What to do if a 4-year-old ingests a small screw?

Management of Small Screw Ingestion in a 4-Year-Old Child

A 4-year-old who has swallowed a small screw requires immediate medical evaluation with radiographic imaging (X-rays) to locate the object and determine appropriate management. 1

Initial Assessment and Evaluation

• Obtain immediate radiographs of the neck, chest, and abdomen to locate the screw

  • Small metal objects like screws are radiopaque and should be visible on X-ray
  • CT scan may be necessary if plain X-rays are negative but symptoms persist 2
  • Contrast studies should be avoided as they may coat the foreign body and impair endoscopic visualization 2

• Assess for symptoms of distress or complications:

  • Difficulty swallowing or excessive drooling
  • Respiratory distress (coughing, wheezing, stridor)
  • Chest or abdominal pain
  • Vomiting, especially bilious vomiting (sign of intestinal obstruction) 3

Management Algorithm Based on Location

If the screw is in the esophagus:

• Urgent endoscopic removal is required 2, 1
  • Timing of endoscopy:
    • Emergent (within 2-6 hours): If complete esophageal obstruction, sharp-pointed object, or battery 2
    • Urgent (within 24 hours): For other esophageal foreign bodies without complete obstruction 2

If the screw is in the stomach or beyond:

• Most small, smooth foreign bodies that have passed into the stomach will pass through the gastrointestinal tract without complications

• Observation is appropriate if:

  • The child is asymptomatic
  • The screw is small, smooth, and not sharp-pointed
  • No signs of obstruction or perforation

• Follow-up X-rays may be needed if:

  • The screw has sharp edges
  • The child develops symptoms
  • The screw doesn't pass within 1-2 weeks

Warning Signs Requiring Immediate Medical Attention

• Instruct parents to seek immediate medical care if the child develops:
  • Vomiting, especially bilious vomiting
  • Abdominal pain or distension
  • Blood in stool
  • Fever
  • Difficulty breathing or swallowing

Prevention Strategies

• Educate parents about keeping small objects like screws out of reach of young children 1
• The American Academy of Pediatrics recommends that objects for children under 3 years should not fit through a cylinder with a diameter of 3.17 cm (1.25 in) 1
• Children under 3 years are at highest risk for foreign body ingestion 1

Important Caveats

• Metal objects like screws are usually visible on X-ray, making them easier to locate than radiolucent objects
• Sharp objects like screws pose a higher risk of complications including perforation
• Children may not always report symptoms accurately, so close monitoring is essential
• If the screw cannot be located on imaging but ingestion is certain, consider CT scan for better visualization 2

Remember that while most small foreign bodies pass without incident, prompt medical evaluation is essential to rule out potential complications and determine appropriate management.