What are the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines for managing radiolucent foreign body ingestion in children?

ESPGHAN Guidelines on Radiolucent Foreign Body Ingestion in Children

Emergent flexible endoscopy (within 2-6 hours) is recommended for radiolucent foreign body ingestion in children when there is complete esophageal obstruction or symptoms of impaction. 1

Initial Assessment

• Radiolucent foreign bodies (such as food boluses, plastic objects) require careful clinical evaluation as they cannot be visualized on plain radiographs 1, 2
• Plain radiographs have limited utility for radiolucent objects with false-negative rates up to 85% 1
• CT scan is the preferred imaging examination for suspected complications with 90-100% sensitivity 1
• Complete blood count, C-reactive protein, blood gas analysis, and lactate should be obtained as part of initial evaluation 1
• Clinical presentation typically includes acute onset of dysphagia or inability to swallow saliva 3

Management Algorithm Based on Obstruction Severity

Complete Obstruction

• Emergent flexible endoscopy (preferably within 2 hours, at latest within 6 hours) is recommended for radiolucent foreign bodies causing complete esophageal obstruction 3, 1
• Complete obstruction presents with inability to swallow saliva, drooling, and respiratory distress 3, 1
• Contrast swallow studies are not recommended and should not delay other investigations/interventions 3

Partial Obstruction

• Urgent flexible endoscopy (within 24 hours) is recommended for radiolucent foreign bodies causing partial obstruction 3, 1
• Partial obstruction presents with ability to swallow but with discomfort 3
• Observation alone may be appropriate for asymptomatic patients with small radiolucent objects that are likely to pass spontaneously 2

Endoscopic Techniques

• For food bolus impaction, the "push technique" (gently pushing the bolus into the stomach with air insufflation) is recommended as first-line treatment with up to 90% success rate 3, 1
• If the push technique fails, retrieval using baskets, snares, or grasping forceps should be employed 3, 1
• Flexible endoscopy remains the "first line" approach; rigid endoscopy has a place as a "second line" therapy, particularly for objects located in the upper esophagus 3
• Diagnostic biopsies (at least 6 from different sites) should be taken during endoscopy to evaluate for underlying esophageal disorders 1

Post-Removal Management

• After foreign body removal, diagnostic work-up for potential underlying disease is recommended 3
• An underlying esophageal disorder can be found in up to 25% of patients, including esophageal stricture, hiatus hernia, Schatzki ring, eosinophilic esophagitis, achalasia, and tumors 3, 1
• Latent eosinophilic esophagitis may be diagnosed in up to 9% of patients with food bolus impaction 3
• Schedule outpatient follow-up to confirm the cause of impaction and institute appropriate therapy for underlying conditions 1

Common Pitfalls to Avoid

• Failure to obtain diagnostic biopsies during index endoscopy, leading to missed diagnoses of underlying conditions 1
• Using contrast swallow studies which may delay intervention and increase aspiration risk 3
• Performing blind finger sweeps that may push foreign bodies further into the pharynx 3
• Losing patients to follow-up if not properly scheduled for outpatient review before discharge 1
• Failing to recognize that each pediatric emergency service should develop an individualized protocol based on local resources and epidemiological context 2

Special Considerations

• In children under 5 years of age, foreign body ingestion is particularly common, with 74% of cases occurring in this age group 4
• Up to 16% of children with foreign body ingestion may be asymptomatic, requiring a high index of suspicion 4
• The upper third of the esophagus is the most common location (79%) for foreign body impaction in children 4