What is the treatment for a pediatric patient who swallowed a toothpick?

Treatment for Pediatric Toothpick Ingestion

Immediate referral to emergency services for evaluation and removal of the toothpick is essential, as toothpicks carry a high risk of gastrointestinal perforation and should be considered a medical emergency in pediatric patients.

Initial Assessment

• Determine if the child is experiencing any symptoms:

  • Abdominal pain (may be acute or chronic)
  • Vomiting
  • Gastrointestinal bleeding
  • Fever
  • Respiratory distress (if aspiration is suspected)

• Assess for signs of perforation:

  • Abdominal tenderness or guarding
  • Peritoneal signs
  • Fever
  • Tachycardia

Diagnostic Approach

1. Imaging is crucial:

   • Unenhanced CT scan is superior for detecting wooden toothpicks 1
   • Plain radiographs may not visualize wooden toothpicks but can detect free air if perforation has occurred 2

2. Laboratory studies:

   • Complete blood count to assess for leukocytosis
   • Basic metabolic panel

Management Algorithm

Step 1: Stabilization

• Ensure airway, breathing, and circulation are stable
• Nothing by mouth until definitive management is determined
• IV fluid resuscitation if signs of dehydration or shock

Step 2: Definitive Management

• Endoscopic removal is the first-line treatment when possible 2

  • Upper endoscopy if toothpick is in esophagus, stomach, or proximal duodenum
  • Colonoscopy if toothpick is in colon

• Surgical intervention is indicated if:

  • Endoscopic removal fails
  • Evidence of perforation with peritonitis
  • Abscess formation
  • Obstruction that cannot be resolved endoscopically

Step 3: Post-removal Care

• Monitor for signs of perforation even after successful removal 2
• Post-procedure imaging may be necessary to check for free air
• Antibiotics if perforation is suspected or confirmed
• Soft diet once oral intake is resumed

Important Considerations

• Unlike dental trauma management discussed in guidelines 3, 4, toothpick ingestion represents a distinct emergency requiring different management
• Toothpicks account for approximately 9% of reported foreign body ingestions 5
• Wooden toothpicks are particularly dangerous as they:
  1. Have sharp pointed ends that can perforate the GI tract 5
  2. Are not radiopaque and may be difficult to detect on plain radiographs
  3. Can cause complications including perforation, obstruction, bleeding, abscess formation, and sepsis 5

Common Pitfalls to Avoid

1. Delayed diagnosis: Many patients (especially children) may not recall or report swallowing a toothpick 6, 7
2. Inadequate imaging: Wooden toothpicks may not be visible on plain radiographs; CT scanning is more sensitive 1
3. Premature discharge: Even after successful endoscopic removal, patients should be monitored for signs of perforation 2
4. Misdiagnosis: Symptoms may mimic other conditions like appendicitis, diverticulitis, or inflammatory bowel disease 7

Follow-up Care

• Close monitoring for 24-48 hours after removal
• Immediate return to medical care if fever, increasing pain, vomiting, or bleeding develops
• Follow-up imaging may be necessary depending on clinical course

Remember that toothpick ingestion carries significant morbidity and mortality risks due to the high likelihood of perforation, and prompt intervention is essential to prevent serious complications.