Abstract
Aspiration of a foreign body is common in children and can cause upper airway obstruction, leading to significant morbidity or mortality. We report 3 cases of aspiration of a popular fruit-flavored gel snack that led to cardiopulmonary arrest and death in 1 case and respiratory failure in 2 other cases. There is increasing concern about the safety of this gel snack and its risk of aspiration, even in older children. Pediatricians should advise parents and children about the dangers of eating this candy during their health maintenance visits.
Foreign body (FB) aspiration is a common occurrence in infants and young children and can be a life-threatening event. Almost 2.5 million children are affected each year in the United States and FB aspiration leads to ∼300 deaths annually.1 The most frequently aspirated objects are organic food items such as peanuts, popcorn, hot dogs, or vegetable matter. Nonfood objects include balloons, coins, pen tops, and pins.1–3 One food item, called fruit gel snack, is widely available in Asia and is increasingly becoming popular in the Western hemisphere. It is sold in the United States under different trade names, including Gel-ly Drop and Fruit Poppers. This candy consists of a small flavored gel with a central fruit core. We present 3 cases of aspiration of this food in children that caused cardiopulmonary arrest and death in 1 case and respiratory failure in 2 other cases.
CASE REPORTS
Case 1
A 5-year-old boy was brought to the emergency department (ED) in cardiopulmonary arrest after choking on a fruit gel snack. He was eating the candy and few minutes later started coughing, gagging and then collapsed. The emergency medical technicians arrived and found that he had no pulse. After examining his airway, they removed a 1.5-cm piece of gel from his oropharynx. Bag-valve mask ventilation and chest compressions were initiated and he was brought to the ED.
On initial examination, he had no spontaneous respirations or pulse. Resuscitation included intubation, chest compressions and administration of epinephrine, atropine, and sodium bicarbonate. After 3 doses of epinephrine, a normal sinus rhythm was obtained. His pulse was 144 beats/minute; blood pressure, 102/58 mm Hg; and temperature, 34.2°C. His skin was cold with peripheral cyanosis. Bilateral equal air entry and normal heart sounds were heard on auscultation. Neurologic examination revealed an unresponsive child with a Glasgow coma scale of 3 and his pupils were 5 mm and nonreactive. An arterial blood gas showed a pH of 6.95, Paco2 of 48 mm Hg, Pao2 of 519 mm Hg and base deficit of −22 mEq/dL. Initial laboratory results revealed a white blood cell count of 8800/mm3, hemoglobin of 12 g/dL, and platelets 214 000/mm3. A chest radiograph demonstrated bilateral pulmonary edema. He was felt to be unstable to go to the operating room for direct laryngoscopy and rigid bronchoscopy. A few hours later he had focal seizure and was given phenytoin and phenobarbital. Computed tomography of the head was normal. Two days later he became febrile to 38.5°C, a repeat chest radiograph was consistent with pneumonia, so therapy was initiated with ceftriaxone, gentamicin, and clindamycin.
Three days after admission he developed diabetes insipidus and received desmopressin acetate. He also required inotropic support for hypotension. His physical examination was consistent with brain death. An apnea test revealed no respiratory effort and after a radionucleotide cerebral blood flow study demonstrated no flow, he was pronounced brain-dead.
Case 2
An 8-month-old previously healthy infant boy presented to the ED after experiencing a respiratory arrest. His mother gave him a piece of fruit gel candy, and while eating it, he immediately started chocking and became cyanotic. Cardiopulmonary resuscitation was started by bystanders and when the paramedics arrived, they found the infant unresponsive, cyanotic, and bradycardic with a heart rate of 40 beats/minute. The paramedics were unable to visualize a FB in the oral cavity. Bag-mask ventilation was successfully instituted and the infant was brought to the ED.
In the ED, he was immediately intubated and a 2.5- to 3-cm piece of pink, gelatinous mass with a central fruit core was removed from his oropharynx. A copious amount of pink, frothy fluid was suctioned from his endotracheal tube. His vitals signs included a temperature of 37°C, heart rate of 186 beats/minute, and blood pressure of 53/33 mm Hg. On physical examination, he was pale and unresponsive. Breath sounds were heard bilaterally with end expiratory rales and occasional wheezing. Cardiac examination was significant for regular rate and rhythm, but decreased peripheral perfusion. A venous blood gas showed a pH of 6.88 with a Paco2 of 80 mm Hg. Chest radiograph revealed bilateral haziness. A normal saline bolus was given with improvement in his hemodynamics.
The infant was immediately taken to the operating room for direct laryngoscopy and rigid bronchoscopy under general anesthesia. No FB was seen in the oropharynx, hypopharynx, subglotic area, or bronchi. He was transferred to the pediatric intensive care unit where he was hypotensive with poor peripheral perfusion. Additional fluids were administered with improvement in his perfusion.
On the second hospital day, he became febrile with a temperature of 39°C. A chest radiograph showed right upper lobe atelectasis. Blood and sputum cultures were obtained and treatment for aspiration pneumonia was initiated with ampicillin/sulbactam. He remained febrile with a temperature as high as 40°C, and his white cell count increased to 22 000/mm3 with78% neutrophils and 17% bands. He was switched to piperacillin/tazobactum and gentamicin. His blood culture grew Pseudomonas aeruginosa and the respiratory culture grew methicillin-sensitive Staphylococcus aureus and P aeruginosa. The infant was extubated 6 days after admission, and he completed a 10-day course of intravenous antibiotics. At the time of hospital discharge, his neurologic examination was normal.
Case 3
A 1-year-old previously healthy girl was eating a lychee-flavored gel when she suddenly started coughing, gagging, choking, and turned blue. The grandfather made multiple attempts to remove the candy from her mouth with finger sweeps and back blows, but he was unsuccessful. When the paramedics arrived, the child was tachycardic, tachypneic, and stridorous. On direct visualization of the oropharynx, they removed a piece of candy and transported the infant to the ED.
On arrival to the ED, she was pale, lethargic, and in moderate respiratory distress. When the oral cavity was examined, another piece of candy was seen and removed. Vital signs included a respiratory rate of 64 breaths/minute, heart rate of 196 beats/minute, blood pressure of 103/63 mm Hg, temperature of 36.2°C, and pulse oximetry saturation of 78% in room air. Chest examination showed bilateral equal air entry and occasional rales.
Because of progressive respiratory distress, she was intubated and large amount of pink, frothy fluid was suctioned from the endotracheal tube. An arterial blood gas after intubation showed a pH of 7.33, Paco2 of 46 mm Hg, Pao2 of 237 mm Hg. A chest radiograph showed bilateral pulmonary edema and a failure of decompression of the right lung on a right lateral decubitus film. She was transferred to another hospital for direct laryngoscopy and rigid bronchoscopy for suspicion of residual FB. In the operating room, no FB was seen in the larynx, trachea, or bronchi.
The infant became febrile later that day with a temperature of 38.3°C. Tracheal aspirate and blood cultures were sent and ticarcillin/clavulanate was administered empirically for aspiration pneumonia. The chest radiograph showed improvement in pulmonary edema. She was extubated the following day and her respiratory cultures grew methicillin-sensitive S aureus, and the antibiotics were changed appropriately. The patient was discharged from the hospital 3 days later with a normal physical and neurologic examination. She was to complete a 10-day course of ampicillin/clavulanate.
DISCUSSION
FB aspiration is a significant cause of morbidity and mortality in children. The degree of airway compromise and the severity of symptoms depend on the location and nature of the aspirated object. Items lodged in the oral cavity, hypopharynx, or larynx can produce airway obstruction leading to hypoxia, respiratory failure, or even cardiac arrest.4,5 However, most items pass through the larynx and become lodged in the trachea or main stem bronchus.6 If the FB remains in the bronchial tree undiagnosed, it can lead to inflammation and pneumonia, chronic infection, or abscess formation.
Aspiration of a FB is most common in the second year of life, with 80% of all events occurring in children 18 months to 3 years of age. The history usually includes an acute onset of coughing, choking, wheezing, respiratory distress, and/or stridor.7 In the cases described, the children were 8 months to 5 years of age and the aspiration was witnessed by the parents. The gel candy was lodged in the oropharynx, leading to immediate upper airway obstruction, respiratory distress and in 1 case, cardiopulmonary arrest. In other cases, the diagnosis may be more difficult and requires a high index of suspicion. Typical physical findings include tachypnea, unequal breath sounds, wheezing, and stridor. Radiologic examination may be helpful if the FB is radiopaque or if there is an area of atelectasis and/or air trapping. However, if there is a strong clinical suspicion of aspiration, evaluation by rigid bronchoscopy in the operating room is indicated, even in the absence of clinical signs or radiographic finding.8
The 3 cases we presented are significant for the aspiration of the same type of fruit-flavored gel snack. This candy consists of a small piece of flavored gel with a central fruit core and is packaged in a soft plastic cup the size of a coffee creamer. It was developed in Japan in the early 1990s and is sold under trade names such as Gel-ly Drop, Fruit Poppers, and Fruit Gel Snacks and is available in different flavors. The main ingredient in the snack is konjac powder, a nonfat, low-calorie fiber food used for weight reduction.9 This ingredient acts as a binding agent, making the snack particularly hard to dissolve. Because of its small size and shape, consistency and central fruit core, it is a significant aspiration risk for children. It does not dissolve easily in saliva, and infants and toddlers are unable to effectively chew it because of their lack of molars. Nonetheless, even older children are at risk as some children who have died from aspiration of this snack were 11 to 12 years old.10
In the cases we presented, a piece of fruit gel was removed from the oropharynx and 2 of the children were taken to the operating room for direct laryngoscopy and rigid bronchoscopy. The third child was deemed too unstable to have this procedure performed. Treatment for suspected FB aspirations consists of direct visualization of the airway and bronchi with a rigid bronchoscopy under general anesthesia.11,12 This allows the FB to be removed and is effective in >95% of cases with a complication rate of <1%. Complete removal of the FB is important to prevent future sequelae.
All 3 patients described in this report had abnormal findings on chest radiograph immediately after relief of the airway obstruction. It is likely that at least 2 of the children aspirated, because they developed evidence of pulmonary infection during their hospital course.13 It is also possible that the patients had postobstructive pulmonary edema.14 It is thought that this occurs when there is a sudden increase in negative intrathoracic pressure as the patient breathes against an obstructed airway, leading to an increase in venous return, a decrease in cardiac output, and fluid transudation into the alveolar space.15,16 Postobstructive pulmonary edema is readily treated with mechanical ventilation and usually resolves rapidly.
Recently, there have been other deaths reported from aspiration of this candy. Because of increasing concerns about its safety, the US Food and Drug Administration has issued a warning that this product poses a significant risk for choking, particularly in infants, children, and the elderly.17 In response to this warning, several large retailers have removed the snack from their shelves. However, it is still readily available from many smaller stores and on the Internet, is widely available in Asia, and can be hand-carried into the United States. Although the package has a warning that this candy is not suitable for children <3 years of age, several aspiration-related deaths have occurred in children older than 3 years, including 1 of the cases we reported, and many parents believe it is safe for older children.
Pediatricians should be aware of the aspiration risks posed by these candies. They should educate parents and children of all ages of the dangers of eating these snacks until such time that they are no longer available.
REFERENCES
- Copyright © 2003 by the American Academy of Pediatrics
