What is the next step in managing a 12-month-old child who may have ingested a small plastic shoe from a doll, is currently asymptomatic, and has normal vital signs?

Management of Suspected Foreign Body Ingestion in a 12-Month-Old Child

The appropriate next step for this 12-month-old boy who may have swallowed a small plastic shoe from a doll is to obtain an abdominal X-ray to locate the foreign body, as the child is currently asymptomatic with normal vital signs.

Initial Assessment

• The child is currently asymptomatic with normal vital signs and physical examination, which is reassuring but does not rule out foreign body ingestion 1
• Foreign body ingestion is common in children under 5 years of age, with small objects being a frequent cause 1
• Since the ingestion was not directly witnessed but a small plastic object is missing, diagnostic imaging is warranted to confirm ingestion and location 1

Diagnostic Approach

• Abdominal X-ray is the first-line imaging study for suspected foreign body ingestion to determine:
  • Presence of the foreign body
  • Location within the gastrointestinal tract
  • Any signs of obstruction or perforation 1
• Although plastic objects may not be radiopaque, they might still be visible on X-ray or reveal secondary signs of obstruction if present 2

Management Algorithm

1. Obtain abdominal X-ray to locate the foreign body

2. If the object is visualized and appears to be in the stomach or has passed beyond:

   • Most small, smooth plastic objects will pass spontaneously through the gastrointestinal tract 2
   • Provide anticipatory guidance to parents about monitoring stools for passage of the object 1
   • Instruct parents to return if symptoms develop (vomiting, abdominal pain, refusal to eat, irritability) 3

3. If the object is not visualized on X-ray:

   • Consider additional imaging such as ultrasound or CT scan if clinical suspicion remains high 2
   • Consider observation in the emergency department if there is concern for potential complications 3

4. If the object is in the esophagus or shows signs of obstruction:

   • Immediate surgical consultation is required 4
   • Prepare for possible endoscopic removal 2

Red Flags Requiring Immediate Intervention

• Development of respiratory symptoms (coughing, gagging, stridor, wheezing) suggesting airway involvement 1
• Bilious vomiting suggesting intestinal obstruction 4
• Signs of peritonitis or perforation (severe abdominal pain, distention, fever) 2
• Inability to tolerate oral intake 3

Important Considerations

• Foreign body ingestion can lead to serious complications including gastrointestinal obstruction or perforation, though most small, smooth objects pass without intervention 2
• The size and shape of the object (small plastic shoe) makes it likely to pass spontaneously if it has reached the stomach 2
• Blind finger sweeps should never be performed as they may push foreign bodies further into the airway 1
• Parents should be educated about preventing future foreign body ingestions through appropriate toy selection and supervision 2

Follow-up Recommendations

• If the object is not passed within 3-4 days or if symptoms develop, follow-up imaging should be obtained 3
• Parents should be instructed to examine stools for passage of the foreign body 3
• Return precautions should include development of abdominal pain, vomiting, fever, or blood in stool 3, 4