Foreign-Body Ingestions of Young Children Treated in US Emergency Departments: 1995–2015

Discussion

During the 21-year study period, nearly 800 000 children <6 years of age were estimated to have sought care for FBIs in US EDs (an average of 99 children each day). This number likely reflects the accessibility of these objects because coins, jewelry, and toys are readily found around the home. Children in this age group are prone to putting objects in their mouths,^26,27 enticed by the various colors, shapes, and sizes of the items investigated in this study. Children aged 1 to 3 years accounted for the majority (61.9%) of all ingestions, likely related to their developmental stage and curiosity about their surroundings.

Overall, this study revealed a 4.4% annual increase in the rate of FBIs over the 2 decades. This rate increase was mirrored in every product category, although the increases in coin and battery ingestions were most conspicuous. Although any inferences made into the increase in rate of FBIs are speculative, it seems that the increase is likely multifactorial. Some of the products investigated in this study are increasingly being used in household items or have seen an advent on the marketplace. The NEISS is also likely capturing more ED ingestions than in previous years.

Coins were the objects most frequently ingested, and children who ingested them were most often hospitalized. Our study revealed, however, that the percentage of all FBIs represented by coins decreased slightly over time. Pennies comprised the majority of coin ingestions. Previous research revealed that pennies are the most frequently ingested coins, and the percentage of penny ingestions found in this study is similar to that reported previously.^15,26,27 Older children were more likely to ingest quarters, whereas younger children were more likely to ingest smaller coins. That younger children disproportionately ingested smaller coins likely reflects their esophageal anatomic constraints and ease of swallowing smaller items. Children ingesting quarters were more frequently hospitalized than those ingesting smaller coins. Coins >23.5 mm (such as the quarter) may have difficulty passing the pylorus and are more likely to become impacted, particularly in the youngest children.¹¹

Toys and toy parts were the second most frequently ingested objects. Interestingly, toy ingestions increased rapidly through the beginning years of this study period, reaching a peak in 2008, at which time the CPSIA went into effect (along with its small parts ruling). The dramatic decrease in toy ingestions through 2011 is likely in part related to the CPSIA and the increased pressure on manufacturers to package items appropriately for children <3 years of age. The fact that toy ingestions again increased after 2011 is more difficult to reconcile, but it may be related to the overall trend of increased FBIs.

The findings of this study reveal how ingestion patterns differ by sex and age. Jewelry and hair products were disproportionately ingested by girls, presumably because girls have more access to these items. Boys more frequently ingested screws and nails. Children ≤1 year of age were considerably more likely to ingest Christmas decorations and small objects such as earrings and screws, again demonstrating that children ingest accessible and easy-to-swallow items.

Batteries and magnets may have represented just 6.8% and 2.2% of all cases, respectively, but they can both enact considerable damage when ingested. Although they were only the fourth most commonly ingested product, batteries were implicated second most frequently among patients who were hospitalized. Battery ingestions increased rather dramatically over the study period, as did their representation among all FBIs. Previous research from the Centers for Disease Control and Prevention revealed a 2.5-fold increase in such ingestions between 1998 and 2010,⁵ but our data revealed a 150-fold increase over the 21-year study period. The advent of BBs is likely culpable for this increase. Although such batteries have been used for nearly 30 years,¹¹ the increase in ingestions is likely related to their increased use in electronic devices.²⁸ Furthermore, the past 3 decades have seen increased morbidity and mortality resulting from BB use, likely related to increased battery diameter and a move to lithium cells,²⁸ which have longer shelf lives and carry more voltage than previous cells.¹¹ These batteries can enact more mucosal destruction and are more likely to become impacted. Given the potential for harm with BB ingestion, the American Academy of Pediatrics (AAP) designed a task force to develop strategies to decrease these ingestions.²⁹

During the study period, the vast majority of magnet ingestions consisted of a single magnet, and those patients were likely to be discharged after their ingestion. Advocacy efforts continue to be focused on the sale of high-powered magnets. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) surveyed its members on neodymium-magnet ingestion and reported its findings to the CPSC.³⁰ Later that year, the CPSC proposed the ban on the production and sale of magnet sets; magnet ingestions decreased thereafter.^23,31 In 2016, the US Court of Appeals for the Tenth Circuit lifted the restriction on the production and sale of high-powered magnet sets, and now these magnet sets can be sold if marketed for purposes other than play.³² Both the AAP and NASPGHAN have alerted their members to the dangers inherent in high-powered magnet ingestion.^33,34

This study has several limitations. Given that the NEISS captures only the patients who presented to its EDs, the total number of FBIs during the study period was likely underestimated. Children who remained at home, sought care at their primary care provider’s office or urgent care, or had unknown ingestions were unlikely to have been captured in this data set. Furthermore, we did not include cases in which caregivers called a poison-control center and were advised that evaluation was unnecessary. We were unable to generate national estimates when there were <20 actual cases of ingestion of a particular product. Because the NEISS is not considered useful for identifying fatalities, we did not address those that may have resulted from FBI in our study. Data regarding confirmation of ingestion and product type were based on case narratives and thus subject to errors in reporting and interpretation. The case narratives do not confer management strategies, sizes of BBs, or types of magnets, so we were unable to make inferences on patient outcomes. Despite those limitations, this study is strengthened by its 21-year study period and use of a large nationally representative sample.

Our study results reveal that FBIs in children <6 years of age have been increasing over the past 2 decades. The rise in coin, toy, and jewelry ingestions is mirrored by an increase in ingestions of products such as batteries, which, when swallowed, have the potential to cause harm. Our study underscores the need for further research and continued efforts to prevent such ingestions, particularly within the home environment, where FBIs most commonly occur. Recommendations for prevention of FBIs by both the AAP and NASPGHAN include keeping such products out of children’s reach, ensuring that child-resistant packaging is used, and keeping particularly dangerous products off the market.^29,33,34 Continued education through the public sphere and primary care office is also of supreme importance.