What is the treatment for a 3-year-old patient (pt) who ingested a pen?

Management of Pen Ingestion in a 3-Year-Old Child

For a 3-year-old child who has swallowed a pen, immediate medical evaluation is necessary to determine the location of the foreign body and prevent potential complications such as perforation or obstruction.

Initial Assessment

• Determine if the child is showing any signs of respiratory distress, drooling, vomiting, refusal to eat, or pain
• Assess when the ingestion occurred and the type/size of the pen
• Evaluate for symptoms suggesting esophageal obstruction:
  • Drooling
  • Inability to swallow
  • Gagging
  • Chest or throat pain
  • Respiratory distress

Diagnostic Approach

• Obtain immediate radiographs (X-rays) of the neck, chest, and abdomen to locate the pen 1
• Most pens contain metal components that will be visible on X-ray
• If the pen is not visible on X-ray but ingestion is confirmed, consider additional imaging

Management Algorithm

1. If the child shows signs of respiratory distress or complete obstruction:

   • Activate emergency services immediately
   • Do not attempt blind finger sweeps which may push the object further

2. If the pen is located in the esophagus:

   • Urgent endoscopic removal is required, typically via rigid esophagoscopy 2
   • Esophageal foreign bodies require prompt removal (within 24 hours) to prevent complications such as perforation 2, 3

3. If the pen is in the stomach or has passed into the intestines:

   • If the child is asymptomatic and the pen is not excessively long:
     • Consider observation with serial X-rays to monitor passage
     • Most foreign bodies that reach the stomach will pass spontaneously 4
   • If the pen is large (>10 cm) or shows signs of causing obstruction:
     • Endoscopic removal may be necessary 2

4. If perforation is suspected (fever, severe abdominal pain, vomiting):

   • Immediate surgical consultation is required
   • Laparoscopic or open surgical removal may be necessary 5

Important Considerations

• Unlike coins or small objects, pens are typically long and rigid, increasing the risk of complications
• A pen measuring nearly 15 cm in length has been reported as the longest non-flexible foreign body ingested by a young child 2
• Do not administer activated charcoal, as it is not effective for foreign body ingestion and is contraindicated in cases where endoscopy may be needed 6
• Do not induce vomiting as this could cause additional trauma if the pen is lodged in the esophagus

Prevention of Future Incidents

• Educate parents about keeping small objects and writing instruments out of reach of young children
• Children under 3 years are at highest risk for foreign body ingestion, with choking rates highest among infants (140.4 per 100,000 population) 1
• The U.S. Consumer Product Safety Commission guidelines recommend that objects for children under 3 years should not fit through a cylinder with a diameter of 3.17 cm (1.25 in) 1

Follow-up

• If the pen passes into the intestines and the child remains asymptomatic, parents should monitor stools for passage of the pen
• Follow-up X-ray in 1-2 weeks if the pen has not been observed in stool
• Return immediately to medical care if the child develops fever, abdominal pain, vomiting, or blood in stool