en POLSKI
eISSN: 2300-8660
ISSN: 0031-3939
Pediatria Polska - Polish Journal of Paediatrics
Current issue Archive Manuscripts accepted About the journal Editorial board Abstracting and indexing Contact Instructions for authors Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
1/2024
vol. 99
 
Share:
Share:
Original paper

How is the COVID-19 pandemic related to ingestion and aspiration of foreign bodies among children – single-institution experience

Piotr Dryjański
1
,
Bartosz Gogolok
1
,
Justyna Pilszak
2
,
Wojciech Apoznański
1
,
Dariusz Patkowski
1

  1. Paediatric Surgery and Urology Department, Wrocław Medical University, Wrocław, Poland
  2. Paediatric Surgery and Urology Department, University Hospital, Wrocław, Poland
Pediatr Pol 2024; 99 (1): 1-6
Online publish date: 2024/03/05
Article file
Get citation
 
PlumX metrics:
 

INTRODUCTION

The COVID-19 pandemic changed the lives for all of us very rapidly. The first known case in Poland was described on 4 March 2020. Two weeks later (on 20 March 2020) the outbreak was described as a pandemic. Despite major inconveniences, the Paediatric Surgery and Urology Department of one of clinical hospitals in Poland continued to provide medical care for children. In this study we aimed to analyse impact of the COVID-19 pandemic on foreign bodies (FB) of the digestive and respiratory tracts among children.
Foreign body ingestion (FBI) or aspiration (FBA) is a common challenge encountered by paediatric providers. Due to lockdown policies, the amount of time spent at home increased significantly, which, theoretically, could increase risk of home accidents among children, because they seem to happen mainly at home. Those 2 factors combined could have become a serious problem for health-care professionals in that time. In this study we aimed to evaluate the relevance of the COVID-19 pandemic and the consequent isolation policy on FB cases among children.
Our department is a third degree reference hospital that ensures a wide range of treatment options. With high experience in endoscopic procedures and equipment available around the clock, we are the ones who provide needed treatment for children with FB ingestions or aspirations. Because there are no strict guidelines, we assess every patient individually, estimating the risk on the base of FB type, its localisation, and general symptoms.

MATERIAL AND METHODS

We retrospectively analysed the medical electronic records of our hospital for all patients assigned to group T17 and T18 ICD-10 diagnoses, who were hospitalised in the Paediatric Surgery and Urology Department of one of the clinical hospitals in Poland between January 2018 and November 2021. The demographic data, hospitalisation time, type of foreign body, its localisation, time and means for removal, and imaging process were extracted in each case. Foreign body types were grouped as food (with distinction for nuts), sharp objects, coins, batteries, magnets, toy parts, and others. Localisation was assessed based on radiological examination and during the intervention, as shown in Table 1. The time before removal was withdrawn and specified into 7 period groups – the division is purely empirical. Impact time was estimated on the basis of anamnesis, which makes exact statistics invaluable.
Between 11 May 2020 and 31 May 2022, every patient underwent real-time polymerase chain reaction (RT-PCR) SARS-CoV-2 test before admission to the ward. For children with positive results additional management was provided: strict isolation, FFP3 face masks, biohazard suits, face shields or goggles, and double gloves. Those were used both on the hospital ward and in the operating theatre.
Statistical analysis parameters in the groups were expressed as medians, means, and percentages. The statistical significance between data was calculated with the χ2 test df (degrees of freedom). A p-value of less than 0.05 was required to reject the null hypothesis – a higher p-value meant no statistical significance of the thesis. Statistical analysis was performed using the PaST software package.

RESULTS

In the study period there were a total of 236 children admitted with suspicion or diagnosis of FBI or FBA. Data for those patients were divided into 2 groups: pre-COVID and during the pandemic, comprising 122 and 114, respectively. Presented as the percentage of monthly admissions, FBs were 0.39–4.98% (mean 1.92% of 6300 admissions) before the pandemic and 0.51–4.94% (mean 2.03% of 3802 hospitalisations) during COVID-19. For the first quarter of 2018 and 2021, FB admissions were responsible for 2.84% and 2.85% of all hospitalisations, respectively. Specific demographic data did not differ significantly, and they are presented below (Table 2). Most of the children were below 5 years old (68.03% vs. 64.04%, respectively), but there were also teenagers (10.66% vs. 14.04% older than 10 years). Males more frequently presented with FBs (n = 74, 60.66% before 20 March 2020 vs. n = 67, 58.77% after the outbreak of the pandemic in Poland) than females (n = 48 vs. n = 47).
Regarding FB types (Table 3): coins, batteries, and magnets are specific for ingestions; on the other hand, nuts are aspirated only. 29.24% of all foreign bodies were ingested during meals, which seems to be the main activity connected with this type of home accident. Magnets (especially magnetic balls) were diagnosed only among children during the pandemic, and that seems to be statistically significant (p = 0.0038). However, before 2018 magnet ingestions were encountered as well.
The times of the presence of foreign bodies in children are summarised in Table 4. They were collected during anamnesis based on the possible time of ingestion or aspiration. Some were unknown because of late symptoms onset or hospitalisation without intervention. They stated a statistically significant difference (p = 0.02519), which could be related to a slight shift towards hospitalisation periods longer than 12 hours. This can be caused by SARS-CoV-2 RT-PCR tests, which patients had to undergo during the time of the pandemic. Hospitalisation times were slightly longer during the pandemic than before (range [in hours] 1.95–122.55 compared to 0.83–186.1). Some of our patients needed Intensive Care Unit care because of their general condition (7 vs. 2), and all of them had foreign bodies removed from their respiratory tract.
Imaging as a diagnostic measure was performed mainly at the Emergency Department; sometimes it was outsourced when a child was referred from another hospital. The shift towards more imaging in general during the pandemic was statistically significant (p = 0.0042). Complete data are shown in Table 5. It is worth pointing out that not every patient had imaging done (19 pre-COVID and 10 during the pandemic). Some children had a history of radiolucent FBs, such as plastic blocks or organic matter. From those, 15 (78.95%) and 8 (80%) underwent some kind of intervention that was connected with the presented symptoms (dyspnoea, dysphagia), and with an obvious need for intervention such as removal or damage assessment after caustic ingestions.
Most children were qualified for interventional treatment (Table 6); 98 (80.33%) vs. 88 (77.19%) underwent some kind of medical procedure under general anaesthesia. The degree of urgency was defined on the basis of in-hospital procedures (emergency < 1 hour, urgent 1–6 hours, semi-urgent 6–168 hours). The median time for intervention shortened during the pandemic, from 3 h 27 m to 2 h 42 m. More interventions were provided in less than one hour (6.12% vs. 19.32%). Specific data are presented in Table 6. Indications were as follows: aspiration, dyspnoea, stridor, FB in oesophagus, anamnesis for sharp objects, battery or multiple magnets, dysphagia, and radiological signs for gastrointestinal perforation. We could assess an effectiveness rate of 71.43% and 78.41%, respectively. A successful intervention was defined as the use of an intervention that led to removal of the FB. Among interventional means, the majority were endoscopic procedures (gastroscopy, bronchoscopy). It should be pointed out that there were 3 laparotomies performed – all in the pandemic group, 2 caused by perforation by magnetic pieces and one because of an enormous trichobezoar. Few foreign bodies were spontaneously expelled during hospital stay (6 vs. 2). Of those patients, 2 vs. 1, respectively, underwent gastroscopy – in one of them an AAA battery was seen passing through the pylorus. The remaining 5 children were treated conservatively because in imaging the foreign bodies were thought to be further than the pylorus.
Of all the 114 patients in the pandemic group, 84 children underwent a RT-PCR SARS-CoV-2 test. That was obligatory for admission between 11 May 2020 and 31 May 2021, excluding people who were diagnosed with COVID-19 in the preceding 12 weeks. Eighty of the results were negative (95.24%). Three patients with a positive test result were isolated and treated with additional precautions (FFP3 face masks, biohazard suits, face shields or goggles, and double gloves). Endoscopies (one bronchoscopy and one gastroscopy) and one surgery (laparotomy) were carried out in single-use operating gowns and the aforementioned barrier equipment. One test was inconclusive, and then negative in a following examination. One child had convalescent status. With the pandemic fading, the policy changed – only people with symptoms of upper respiratory tract infection were tested (none in the study group).

DISCUSSION

Foreign body ingestions and FBAs remain a significant and serious healthcare concern [1–5]. Nationwide databases are being created for better understanding of the subject. Surprisingly, no such study has been carried out for the Polish population in the last 10 years, leaving us without region-specific data. Nonetheless, the demographics seem to be similar and the problem is serious among children younger than 4 years old [6–8]. Despite the hypothesis that isolation policies and home-office movement can be additional risk factors for FBI and FBA [9], our study showed no major changes in the demographic profile of patients admitted for FB and no major impact of COVID-19 on the presented subject [10]. Because most of the authors agreed on the increasing trend in foreign body diagnoses, there are some suggesting that better parental supervision could lead to improvement in that field [10, 11]. There is limited literature in the topic of foreign bodies in children during COVID-19. As we presented a history of 236 children, most of the studies contributed less than 100 patients [10, 12, 13], some of them being case reports [14, 15] and others using national electronic databases [16].
Another concern making that time so special was the use of additional equipment to protect healthcare professionals, such as full-face snorkel masks [17], protective barriers, or even putting patients in separate air-vent bags. All our patients had SARS-CoV-2 RT-PCR tests done. Procedures in a separate operating theatre were performed for children with a positive test result, and additionally disposable personal protective equipment (operating gowns, biohazard suits), FFP-3 face masks, eye-protection (face shields or goggles), and double gloves were used. Patients with a negative PCR test were treated in concordance with standard procedures.
Some authors observed a rise in button battery ingestions [9, 12, 16, 18]; however, that was not observed in our institution. Our study found [9, 16] an increasing presence of magnetic objects in children in this period (p = 0.0038). Especially for magnetic balls, there is higher risk of perforation and need for a much more serious intervention [19]. This specific type of FB is substantially more dangerous when ingested in large amounts [20–22]. In our institution we were forced to use a surgical approach (radiological signs of gastrointestinal perforation) only in 16.67% of magnetic piece ingestions, with some authors reporting a more than 5-fold higher rate for laparotomies [23].
Rigid bronchoscopy seems to be a procedure of choice in FBA cases [24, 25] and so is the history of the bronchoscope itself; however, some authors present a rise in the usage of flexible bronchoscopy [10]. During the analysed period we performed 70 rigid bronchoscopies, 13 of which resulted in no FB presence, and all the rest ended successfully with FB removal.
The management of foreign body ingestions and aspirations did not change after the given time period in our department. The vast amount of interventions were carried out urgently according to life-threatening indications. Guidelines available in the literature are recommendations rather than strict management algorithms, and the authors emphasise their low quality of evidence [26–31]. The differences in the degree of urgency between guidelines and the presented article are the result of in-hospital procedures. The decision-making process, however, seems to be compatible with proposed guidelines, and so is the distinction of type and localisation of foreign bodies, especially listing the dangerous ones leading to emergent intervention [27, 32–36].
We are aware that our study limitations come from its retrospective nature and data acquired from a single institution. Further studies are required to work out proper algorithms and recommendations, and we are preparing for those.

CONCLUSIONS

We state that the primary thought that the outbreak of the pandemic, isolation policy, and boredom might lead to growth of FB diagnosis among children surprisingly turned out to be false.

DISCLOSURE

The authors declare no conflict of interest.
REFERENCES
1. Kim IA, Shapiro N, Bhattacharyya N. The national cost burden of bronchial foreign body aspiration in children. Laryngoscope 2015; 125: 1221-1224.
2. Orsagh-Yentis D, McAdams RJ, Roberts KJ, McKenzie LB. Foreign- body ingestions of young children treated in US emergency departments: 1995–2015. Pediatrics 2019; 143: e20181988.
3. Wood ML, Potnuru PP, Nair S. Inpatient pediatric foreign body ingestion: national estimates and resource utilization. J Pediatr Gastroenterol Nutr 2021; 73: 37-41.
4. Bourrous M, Lahmini W, Nouri H, Haimeur N. Subcutaneous emphysema and pneumomediastinum in child with asthma revealing occult foreign body aspiration: a case report. J Med Case Rep 2019; 13: 157.
5. Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body aspiration. Am J Otolaryngol 2013; 34: 85-88.
6. Speidel AJ, Wölfle L, Mayer B, Posovszky C. Increase in foreign body and harmful substance ingestion and associated complications in children: a retrospective study of 1199 cases from 2005 to 2017. BMC Pediatr 2020; 20: 560.
7. Eskander AE, Sawires HK, Ebeid BA. Foreign body ingestion in Egyptian children: a 10-year experience of endoscopic intervention in a tertiary hospital. Minerva Pediatr 2019; 71: 443-448.
8. Boufersaoui A, Smati L, Benhalla KN, et al. Foreign body aspiration in children: experience from 2624 patients. Int J Pediatr Otorhinolaryngol 2013; 77: 1683-1688.
9. Festa NT, Thakkar H, Hewitt R, et al. Foreign body ingestion during COVID-19 pandemic: a retrospective single centre review. BMJ Paediatrics Open 2021; 5: e001042.
10. Golan-Tripto I, Tsabari R, Picard E, et al. Foreign body aspiration in Israeli children during the COVID-19 pandemic. Pediatr Pulmonol 2022; 58: 425-432.
11. Bucci C, Caruso F, Quitadamo P, Tipo V, Martemucci L, Marmo R. COVID-19 lockdown led to fewer ingestion cases but a higher percentage of more serious cases needed hospitalisation. Acta Paediatr 2021; 110: 1293-1294.
12. Pizzol A, Rigazio C, Calvo PL, et al. Foreign-body ingestions in children during COVID-19 pandemic in a pediatric referral center. JPGN Rep 2020; 1: e018.
13. Klein LD, Black K, Dole M, Orsagh-Yentis DK. Epidemiology of pediatric foreign body ingestions amidst the coronavirus 2019 pandemic at a Tertiary Care Children’s Hospital. JPGN Rep 2022; 3: e168.
14. Leitao DJ, Jones JLP. Pediatric rigid bronchoscopy and foreign body removal during the COVID-19 pandemic: case report. J Otolaryngol Head Neck Surg 2020; 49: 66.
15. Salmi H, Harve-Rytsälä H, Rautiainen P, Pyörälä S, Hästbacka J. Overlooking the obvious during the covid-19 pandemic: dyspnoea with asymmetric breath sounds in a Toddler Case Rep. Pediatr 2021; 2021: 8855962.
16. Geibel E, Pasman E, Nylund C, Rudolph B, Reeves P. The impact of the COVID-19 pandemic on foreign body ingestion trends in children: a comparison of the pre-pandemic period to 2020. J Pediatr Gastroenterol Nutr 2022; 75: 299-303.
17. Pugmire BS, Lim R, Avery LL. Review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. Radiographics 2015; 35: 1528-1538.
18. Injuries from batteries among children aged < 13 years – United States, 1995–2010. Weekly 2012; 61: 661-666.
19. Lukish AC, Pat V, Apte A, Levitt MA. Battery ingestion with colonic perforation after colostomy closure in a toddler. Eur J Pediatr Surg Rep 2022; 10: e41-e44.
20. Xian-Ling L, Qin-Ming Z, Shou-Yan L, et al. Clinical report and analysis of 24 cases of multiple magnetic beads foreign body in gastrointestinal tract of children. Turk J Gastroenterol 2020; 31: 819-824.
21. Yi J, Zhigang G, Yuebin Z, et al. Management of multiple magnetic foreign body ingestion in pediatric patients. BMC Pediatr 2022; 22: 448.
22. Seguier-Lipszyc E, Samuk I, Almog A, Silbermintz A, Kravarusic D. Multiple magnet ingestion in children: a problem on the rise. J Paediatr Child Health 2022; 58: 1824-1828.
23. Price J, Malakounides G, Stibbards S, Agrawal S. Ball magnet ingestion in children: a stronger and more dangerous attraction? Emerg Med J 2022; 39: 467-470.
24. Wu Y, Dai J, Wang G, et al. Delayed diagnosis and surgical treatment of bronchial foreign body in children. J Pediatr Surg 2020; 55: 1860-1865.
25. Mohammad M, Saleem M, Mahseeri M, et al. Foreign body aspiration in children: a study of children who lived or died following aspiration. Int J Pediatr Otorhinolaryngol 2017; 98: 29-31.
26. Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 489-496.
27. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN endoscopy committee. J Pediatr Gastroenterol Nutr 2015; 60: 562-574.
28. Nation J, Jiang W. The utility of a handheld metal detector in detection and localization of pediatric metallic foreign body ingestion. Int J Pediatr Otorhinolaryngol 2017; 92: 1-6.
29. Hamzah HB, James V, Manickam S, Ganapathy S. Handheld metal detector for metallic foreign body ingestion in pediatric emergency. Indian J Pediatr 2018; 85: 618-624.
30. Montana A, Salerno M, Feola A, et al. Risk management and recommendations for the prevention of fatal foreign body aspiration: four cases aged 1.5 to 3 years and mini-review of the literature. Int J Environ Res Public Health 2020; 17: 4700.
31. Sink JR, Kitsko DJ, Mehta DK, Georg MW, Simons JP. Diagnosis of pediatric foreign body ingestion: clinical presentation, physical examination, and radiologic findings. Ann Otol Rhinol Laryngol 2016; 125: 342-350.
32. Mubarak A, Benninga MA, Broekaert I, et al. Diagnosis, management, and prevention of button battery ingestion in childhood: a European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. J Pediatr Gastroenterol Nutr 2021; 73: 129-136.
33. Laya BF, Restrepo R, Lee EY. Practical imaging evaluation of foreign bodies in children: an update. Radiol Clin North Am 2017; 55: 845-867.
34. Pitiot V, Grall M, Ploin D, Truy E, Ayari-Khalfallah S. The use of CT-scan in foreign body aspiration in children: a 6 years’ experience. Int J Pediatr Otorhinolaryngol 2017; 102: 169-173.
35. Manach Y, Pierrot S, Couloigner V, et al. Diagnostic performance of multidetector computed tomography for foreign body aspiration in children. Int J Pediatr Otorhinolaryngol 2013; 77: 808-812.
36. Shen J, Huang L, Hao C. Value of multi-slice spiral computed tomography for diagnosis of tracheobronchial foreign body aspiration in children: 5-year retrospective study. Pediatr Int 2020; 62: 1184-1188.
Copyright: © 2024 Polish Society of Paediatrics. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.