or impossible for many children until they reach their fourth birthday.1 Coins and difficult-to-chew foods are the leading environmental risk. A safer environment is in the hands of the parents if they eliminate small coins and these foods from the child's reach. This reduction of risk becomes significant when parents are guided by counseling from pediatricians, educational programs, and labeling of products that may be hazardous.

Section snippets

DIAGNOSTIC EVALUATION

The evaluation and correct diagnosis of a child who experiences a choking event invariably falls on the shoulders of the pediatrician. This responsibility is made more difficult because the parents and other caretakers often have not observed the child ingest and choke on food or another object and do not provide a history that elicits the proper examination and evaluation. Yet, too often, the pediatrician is improperly held responsible for the late diagnosis, when symptoms are absent or

RADIOLOGIC STUDIES

Radiographic examination should be considered and offered unless there is sufficient evidence that the precipitating episode was self-limited and no evidence of residual disease is present. For example, if a child is observed by the parent to choke on a penny that is coughed out, and he or she is without symptoms and is not in distress, he or she may not require radiographic evaluation. However, for all children with an incomplete history and the clinical suspicion of choking, the initial

PROGRESSION OF DISEASE

Undiagnosed foreign bodies invariably cause infection and sometimes death. The sequence of events from the initial choking event to the correct diagnosis is an evolving and constantly changing medical picture, wherein the probability that a foreign body is present looms larger and larger. The early picture is generally of a healthy child with minor complaints. Children who have foreign bodies present for weeks or months become invariably sicker, and the clinical findings of pneumonia,

ROLE OF BRONCHOSCOPY AND ESOPHAGOSCOPY

The correct diagnosis can best be attained by direct endoscopic evaluation of the aerodigestive tract, but this is not practical or cost effective for the millions of children who choke when eating at home or at restaurants. Physicians have the responsibility and the right to determine when bronchoscopy, esophagoscopy, or both should be performed. When the child's diagnosis is unclear, or when symptoms are unexplained, then direct examination by bronchoscopy, esophagoscopy, or both is necessary.

FUTURE GOALS OF FOREIGN BODY SAFETY

Pediatricians are the most important leaders in advocating public health issues that protect young children. Great progress has been made to reduce mortality from almost 100% to 0.01% in just 100 years. Federal regulations over the last 25 years have forced manufacturers to restrict products intended for children fewer than 3 years of age to a minimum size that exceeds the dimensions of the Small Parts Test Fixture (SPTF) (31.7 mm in diameter by 57.1 mm in depth).4, 9 These regulations have

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Address reprint requests to James S. Reilly, MD, Alfred I. duPont Institute, 1600 Rockland Road, Wilmington, DE 19899

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From the Section of Pediatric Otolaryngology, Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware (JSR, SPC); the Departments of Otolaryngology (JSR, SPC) and Pediatrics (JSR), Thomas Jefferson Medical College, Philadelphia, Pennsylvania; and Inchcape Testing Services, Oakbrook, Illinois (DS, GR)

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