What is the management of corrosive caustic ingestion in pediatric patients?

Management of Corrosive Caustic Ingestion in Pediatrics

Immediate Emergency Management

In pediatric caustic ingestion, do NOT induce vomiting, perform gastric lavage, or administer neutralizing agents—these interventions are absolutely contraindicated and can cause further injury including perforation. 1

Initial Stabilization and Assessment

• Assess airway, breathing, and circulation immediately as the first priority, monitoring for signs of respiratory distress from vapor aspiration or upper airway edema 1
• Contact Poison Control Centers to evaluate potential systemic toxicity of the specific ingested agent 2
• Obtain detailed history including the nature of the corrosive (acid vs. alkali), physical form (solid vs. liquid), quantity ingested, and whether ingestion was accidental (most common in children at 89%) or intentional 2, 3
• Do not rely on clinical symptoms alone—the absence of oral lesions or pain does not rule out life-threatening gastrointestinal injuries 2

Laboratory Evaluation

Obtain initial laboratory tests including: 2

• CBC with differential
• Comprehensive metabolic panel (sodium, potassium, chloride, magnesium, calcium, urea, creatinine)
• Liver function tests (bilirubin, ALT, AST)
• Arterial blood gas with pH and serum lactate
• Blood alcohol level if indicated

Monitor laboratory trends closely—abnormal values such as severe acidosis, elevated lactate, deranged liver function, leukocytosis, elevated CRP, renal failure, or thrombocytopenia predict transmural necrosis and poor outcomes 2

Diagnostic Imaging Strategy

Contrast-Enhanced CT: The Preferred Initial Diagnostic Tool

Perform contrast-enhanced CT scan 3-6 hours after ingestion as the primary diagnostic modality in pediatric caustic ingestion. 1 CT is superior to endoscopy for detecting transmural injuries and better predicts stricture formation risk 1

The CT grading system for esophageal injury includes: 2

• Grade I: Homogeneous wall enhancement without edema
• Grade IIa: Internal mucosal enhancement with hypodense thickened wall ("target sign")
• Grade IIb: Fine rim of external wall enhancement with non-enhancing necrotic mucosa
• Grade III: Absence of post-contrast wall enhancement (transmural necrosis)

Role of Endoscopy in Pediatric Patients

Endoscopy remains the upfront evaluation in children because severe injuries are rare and long-term radiation exposure is a significant concern 2

Perform emergency endoscopy when: 2

• CT is unavailable
• CT with contrast is contraindicated (renal failure, iodine allergy)
• CT suggests transmural necrosis but interpretation is uncertain
• In the pediatric population as first-line evaluation

Timing is critical: 1, 3, 4

• Perform endoscopy within 12-48 hours after ingestion for initial assessment
• Endoscopy is considered safe on days 1-5 after ingestion
• Avoid endoscopy between 1-3 weeks post-ingestion due to significantly elevated perforation risk during the healing phase
• Use gentle air insufflation or preferably CO2 during the procedure

The Zargar endoscopic classification is most commonly used, though CT outperforms it for predicting stricture formation 2

Medical Management

Supportive Care Protocol

Keep the patient NPO (nothing by mouth) until diagnostic evaluation is complete. 5

Administer: 5

• IV fluids for hydration
• Broad-spectrum antibiotics if indicated (59% agreement among gastroenterologists) 3
• Acid suppression therapy (proton pump inhibitors or ranitidine) in all cases 3, 5
• Single-dose steroid may be given initially, though steroids do NOT prevent stricture formation in full-thickness injuries 6, 5

Feeding Strategy Based on Injury Severity

Base feeding decisions on endoscopic findings: 3, 5

• Grade 1 and 2a burns: Discharge after endoscopy with oral feeding
• Grade 2b and Grade 3 burns: NPO for one week except water when swallowing saliva; provide total parenteral nutrition (TPN)
• After the first week, introduce liquid foods if swallowing is intact
• Place nasogastric tube under endoscopic guidance if needed (80% of gastroenterologists use this approach) 3

Avoid intraluminal tubes in the esophagus—limiting oral intake and avoiding foreign bodies provides good success rates 5

Surgical Indications

Emergency surgical intervention is indicated for: 1

• Transmural necrosis (Grade III CT findings)
• Gastrointestinal perforation with mediastinitis or peritonitis
• Progressive clinical deterioration despite non-operative management

Patients without full-thickness necrosis should undergo non-operative management. 2

Long-Term Management: Stricture Formation

Surveillance and Detection

Perform barium swallow and upper GI series at the end of the 3rd week to assess for stricture development 5

Strictures typically occur within 4 months after ingestion, with esophageal involvement more common than gastric 2, 1

Endoscopic Dilation Protocol

Begin endoscopic dilation 3-6 weeks post-ingestion for patients with few (<3) short (<5 cm) esophageal strictures 2, 1

Dilation parameters: 2, 1

• Interval between dilations: Less than 2-3 weeks (shorter than standard benign strictures)
• Expected sessions: 3-5 sessions typically provide satisfactory results
• Use fluoroscopic guidance to improve safety
• Perforation risk is substantially higher (0.4-32%) compared to standard benign strictures (0.1-1.1%)

Monitor closely for perforation signs: persistent chest pain, breathlessness, fever, or tachycardia—obtain chest X-ray immediately if suspected 1

Refractory Stricture Management

Consider esophageal reconstruction after 5-7 failed dilation attempts or recurrent failure of endoscopic dilation 2, 1

For refractory strictures: 1

• Intralesional steroid injections combined with dilation
• Fully covered self-expanding metal stents (with limitations including chest pain and migration)
• Major esophageal surgery (esophageal resection with reconstruction) is performed in approximately 23% of pediatric cases at a median of 208 days post-ingestion

Substernal right colonic interposition is well-tolerated with few complications and satisfactory long-term growth and development 6

Critical Pitfalls to Avoid

Common management errors include: 1

• Relying solely on clinical symptoms to assess severity—this is unreliable and may delay appropriate intervention
• Performing gastric lavage—this is absolutely contraindicated
• Delaying surgical intervention when transmural necrosis is present—this increases mortality
• Performing endoscopy during the 1-3 week healing phase—perforation risk is significantly elevated
• Neglecting psychiatric evaluation in intentional ingestions

Prevention Considerations

Most pediatric ingestions are accidental (89%) and occur in children aged 2-5 years due to improper corrosive storage 3, 4

The most common caustic agents in children are: 3, 4

• Laundry detergent pods (25%)
• Sodium hydroxide/lye (14%)
• Alkali preparations (most injurious overall)

Proper storage and labeling of corrosives can potentially prevent the majority of pediatric cases. 3