Nuts and seed: a natural yet dangerous foreign body

Risk factors for difficult removal of tracheobronchial foreign bodies in children by rigid bronchoscopy

OBJECTIVE

To characterize the risk factors for difficult removal of tracheobronchial foreign body (FB) by rigid bronchoscopy in children.

METHODS

We retrospectively analyzed clinical data of 1026 pediatric patients (age: 0-18 years) diagnosed with tracheobronchial FB between September 2018 and August 2021. All patients underwent rigid bronchoscopy as the first intervention at our hospital.

RESULTS

Children aged 1-3 years accounted for 83.7% cases in our cohort. The most common symptoms were cough and wheeze. FBs were more frequently found in the right bronchus, and trachea FBs accounted for only 8.19% cases. The success rate of rigid bronchoscopy in a single attempt was 97.27%. 12.18% of the cases were defined as difficult removal of FB. On univariate analysis, age, CT findings (pneumonia), type of FB, diameter of FB, FB location, granulation tissue formation, and the seniority of the surgeon were identified as risk factors for difficult removal of tracheobronchial FBs. On multivariate analysis, age ≥3 years, FB diameter ≥10 mm, FBs located in left bronchus, multiple FBs, granulation tissue, and the seniority of surgeon (<3 years, ≥5 years) were independent risk factors for difficult removal.

CONCLUSIONS

Age, FB diameter, location of FB, granulation tissue formation, and the seniority of the surgeon were risk factors for difficult removal of FBs by rigid bronchoscopy.

Regulatory and Educational Initiatives to Prevent Food Choking Injuries in Children: An Overview of the Current Approaches

Choking injuries are one of the major causes of death among children ages 0-3, and most of these injuries are related to food. This work provides an overview of the current recommendations for food choking prevention and educational targets as a basis for developing a unified common set of knowledge for primary prevention policies development. Guidelines published by professional membership organizations and national governments in the English language were considered. All of these guidelines provide lists of hazardous food items and recommendations for food preparation to minimize choking hazard. Together with recommendations for food preparation, also recommendations aimed at stakeholders (food manufacturers, health care providers, and public authorities) are provided, underlining that this severe public health problem should be further addressed by adopting integrated public health interventions. Our overview stressed the importance of developing educational and primary prevention policies to sensitize adult supervisors and to regulate dangerous food products in the market.

Epidemiology and Trends over Time of Foreign Body Injuries in the Pediatric Emergency Department

This paper presents the epidemiology of foreign body injuries in the Pediatric Emergency Department (PED) of Padova (Italy) along with its trends over an eleven-year period based on administrative data. Annual incidence rates (IRs) of PED presentations for foreign body (FB) injuries per 1000 person-years were calculated. Univariable and multivariable generalized linear (GLM) Poisson models were estimated to evaluate the relationship between FB injury incidence and year, triage priority, nationality, injury site, and FB type. During the study period, there were 217,900 presentations of pediatric residents in the province of Padova; of these, 3084 (1.5%) reported FB injuries involving the ears, nose, throat, gastrointestinal tract or eyes. The annual IR of FB injury episodes increased from 10.45 for 1000 residents in 2007 (95% CI, 9.24, 11.77) to 12.66 for 1000 residents in 2018 (95% CI, 11.35, 14.08). Nonfood items were the FBs that were most frequently reported. The intermediate urgent triage code was the most represented for FB injuries, with IRs ranging from 5.44 (95% CI: 4.59, 6.40) in 2008 to 8.56 in 2018 (95% CI: 7.50, 9.74). A total of 170 patients who presented for FB injuries were hospitalized (5.5%). The annual FB-related injury IR has increased over time, although most episodes are not life threatening. Educational and prevention programs on FB-related injuries should be promoted and dedicated to childcare providers.

Comparing foreign body injuries patterns between Turkey and European Countries: are female Turkish children more vulnerable?

OBJECTIVES

The present study aimed at analyzing and comparing Foreign Body (FB) injuries patterns in children from Turkey and other European countries in order to assess any country and culturally specific aspects of FB risk.

METHODS

Data from Susy Safe register were included in the analysis. For this study, ICD-935 (mouth, esophagus and stomach) and ICD-934 (trachea, bronchus, and lung) cases from European countries and from a single center in the Istanbul Bahcelievler State Hospital, Turkey, were extracted from the Susy database. A Multiple Correspondence Analysis (MCA) approach was employed to identify differences or similarities between the groups of FB injuries.

RESULTS

The Turkey dataset has a larger proportion of females in comparison to the European data (p-value 0.002). According to the MCA analysis, the first two dimensions are explaining 48.11% of the variability (dimension 1, 37.44%; dimension 2, 10.67%). The three largest contributions to dimension 1 are via naturalis removal, not hospitalized, and ICD-935. The greatest contributions to dimension 2 are FB type, and consistency.

CONCLUSION

The most interesting study finding is the higher incidence of females suffering a FB injury in ICD-934-935 in the Turkey dataset compared to that seen in the European dataset and also higher than that for all ICD locations within the Susy Safe register. The higher incidence of females tends to go against the belief that boys suffer higher FB injuries and needs to be further investigated.

Detectability of foreign body materials using X-ray, computed tomography and magnetic resonance imaging: A phantom study

PURPOSE

To evaluate the effectiveness of plain radiography (X-ray. XR), computed tomography (CT) and magnetic resonance imaging (MR) in visualising commonly seen foreign bodies. A special focus was put on objects relevant to head and neck surgery.

METHOD

Thirty-four commonly encountered objects of different compositions including wood, plastic, and glass were embedded in a gelatin gel phantom and imaged using XR, CT and MR. The success rates of radiologists in detecting and correctly identifying the foreign objects were evaluated. Subjective visibility was rated on a 4-point Likert scale. Objective visibility was analysed using region of interest-based contrast for CT.

RESULTS

Sensitivity in foreign bodies detection was highest in MR (97.1 %) followed by CT (86.0 %) and x-ray (61.8 %). Success rates for the correct identification of the objects and material types were highest in MR (33.3 % and 39.2 %, respectively) followed by CT (25.5 % for both) and XR (16.7 % and 15.7 %). Overall, subjective visibility was rated higher in CT and MR imaging ("good visibility"), as compared to XR ("poor visibility"). Interreader agreement was high across modalities (Kendall's W = 0.935, 0.834 and 0.794 for XR, MR and CT, respectively).

CONCLUSIONS

Detection and identification of non-ferromagnetic objects was most successful in MR followed by CT imaging in this experimental setup.

Perception of Choking Injury Risk Among Healthcare Students

Choking injuries in children represent a severe public health burden. Although most choking injuries are due to food, parents have often been found to be unaware of the choking hazards presented by food. In this context, healthcare professionals may play an important role in choking prevention by educating families. We investigate the perception of choking injury risk among healthcare profession students by comparing their awareness and knowledge of choking hazards with those of people without a specific health education. A survey was conducted among a sample of final year healthcare profession students from two universities in northern Italy and a sample of adults from the general population without any health education. Respondents were asked to look at ten pictures and identify the items that pose the greatest choking hazard to children of different age groups. Seventy-one students and 742 adults without any health education responded to the survey. A higher percentage of the adults without a health education identified a food item as posing the greatest choking hazard in comparison to the percentage of healthcare profession students. The results of this study suggest that there is a need to include specific educational modules on choking prevention in healthcare-related degree programs.

Foreign Body injuries in children in India: Recommendations for prevention from a comparative analysis with international experience

OBJECTIVES

This study aims to identify specific patterns of risk in order to contribute to the prevention of Foreign Body (FB) injuries by assessing FB injury characteristics in Indian children.

METHODS

Single center case series are included in the worldwide registry on Foreign Bodies Injuries www.susysafe.org. Statistical analysis performed on FB injury data (age, medical information, FB anatomical location (ICD) and characteristics, and situational data) from 252 Indian children (0-14 years) was used to identify FB risk patterns.

RESULTS

The study included 252 FB injury cases, out of which 110 occurred in females (43.7%). Most of the reported FB injuries (N = 252) were located in the mouth, esophagus and stomach, or intestines and colon (34.5%), and in the nose (31.3%). The analysis of the median duration of all injuries (i.e., the difference between the reported injury time/date and the reported time/date of arrival at hospital) showed that children with a FB in the airways were those referred to the hospital latest (median of 332.50 min, p-value <0.001). With regards to FB type, the majority of FB objects were non-food items and ingestion of coins accounted for 25% of all FB injuries.

CONCLUSIONS

Cultural differences may exist with regards to the Indian diet being conducive to lower choking food risk for children, and to acceptability and accessibility to objects such as coins and stationery. Such findings should be taken into account when developing primary and secondary prevention strategies aimed at reducing the burden of such injuries in India.

Increasing awareness of food-choking and nutrition in children through education of caregivers: the CHOP community intervention trial study protocol

BACKGROUND

Choking is one of the leading causes of death among unintentional injuries in young children. Food choking represents a considerable public health burden, which might be reduced through increased effective preventative education programs. We present a protocol for a community intervention trial termed CHOP (CHOking Prevention project) that aimed to teach Italian families how to prevent food choking injuries and increase knowledge relating to nutrition.

METHODS

Italian educational facilities were enrolled. Stratified randomization blocked by geographical area was performed. Each stratum was randomized to one of three different intervention strategies or to a control group. Educational intervention was delivered in the schools by experts and certified trainers as per the following three intervention strategies: directly to families (Strategy A); to teaching staff only, who subsequently delivered the same educational intervention to families (Strategy B); to health service staff only, who then delivered the educational intervention to teaching staff, who subsequently delivered the intervention to families (Strategy C). Participants completed a questionnaire about their knowledge on the topics presented during the educational interventions (pre-, post-, and follow-up of intervention). Information from the questionnaires was synthetized into 6 indicators in order to measure how effective each intervention strategy was.

DISCUSSION

The issue of food choking injuries in children is relevant to public health. The protocol we present provides an opportunity to progress towards overcoming such challenges through a working model that can be implemented also in other countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03218618. The study was registered on 14 July 2017.

Basic choking education to improve parental knowledge

OBJECTIVE

To evaluate the effect of an educational intervention on parental knowledge of choking hazards and prevention.

METHODS

A quasi experimental study was performed utilizing an internet based educational video intervention for parents with a child 6 months to 4 years old presenting to a Pediatric Otolaryngology clinic at a Level 1 pediatric hospital. Following the clinic visit, participants were sent a choking video (intervention) or general safety video (control) with a pretest and posttest knowledge survey (via email). An additional posttest knowledge survey was sent 30 days later as a surrogate measure for knowledge retained over time. Frequencies, chi square test, Independent t-test and McNemar's test were used for statistical analyses.

RESULTS

202 participants viewed the video and completed both the pretest and immediate posttest knowledge survey. Average change in total knowledge scores from the pretest to immediate posttest was statistically significant between the intervention (μ = 1.88, σ = 1.20) and control group (μ = 0.14, σ = 1.05); t (200) = -10.99, P < .001. This finding was consistent when assessing change from the pretest to 30 day posttest between the intervention (μ = 1.41, σ = 1.32) and control group (μ = 0.17, σ = 1.41); t (118) = -4.95, P < .001. A majority of the knowledge questions (5 of 7) showed a significant change in score from the pretest to immediate posttest (P = .001-.027). Additional analyses revealed accuracy on 4 of 7 knowledge questions significantly changed from the pretest to 30 day later posttest (P < .001- .002).

CONCLUSION

The brief educational video overall improved parental knowledge of choking hazards and prevention immediately after the video and 30 days later. Importantly, improved parental knowledge may decrease rates of choking among children.

Temporal and regional trends of choking injuries in children in Italy, 2001-2013

BACKGROUND

Choking injuries in children are a significant public health problem. The present study was aimed at examining the epidemiologic patterns of choking injuries in children using Italian official data from hospital discharge records.

METHODS

Hospital discharge records (from 2001 to 2013) reporting cases of choking injuries corresponding to the ICD-9 CM codes 933 ("Foreign body in pharynx and larynx"), 934 ("Foreign body in trachea, bronchus, and lung"), and fourth digit specifications (933.0 "pharynx", 933.1 "larynx", 934.0 "trachea", 934.1 "main bronchus", 934.8 "other specified parts", 934.9 "respiratory tree, unspecified") occurred in children aged 0-14 years were analyzed to assess the temporal and regional trends. Annual rates of hospitalizations due to choking injuries per 100,000 person-years were calculated and compared between boys and girls.

RESULTS

During the 13-year study period, there were a total of 7143 hospitalizations due to choking injuries in Italian children. The annual rates of hospitalizations due to choking injuries per 100,000 person-years decreased from 5.28 in 2001 to 3.46 in 2013 (p < 0.001). The reduction in choking injuries occurred across all the regions, particularly in Campania, Lombardia, Puglia, and Veneto.

CONCLUSIONS

Hospitalizations for choking injuries in Italian children have decreased significantly in recent years. Choking injuries in children remain a cause of concern in some regions. Future research needs to elicit the causal factors underlying the downward trends and regional variations and develop targeted interventions to further reduce choking injuries in Italian children.

A novel approach for comparing patterns of foreign body injuries across countries: A case study comparing European Countries and Bosnia and Herzegovina

OBJECTIVES

The present study aimed at analyzing the characteristics of FB injuries from Bosnia and Herzegovina (B&H), a rapidly growing newly industrialized country, and to compare them with cases from European countries.

METHODS

The analysis is based on FB injury cases included in the Susy Safe registry. Cases from the Ear-Nose-Throat (ENT) Clinic, University Clinical Center of Tuzla (B&H) were compared with cases from European countries participating in the Susy Safe project. Multiple Correspondence Analysis (MCA) was performed to elucidate differences within a large data set regarding mechanisms and objects causing injuries.

RESULTS

The results of the MCA showed that the first three dimensions explained 43% of the variability. The first dimension was identified by children hospitalized for FB ingestion, the second one by children hospitalized for FB aspiration (lower airways), and the third one by children with an FB in the ear or in the upper airways. The analysis of the median of coordinates of factors contributing to each dimension showed that the greatest difference between B&H and European countries regarded the third one. Looking at the profile of these patients, it might be suggested that the proportion of males and females and the type of activity in which they were involved at time of injury occurrence are different among the countries considered CONCLUSIONS: This study proposes a simple tool for assessing differences among countries in the distribution of FB injuries. This case study shows that B&H has different patterns of FB injuries in the upper respiratory tract.

Intestinal perforation secondary to ingested foreign bodies: a single-center experience with 38 cases

OBJECTIVE

The aim of this study is to report our experience with patients with intestinal perforation secondary to ingested foreign bodies (FBs) who were treated surgically at our institution.

METHODS

Between 2001 and 2015, a total of 38 pediatric patients with the diagnosis of intestinal perforation secondary to FBs were retrospectively reviewed.

RESULTS

The series comprised 22 males and 16 females. The average age of the patients was 1.9 years. A definitive preoperative history of the ingestion of FBs was obtained for only eight patients. Crying and abdominal pain were the main clinical manifestations. Perforation repair was performed in 29 patients (76.3%), while enterostomy was utilized in five patients (13.2%) and enterectomy in four patients (10.5%). Five perforations occurred in the large intestine, and 33 perforations occurred in the small intestine with the most common site being the distal ileum. Of the 38 FBs recovered, 26 were food objects, while non-food objects were found in 12 patients. All patients recovered well, except one patient with an intestinal obstruction from adhesions that occurred approximately 1 month after discharge.

CONCLUSIONS

Clinical performance of intestinal perforation secondary to FBs in children is atypical. Most perforations occur in the small intestine. Primary perforation repair is safe and effective, and better outcomes can be achieved.

Risk factors for granuloma formation in children induced by tracheobronchial foreign bodies

OBJECTIVE

The aim of this study was to analyze the risk factors for granuloma formation caused by plant-based tracheobronchial foreign bodies in children, and investigate the underlying pathogenesis.

METHOD

In this retrospective analysis of 153 cases with tracheobronchial foreign bodies (peanuts and watermelon seeds), 35 cases of granuloma formation as granulation group (G), and 118 cases of no granuloma formation as non-granulation group (NG) were studied. Clinical data pertaining to sex (S), age (A), foreign body surface smoothness (SF), foreign body shape (SH), foreign body oil release state (O), the location of foreign bodies (L), and foreign body retention time (T) were collected for statistical analysis.

RESULTS

Univariate analysis showed no significant difference between the two groups (G and NG) with respect to S, A, SH and L. Significant factors based on univariate analysis included SF, O and T. Multivariate logistic regression analysis revealed that SF and T were independent risk factors associated with development of granuloma.

CONCLUSIONS

SF, O and T had relationship with the granuloma formation. Local trauma caused by an irregular and sharp foreign body, and extended period of time represent the main factors causing granuloma formation.

Complications in children from foreign bodies in the airway

INTRODUCTION AND OBJECTIVES

Foreign body aspiration in childhood is a common and potentially serious problem. Complications may be the result of the aspiration episode itself, delayed diagnosis or treatment. We describe our experience in a paediatric hospital in Argentina.

METHODS

We retrospectively evaluated 56 patients with complications due to foreign body aspiration recorded in the Susy Safe Project between January 2010 and November 2013. The clinical variables analysed were sex, age at time of aspiration, foreign body location and type, time elapsed from the event until object removal, extraction technique, complications, need for hospitalisation and circumstances of the event.

RESULTS

58.9% of the cases described occurred in males, with high presence of adults (76.8%) at the time of aspiration. The incidence was slightly higher in children older than 3 years. In 37 cases (66.1%), the foreign body was located in bronchus; sunflower seeds and ballpoint caps were the most common foreign objects. Only in 10 cases (17.9%) was the object extracted within 24h of the event. The most common complications were pneumonia (18 cases), granuloma (15 cases) and mucosal erosion (9 cases). Hospitalisation was necessary for 41 patients.

CONCLUSION

Early diagnosis and immediate control through specialised teams are essential to ensure proper treatment, usually endoscopic, without risk of complications.

Foreign body aspiration in children: experience from 2624 patients

OBJECTIVES

The objective of this study is to analyze the epidemiological, clinical, radiological and endoscopic characteristics of pediatric foreign body aspiration in Algeria.

METHODS

In this retrospective study, the results of 2624 children younger than 18 years admitted in our department for respiratory foreign body removal between 1989 and 2012, were presented. Most of them had an ambulatory rigid bronchoscopy.

RESULTS

The children (62.34% males and 37.65% females) were aged 4 months to 18 years with 66% between 1 and 3 years. Choking was related in 65% of cases. The delay between aspiration and removal was 2-8 days in 65.8% and within 24 h in 9.2%. In the most cases, the children arrived with cough, laryngeal or bronchial signs and unilateral reduction of vesicular murmur. The examination was normal in 13%. The most common radiologic finding was pulmonary air trapping (40.7%). The aspirated bodies were organic in 66.7%, dominated by peanuts, while sunflower seeds, beans and ears of wheat were the most dangerous. In the other cases, they were metallic or plastic as pen caps and recently scarf pins. The endoscopic removal by rigid bronchoscopy was successful and complete in 97%. Cases with extraction failure (3%) limited to certain FBs, all of them inorganic were assigned to surgery. The complications related to the endoscopic procedure were 0.29% with a mortality of 0.26%.

CONCLUSION

Foreign body aspiration is a real public health problem in Algeria. The best way to manage it is an early diagnosis and a rigid bronchoscopy removal under general anesthesia used by fully trained staff. The prevention of this domestic accident should consider the population lifestyle and cultural habits to be more effective.

Logistic regression analysis of risk factors for prolonged pulmonary recovery in children from aspirated foreign body

OBJECTIVE

Foreign body aspiration is a life-threatening emergency for children. Fried chicken is commonly available all over the world, but no cases have previously been reported addressing this food as a tracheobronchial foreign body. We report an extremely rare case of tracheobronchial aspiration of fried chicken complicated by severe bronchitis and postoperative atelectasis. To clarify predisposing factors related to bronchopulmonary complications, we also reviewed paediatric cases of tracheobronchial foreign bodies treated in our department over the past 14 years.

METHODS

We retrospectively reviewed a total of 77 cases of tracheobronchial foreign bodies from 1988 to 2011. The main outcome measure was duration of hospitalisation, reflecting postoperative therapy. Logistic regression analyses were conducted to determine risk factors for longer hospitalisation.

RESULTS

Age, sex, and interval between the aspiration episode and bronchoscopy were not significantly associated with longer hospitalisation. Regarding kinds of foreign bodies, higher rates of longer hospitalisation were noted for patients who had aspirated peanut or animal material, as compared to patients who had aspirated non-organic material (odds ratio, 5.80; 95% confidence interval, 1.12-30.43).

CONCLUSIONS

In terms of predicting the risk of pulmonary complications, the type of foreign body aspirated offers a more meaningful factor than the interval between aspiration and operation. Specifically, peanuts or animal material containing oils appear to be associated with a more prolonged pulmonary recovery even after retrieval of the foreign body.

Mothers' knowledge about foreign body aspiration in young children

OBJECTIVE

To evaluate parents' knowledge regarding foreign body aspiration (FBA) and determine the factors that are associated with lack of knowledge.

METHODS

An 8-item questionnaire regarding knowledge of FBA was developed and distributed at regular check-ups for children younger than 24 months old.

RESULTS

Out of the 1766 questionnaires distributed, 1603 were recovered and most of them (1539) were answered by mothers. After omitting 49 questionnaires with incomplete data, 1490 questionnaires answered by mothers were analyzed. Only 4.3% [95% CI 3.3-5.3] of mothers did not recognize a small toy as a cause of FBA, while 20.2% [95% CI 18.2-22.2] did not know that peanuts and other nuts can be causes of FBA, and 48.1% [95% CI 45.5-50.6] did not know that they should not give peanuts to a child younger than 3 years old. Regarding clinical signs, 27.7% [95% CI 25.4-30.0] and 41.8% [95% CI 39.3-44.3] of mothers did not know that sudden choking and sudden coughing were symptoms suggesting FBA, respectively. Being a mother with a child younger than 12 months old and being a mother with a first child were independent risk factors for lack of knowledge about FBA, regardless of the age of the mother.

CONCLUSIONS

A substantial number of mothers lack knowledge regarding FBA. To prevent FBA and to make timely diagnoses, parents, especially mothers with children younger than 12 months old and mothers with a first child should be given adequate information.