Toddler Swallowed Paperclips

Dear Lisa,

My 20 month old swallowed two paperclips and I panicked. Did he really need to go to the ER?

“Toddler Swallowed Paperclips”

Dear “Toddler Swallowed Paperclips”,

Kids do the darndest things! Unfortunately, swallowing objects is one of their special talents. Children’s preference for using their mouth to explore puts them at risk for ingesting foreign objects such as coins, pins, tacks, pencil erasers, the tops of pens, wood chips, beads, paper clips and small toys.

Some children who put things into their mouths ingest them and others aspirate the object into their lungs. Although both scenarios are concerning, aspiration can lead to airway obstruction which can interfere with breathing. The anatomy of a child’s small airway in conjunction with their immature protective response lends itself to the aspiration of these small objects into their lungs.(1) The incidence of foreign body aspiration is highest amongst toddlers between 24 and 36 months old.(2)

Luckily when a small round object without sharp edges, such as a coin is ingested and not aspirated, it usually passes right through the bowels without a problem. Typically, swallowed coins can be found in a child’s stool a couple of days after ingestion. It’s just a messy job looking for the object in the child’s stool, and making sure that it passes without complications.

The complication rate of the ingestion of most foreign objects is as low as 1%.(3) On the other hand, sharp objects such as a tack or a group of sharp pins can cause a lot of damage, because they can pierce the bowel and cause bowel perforation, internal bleeding and seepage of stool. The complication rate for a sharp object increases to about 25%.(3) The complications of foreign body ingestion includes ulceration, internal bleeding, perforation of the bowel or obstruction of the bowel.(4) These are all serious conditions that require medical attention and want to be avoided.

The typical treatment for a child who swallows a foreign object is close observation and serial x-rays to follow the path of the object until it is expelled from the body.(4) Unfortunately many times this warrants a trip to the Emergency Room. An Emergency Room visit is also important because sometimes it is difficult to tell whether a child “ingested” (swallowed into the stomach) or “aspirated” (sucked into the lungs) the object. It is common for parents to find their child with an object in his mouth and in some cases the object disappears. Many times the initial assumption is that the child swallowed the object but in some cases the child actually sucked it into his airway.

Foreign body aspiration is especially a concern if an incident is not witnessed by an adult caregiver. A child could have an object in his mouth and then quickly take a deep inspiration and aspirate the object into his lungs without anyone knowing it. Initially the symptoms could include a period of gagging, coughing or wheezing. These symptoms may go away even though there is an object caught in the lungs depending upon the size, location and chemical composition of the object.(5)

A small object could become lodged into a child’s right main stem bronchus for example, leaving the left main bronchus patent and functioning well. As a result the child can be asymptomatic and appear to be breathing normal. (6) It is through a thorough history and physical examination as well as radiologic testing that the placement of foreign body can be determined.

The symptoms of foreign body ingestion and foreign body aspiration can be similar. Signs of foreign body ingestion (swallowed into the stomach) include coughing, choking, pain behind the sternum, and excessive salivation or drooling. (4) Signs that a child aspirated a foreign body (inhaled into the lungs) include cough, wheeze and decreased breath sounds.

In addition, the symptoms of foreign body aspiration can mimic the symptoms of common pediatric respiratory conditions. Symptoms such as coughing, wheezing and decreased breath sounds may also be found in conditions such as Bronchiolitis, Asthma, Pneumonia and Bronchitis. In my practice I have found on more than one occasion that a child was diagnosed with Asthma, when they actually had a foreign body caught in their lungs that their parent didn’t know about. It is not surprising that one study showed that only 15.7% of patients with a foreign body aspiration presented with the clinical triad of concomitant cough, localized wheezing and decreased breath sounds. (2)

It is important for a child with a foreign body ingestion to have an evaluation by a medical professional because of the many potential complications and because of the danger of a foreign body being caught in the airway. A foreign body in a child’s airway can cause airway obstruction, inflammation, infection and respiratory arrest.

Unfortunately a paper clip does have a sharp edge if bent a particular way and should be closely observed because of the potential for complications. In addition, when more than one object is ingested, there is a chance that the objects could become tangled and create a blockage in the intestines. Therefore your trip to the Emergency Room was a good idea and any time spent there was well spent. So I would not be concerned that you "panicked" or "over-reacted" because going to the Emergency room was the right thing to do.

Any child that ingests a foreign body and develops a fever, pain, vomiting, abdominal distention, bloody stools, black stools, constipation, listlessness, lethargy, chronic respiratory symptoms, changes in the sound of his cry or voice, drooling or the inability to eat or swallow should be evaluated by his doctor without delay. The ingestion of a battery or corrosive substance is considered a medical emergency and should be treated accordingly.

I hope everything with your child turns out smoothly.

References:
(1)Johnson DG, Condon VR. Foreign bodies in the pediatric patient. Curr Probl Surg. 1998;35:271-379.
(2)Midulla F. Guide R, Barbato A. Foreign Body Aspiration in Children. Pediatr Int. 2005;47:663-668.
(3)Harrington J, Fareri M. Tack Ingestion. Consultant for Pediatricians. 2006. August:508.
(4) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:393-394.
(5)Tokar B, Ozkan R, Illhan H. Tracheobronchial foreign bodies in children: Importance of accurate history and plain chest radiography in delayed presentation Clin Radiol. 2004;59:609-615.
(6) Madhok M, Jimenez-Vega J. Pin Ingestion. Consultant for Pediatricians. 2006. August:505-506.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Safe