What are the criteria for removing an ingested foreign body from a child's stomach?

Criteria for Removal of Ingested Foreign Bodies in Children's Stomachs

Urgent endoscopic removal is required for high-risk foreign bodies in a child's stomach including button batteries (especially lithium batteries ≥1.5 cm, 3V), sharp objects, magnets, and objects >2.5 cm in length or >2 cm in diameter, regardless of symptoms. 1, 2

Classification of Foreign Bodies and Management Approach

High-Risk Foreign Bodies (Require Urgent Removal)

• Button batteries

  • Lithium batteries (≥1.5 cm, 3V) require urgent removal within 24 hours even when in the stomach and asymptomatic 2
  • Can cause severe tissue damage through electrical discharge, pressure necrosis, and alkaline leakage

• Sharp objects

  • Items like pins, needles, bones, open safety pins
  • High risk of perforation, especially in the esophagus, pylorus, duodenal sweep, and ileocecal valve

• Magnets

  • Multiple magnets or magnet with metallic object
  • Can cause pressure necrosis and perforation between intestinal loops

• Large objects

  • Objects >2.5 cm in length or >2 cm in diameter
  • Unlikely to pass the pylorus

Medium-Risk Foreign Bodies (Consider Removal)

• Coins

  • Most common ingested foreign body in children 3
  • If in stomach and child is asymptomatic, can be observed for passage
  • Remove if symptomatic or not passing after 2-4 weeks

• Small blunt objects

  • Can be observed if asymptomatic and <2 cm in diameter
  • Remove if symptomatic or not passing after 3-4 weeks

Low-Risk Foreign Bodies (Observation)

• Small, blunt, non-toxic objects (<2 cm)
  • Can usually pass spontaneously
  • Observe with follow-up radiographs as needed

Decision Algorithm for Management

1. Initial Assessment

   • Determine type, size, and location of foreign body through history and appropriate imaging
   • Assess for symptoms (vomiting, drooling, coughing, stridor, abdominal pain)
   • Perform radiographic evaluation for all suspected cases

2. Immediate Endoscopic Removal Indications (within 24 hours)

   • Any button battery in the stomach, especially lithium batteries 2
   • Sharp or pointed objects
   • Magnets (single large or multiple)
   • Objects >2.5 cm in length or >2 cm in diameter
   • Any object causing symptoms (pain, vomiting, drooling)

3. Observation with Follow-up

   • Small (<2 cm), blunt objects without symptoms
   • Follow with serial radiographs if radiopaque
   • Parental education about monitoring stool for passage
   • Return for evaluation if symptoms develop

Special Considerations

• Button Batteries: The American Gastroenterological Association recommends urgent removal of all button batteries in the stomach due to the risk of severe tissue damage, even when asymptomatic 1

• Coins: While most common, they typically pass spontaneously if in the stomach. However, they should be removed if symptomatic or not passing after 2-4 weeks 3

• CT Scan: Recommended over plain radiographs for accurate assessment of foreign body location and potential complications, especially if perforation is suspected 1

• Post-Procedure Care: After removal or confirmed passage, evaluate for underlying esophageal disorders, which are found in up to 25% of patients with food bolus impaction 1

Common Pitfalls to Avoid

• Delay in removing high-risk objects: Button batteries, particularly lithium batteries, can cause significant tissue damage within hours, even when in the stomach 2

• Relying solely on plain radiographs: These have limited utility with high false-negative rates (up to 85%) for small objects 1

• Missing underlying conditions: Up to 25% of children with foreign body ingestion have underlying esophageal disorders that should be evaluated 1

• Inadequate follow-up: Ensure proper follow-up for objects being managed conservatively to confirm passage

By following these criteria, clinicians can appropriately manage ingested foreign bodies in children's stomachs, minimizing the risk of complications while avoiding unnecessary interventions.