What should be done if a 6-year-old swallows a chicken bone?

Management of Swallowed Chicken Bone in a 6-Year-Old Child

Obtain plain radiographs immediately (neck, chest, and abdomen), but if the child has persistent symptoms—especially dysphagia, drooling, inability to swallow saliva, or throat/chest pain—proceed directly to CT scan regardless of X-ray findings, as chicken bones have an 85% false-negative rate on plain films. 1, 2

Immediate Clinical Assessment

Key Symptoms to Identify

• Acute dysphagia or inability to swallow saliva indicates potential esophageal impaction requiring emergent intervention 1
• Drooling, retching, or vomiting suggests esophageal obstruction 1
• Neck tenderness, retrosternal pain, or sore throat may indicate bone lodgment 1
• Choking, stridor, or dyspnea signals possible airway involvement requiring immediate airway management 1
• Fever or cervical subcutaneous emphysema indicates perforation and represents a surgical emergency 1

Physical Examination Priorities

• Check for cervical erythema, tenderness, or subcutaneous emphysema as signs of perforation 1
• Assess ability to handle secretions and respiratory status 1

Diagnostic Imaging Algorithm

Initial Plain Radiographs

• Obtain biplanar (AP and lateral) neck, chest, and abdominal X-rays to assess for radiopaque objects and signs of perforation 1, 2
• Critical limitation: Plain radiography has a 47% false-negative rate for esophageal foreign bodies and up to 85% false-negative rate specifically for chicken bones 1, 2, 3
• The lateral view is essential to differentiate esophageal from tracheal location 1

When to Proceed Directly to CT Scan

CT scan should be performed in any of the following scenarios:

• Persistent symptoms despite negative X-ray (sensitivity 90-100%, specificity 93.7-100% for bone detection) 1, 2
• Any suspicion of perforation (free air, fever, severe pain) 1, 2
• Negative X-ray in a symptomatic child reporting chicken bone ingestion 1, 2
• CT is essential because it detects complications including perforation, abscess, and mediastinitis 1, 2

Laboratory Testing

• Obtain CBC, CRP, blood gas analysis for base excess and lactate if intervention is anticipated or perforation suspected 1, 2

Avoid Contrast Studies

• Do not perform barium or gastrografin swallow studies, especially with complete obstruction, due to aspiration risk and impaired endoscopic visualization 1
• Contrast studies should not delay other investigations or interventions 1

Endoscopic Management

Emergent Endoscopy (Within 2-6 Hours)

Indications requiring emergent flexible endoscopy: 1, 2, 4

• Complete esophageal obstruction (inability to swallow saliva, drooling)
• Sharp-pointed objects like chicken bones (up to 35% perforation risk)
• Any esophageal foreign body in a symptomatic child

Urgent Endoscopy (Within 24 Hours)

• Persistent esophageal symptoms even with negative radiographic examination 1, 2
• Confirmed esophageal chicken bone without complete obstruction 2, 4

Endoscopy Considerations for Children

• Most cases require general anesthesia with endotracheal intubation to protect the airway 1
• Flexible endoscopy is first-line treatment for esophageal foreign bodies 1, 2
• Rigid endoscopy should be considered for upper esophageal foreign bodies 4

Anatomical Vulnerability in 6-Year-Olds

Why This Age Group Is High-Risk

• Children aged 3-6 years have molars but are still learning to chew effectively, making them vulnerable to swallowing bone fragments 1
• Common impaction sites: cricopharyngeus muscle, aortic arch level, and upper esophageal sphincter 1, 4
• Smaller airway diameter means even small objects can cause significant obstruction 1, 4

Behavioral Risk Factors

• High activity while eating (running, talking, laughing) increases choking risk 1
• Children at this age may be easily distracted during meals 1

Serious Complications to Monitor

Life-Threatening Risks

• Esophageal perforation can occur with sharp chicken bones, leading to mediastinitis, abscess formation, or vascular injury 1, 5, 6
• Delayed presentation (days to months) can result in pressure necrosis and catastrophic hemorrhage from major vessel erosion 5, 6
• Aspiration if the bone dislodges into the airway 4, 7

Red Flags for Perforation

• Fever, cervical subcutaneous emphysema, or persistent severe pain mandate immediate CT and surgical consultation 1

Observation vs. Intervention Decision

When Observation May Be Appropriate

• If the child is completely asymptomatic and imaging shows the bone has passed into the stomach, 80-90% of ingested foreign bodies pass spontaneously 1
• However, chicken bones are sharp-pointed objects and warrant close monitoring even in the stomach

When Intervention Is Mandatory

• Any esophageal chicken bone requires endoscopic removal due to perforation risk 1, 2
• Complete obstruction requires emergent intervention within 2-6 hours 1, 2, 4

Common Pitfalls to Avoid

• Do not rely on negative X-rays alone in a symptomatic child—proceed to CT scan 1, 2, 3
• Do not delay endoscopy for contrast studies or additional imaging if clinical suspicion is high 1
• Do not assume the bone has passed just because the child seems comfortable—chicken bones can cause delayed perforation 5, 6
• Do not discharge without imaging if there is any history of chicken bone ingestion with symptoms 1, 2