What is the management of a pediatric patient who swallowed a cloth without showing any respiratory symptoms?

Emergency Department Disposition for Pediatric Cloth Ingestion Without Respiratory Symptoms

For a pediatric patient who swallowed a cloth without respiratory symptoms, obtain an abdominal X-ray to confirm location, maintain the child NPO (nothing by mouth) initially, and admit for observation with urgent gastroenterology consultation for endoscopic removal within 24 hours. 1, 2

Immediate Assessment and Imaging

• Obtain abdominal X-ray as first-line imaging to determine the presence and location of the foreign body, even though cloth is radiolucent and may not be visible. 1, 3
• Plain radiographs have limited utility for radiolucent objects like cloth, with false-negative rates up to 85%, so a normal X-ray does NOT exclude the presence of the foreign body. 2
• If X-ray is negative but history is reliable, proceed with CT scan, which has 90-100% sensitivity for radiolucent foreign bodies and can identify complications. 2
• Clinical history takes precedence over imaging findings—a witnessed ingestion mandates intervention regardless of radiographic findings. 3

Risk Stratification and Disposition Decision

This patient requires hospital admission rather than discharge home because:

• Cloth is a non-food, radiolucent foreign body that will not pass spontaneously like coins or small smooth objects. 1, 4
• Cloth can cause obstruction, particularly at the pylorus or ileocecal valve, and has potential for bezoar formation. 5, 6
• The majority of ingested foreign bodies pass spontaneously, but cloth is an exception due to its size, texture, and tendency to retain fluids and expand. 4, 5
• Surgical intervention may be required if the object becomes impacted, with one study showing surgery was needed when follow-up exceeded 4 days. 6

Initial Management in the Emergency Department

• Make the patient NPO immediately to prevent further passage into the small bowel and to prepare for potential endoscopy. 1, 2
• Maintain IV hydration while NPO. 1
• Do NOT give laxatives or attempt to induce vomiting, as this does not accelerate passage and may cause complications. 1
• Avoid barium contrast studies, as they can coat the foreign body, increase aspiration risk, and interfere with subsequent endoscopy. 1, 3

Timing of Endoscopic Intervention

Urgent flexible endoscopy within 24 hours is recommended for cloth ingestion, even in asymptomatic patients. 2, 7

• If the cloth is lodged in the esophagus causing complete obstruction (inability to handle secretions, drooling), emergent endoscopy within 2-6 hours is required. 2
• For partial obstruction or gastric location without complete obstruction, urgent endoscopy within 24 hours is appropriate. 2, 7
• Flexible endoscopy is first-line, with rigid endoscopy reserved as second-line therapy, particularly for upper esophageal objects. 2

Red Flags Requiring Immediate Escalation

Watch for and immediately escalate if the patient develops:

• Persistent vomiting or inability to swallow secretions (suggests complete obstruction). 1, 2
• Severe abdominal pain (suggests perforation or ischemia). 1, 3
• Signs of perforation: fever, peritoneal signs, hemodynamic instability. 1
• Respiratory distress or stridor (suggests airway involvement despite initial lack of symptoms). 3
• Hematemesis (suggests mucosal injury). 1

Consultation and Admission Orders

• Urgent gastroenterology consultation for endoscopic removal planning. 2, 7
• Surgical consultation should be obtained concurrently, as cloth may be irretrievable by endoscopy and require surgical removal. 1, 6
• Admit to pediatric ward with continuous monitoring for development of symptoms. 6, 7
• Serial abdominal exams every 4-6 hours to detect early signs of obstruction or perforation. 1, 6

Common Pitfalls to Avoid

• Do not be falsely reassured by absence of symptoms—cloth can cause delayed obstruction or perforation. 3, 6
• Do not discharge home for outpatient follow-up—cloth requires active intervention, not expectant management. 4, 6
• Never perform blind finger sweeps, as this may push the foreign body further into the airway if any portion remains in the pharynx. 1, 3
• Do not delay intervention beyond 4 days, as this significantly increases the likelihood of requiring surgical intervention. 6

If Endoscopic Removal Fails

• Surgical intervention is indicated for foreign bodies irretrievable by endoscopy, evidence of perforation, or development of complete bowel obstruction. 1
• Laparotomy or laparoscopy may be required, with the approach depending on the location and clinical condition. 5, 8, 6