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14 July, 2021

Foreign body aspiration in children

Coughing and choking is a common event causing respiratory complications in children under the age of 3-4 years. Children under the age of 2 years are particularly vulnerable to aspiration of foreign bodies. Children with neurodevelopmental abnormalities are also at risk.

This predisposition is due to multiple reasons. Young infants have varying developmental abilities and try to explore surroundings by mouth. Young children have poor ability to grind and swallow food particles. They have small airways which are more prone for obstruction. Also, the force of cough in young children is less effective in dislodging foreign bodies from airways compared to older children/adults.

The most commonly ingested foreign bodies include nuts, seeds and  vegetables. Aspirated inorganic foreign bodies include coins, pins, Jewellery and toys.

SYMPTOMS

The symptoms of foreign body aspiration depend on the age of the child,  characteristics of the foreign body and duration.

The foreign body can lodge and obstruct upper airways (larynx/trachea- less common) or may pass on to lower airways (bronchi-more common). The symptoms can range from asymptomatic state to severe breathing difficulty. These include: 

  • Initial coughing , choking and gagging
  • Sudden onset difficulty in breathing following such event 
  • Noisy breathing (stridor)
  • Inability to speak or cough
  • If delayed presentation 
  • Noisy breathing
  • Breathing difficulty
  • Recurrent pneumonia
  • Blood in sputum

DIAGNOSIS

  • History is the most important clue in establishing diagnosis
  • A negative history may be misleading; Unwitnessed events do happen
  • Always enquire about the presence of small objects in the surroundings of the child and about feeding habits
  • Physical examination may reveal hyperinflation of chest or loss of lung volume, decreased breath sounds on involved side and wheezing
  • Chest radiographs may help in diagnosis
  • Radio-opaque foreign bodies are visible; However, they are less common
  • Radiolucent foreign bodies are not visible
  • Findings suggestive of foreign body aspiration include
  • Hyperlucency of involved lung due to partial obstruction of airway
  • Collapse of the lung due to complete obstruction of airway
  • Mediastinal shift
  • Expiratory films may be helpful in revealing trapped air
  • CT scan may be considered in occasional cases with diagnostic dilemma or  prolonged history
  • In cases where history and examination is not conclusive, flexible bronchoscopy may help in establishing the diagnosis.

COMPLICATIONS OF MISSED FOREIGN BODY

  • Recurrent or persistent pneumonia
  • Chronic cough
  • Hemoptysis
  • Bronchiectasis (Abnormal dilatation of airways)
  • Lung fibrosis

TREATMENT

  • In children with near total obstruction from upper airway, prompt removal by five back blows and chest thrusts in young infants or Heimlich maneuver in older children will be lifesaving
  • Prompt rigid bronchoscopy and removal of the foreign body is recommended 
  • Flexible bronchoscopic removal also can be done by experienced personnel
  • Complications of bronchoscopic removal of foreign body include pneumothorax, bronchospasm, bleeding, desaturation and airway edema; These are rare less common

PREVENTION

  • Educating parents and caregivers regarding prevention strategies to prevent such events in young children 
  • Avoid giving foods at high risk of choking to young children
  • Training children to chew slowly, eat while seated and to avoid running or playing during eating
  • Age appropriate toys should be used and small toys or toys that are easily  disassembled should be avoided 

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