Foreign Body Ingestion: A Real Hazard during the Covid Pandemic

Children curiosity for exploring their surrounding environment make them prone to foreign body (FB) ingestion which may lead to injuries and surgical intervention. COVID pandemic and national lockdown has impacted children's normal environment in addition to the changes in the health care system provision. The aim was to determine if the pandemic had a direct impact on the number and management of FB ingestion cases. Method All patients who were referred to our institution with diagnosis of FB from March 2020 to December 2020 were included. They were compared with FB referral during the period March-Dec 2019 as a control. Data included patients' demographics time to presentation type of FB ingested and management approach. Results There was a total of 30 patients with diagnosis of gastrointestinal FB during the study period as compared to 12 patients during the control periods. Thus during the COVID pandemic there was 2.5 times rise in number of cases. The mean age at presentation was 6.4 years during the study period as compared to 4.6 years in the control group. Timing of presentation varied from 0 to 57 days during the COVID pandemic as compared to control group who presented within 24hr except one who presented after 48hr.The most common foreign bodies encountered during the pandemic were button batteries (12) magnets (7) coins (5), other sharp and metallic objects (6). Two third (67%) of patients in the study period required surgical intervention as compared to one third (33%) during the control period. Most common site of impaction was stomach (40%) followed by oesophagus (36.6%). Conclusion The total number of children diagnosed with FB ingestion had significantly increased during the COVID pandemic. Public campaigns should be focused on raising awareness about the danger and medical emergency as a result of FB ingestion.

A "missed" nasal button battery in a child during the COVID-19 pandemic

A 5-year-old boy was referred acutelytoThe on-call ENT doctor following multiple remote consultations with his General practitioner with 2 months history of worsening left-sided foul-smelling nasal discharge and bleeding. He underwent examination under anaesthesia and removal of nasal foreign body which was subsequently identified as a button battery (intra-operative as well as imaging pictures included). This case highlights The challenges posed to clinicians during The COVID-19 pandemic but also serves as a reminder to keep a high index of suspicion and low threshold for clinical examination in suspected cases of nasal foreign body. It also highlights that since COVID19 omicron variant has emerged it is more than significant to evaluate cases that are assessed remotely with increased care to avoid any further misses or mistakes.

Increased Emergency Department Visits for Foreign Body Ingestions Requiring Hospitalizations during the Covid-19 Pandemic in the Pediatric Population

Background: Foreign body ingestions (FBI) are most commonly seen in children aged 6 months to 4 years and occur at home. Most foreign bodies pass through the gastrointestinal tract without causing any injury. However, 10-20% of cases require endoscopic intervention and <1% require surgery. On March 4th, 2020, a state of emergency in California was announced in response to the evolving COVID-19 pandemic, including closure of all county public schools on March 13th, 2020, and a shelter-in-place order ceasing all non-essential business and travel on March 16th, 2020. Despite the breadth of data on FBIs prior to the pandemic, and others outlining findings from surgical perspectives or in other countries during the pandemic, there is limited data on FBIs and the COVID-19 pandemic in a US pediatric Level 1 Trauma Center in a state with extended and strict mandated shutdowns. Method(s): We used the National Electronic Injury Surveillance System (NEISS) data set for a single large tertiary center, retrospective analysis of FBI, patient demographics, and patient disposition between 3/16/2019-3/15/2021 to better characterize FBI prior to and during the COVID-19 pandemic. Our primary outcome measure was the number of patients presenting to our emergency department (ED) and admitted to our hospital for FBI. High Risk FBI were events involving button batteries, magnets, lead-based objects, or sharp objects (broken glass, needles, nails). We also conducted a secondary chart review to collect demographic data on FBI patients who required admission. All automatically collected data was qualitatively screened and systematically categorized for more effective data presentation. Result(s): While the overall number of presentations to the ED remained similar (279 to 268), there was a higher rate of admissions (8.9% vs 12.3%) during the pandemic. The average age of patients with an ingestion was 42.5 months pre-pandemic, 52.7 months during pandemic;the average age of patients admitted for an FBI was 35.4 months pre-pandemic, 50.9 months during pandemic. The number of high-risk ingestions during the pandemic (10.8% vs 14.2%) was higher. Of children who needed to be admitted, a greater number required endoscopic procedures during the pandemic (29.9% vs 38.5%). There was also a larger proportion of patients belonging to ethnic minorities (Black, Asian, Hispanic/Latino) that were admitted during the pandemic (45.5% vs 63.0%). Conclusion(s): Both ED and hospital admission data reflect the disruption to the home and work environments that the general population experienced in the pandemic. The increased average age of a FBI-presenting and FBI-admitted patient could reflect the increased incidence in older, possibly school-aged children, in light of the state-wide shutdown of schools and children being at home full-time. The increase in high risk and admission rates in the pandemic also suggests that mandates placing children in the home increase their exposure to harmful materials and increased risk of serious injury requiring invasive procedures. We serve a particularly vulnerable population;the majority of our patients are insured by Medicaid and of lower socioeconomic status (SES), and we would expect that the increase in FBI is correlated to SES. Moving forward, we would like to further investigate how the COVID-19 pandemic may have further exacerbated pediatric health disparities by analyzing health outcomes based on patients' preferred language (English or other) and home zip code and corresponding census info (median household income, percent living below the poverty line). In our at-risk population, based on the above data, we propose implementing proactive counseling by primary care providers (PCP) on safety around FBI. Education provided to families at PCP visits on securing dangerous objects in the home may help decrease FBI especially during times when children are required to be at home more often, like during a pandemic.

The Dark Side of the Force Rises: Uptrends of Button Battery and Magnet Ingestions by Children Two Years into the Covid-19 Pandemic

Background Foreign body ingestion among children is a well-known, potentially hazardous injury that can prove fatal. We recently reported on trends in foreign body ingestions during the first year of the pandemic. This study aims to investigate whether the trends seen during the first year of the pandemic in the setting of stay-at-home orders, including decreases in foreign body ingestions at school and increase in danger foreign body ingestions (button batteries and magnets) continued into the second year of the pandemic. Methods We used the National Electronic Injury Surveillance System (NEISS) database to evaluate the frequency of suspected-foreign body ingestions (FBI) in children ages 0-17 years of age for years 2017-2021. For the purposes of our analyses, we identified 2017-2019 and 2020-2021 as the pre-COVID-19 and COVID-19 periods, respectively. FBI frequencies were then annualized based on the number of years contained within each period. We used the NEISS coding manual to assign classes to the consumer products implicated in FBI including: electronics (including cylindrical and button batteries), magnets, coins, toys, desk supplies, bathroom items, jewelry, fasteners (screws, nails, etc.) and holiday items (Christmas ornaments, holiday decor, etc.). Escalation of care was defined as hospital admission or transfer. All reported values are populations national estimates generated from actual FBI encounters at NEISS sampled emergency rooms and were calculated using the NEISS-supplied weights and variance variables. Rao-Scott Chi-square was used for all categorical comparisons. Logistic regression modeling was used for comparison of continuous variables. Results The majority of FBI occurred in children age 0-5 years. During the COVID period, 56% of ingestions occurred in males. There was no significant increase in estimated total FBI between the pre-COVID-19 and COVID period (55,175 (95% confidence intervals (95% CI) 39,329-71,020) vs 54,325 (95% CI 37,880-70,769), P=0.06). The estimated number of ingestions occurring in school decreased from pre-COVID-19 (2,306 (95% CI 1,635-2,976)) compared to COVID-19 (1,327(95% CI 640-2,015), P=0.07). The estimated number of children requiring escalation of care due to FBI increased between the two time periods (6,375 (95% CI 4,167-8,583) vs 7,508 (95% CI 4,673-10,343);p=0.8) (table 1). The estimated frequency of magnet ingestions increased significantly between the two time periods (2,603 (95% CI 1,627-3,579) vs 4,481 (95% CI 2,982-5,890), P<0.0001). The number of multiple magnet ingestions also increased (738 (95% CI 371-1,106) vs 1,355 (95% CI 841-1,869), P<0.0001). The number of estimated button battery ingestions also increased (300 (95% CI 101-498) vs 510 (95% CI 283-738), P<0.01) (figure 1). Conclusion While there was no significant increase in the frequency of total foreign body ingestions during the pandemic, the proportion of the most dangerous ingestion subtypes (magnets and button batteries) and the need for care escalation increased significantly. The injury patterns described in this analysis, provides an opportunity for targeted advocacy and education of patients, parents, educators, caregivers, and policymakers. This should guide future pandemic public health campaigns to increase home safety and prevent harmful FBI.

Foreigh Body Ingestion in Pediatric Patients : 7 Years Expefrience before and during the Covid-19 Pandemic in a Tertiary Center

Introduction and Objective During the last 2 years we have been under a special situation due to COVID-19 pandemic. Pediatric patients were out of school and daycare centers for a prolong period of time, forcing them to be at home, increasing the risk of certain dangers, like foreign body ingestions. In our pediatric gastroenterology service we perceive an increase of cases of children with foreign body ingestion refer to our institution during the last 2 years, COVID-19 pandemic years .We would like to explore if our perception is real by comparing the cases of foreign body ingestion during and before the COVID-19 pandemic. Method A retrospective review of hospital electronic records of all pediatric patients referred to our hospital for evaluation and management of foreign body ingestions during a period of 7 years ( 2015-2021). Data was extracted during April 2022, and include demographics, type of object, complications and frequency of cases per year of the 7 years period. Results 66 cases of foreign body ingestions were referred to our institution in 7 years, 69% were male. Ages of children were between 9 months to 14 years , with a mean age of 5 years. Most of the objects were removed from stomach and esophagus. 57% of the objects recovered were coins followed by button batteries (10%).All the cases of button batteries ingestion were admitted and only one was complicated during admission due to severe erosive reaction of the esophagus because the patient did not informed the mother that he swallowed the battery and it was found incidentally due to symptom, (chest pain). 5 years before the COVID-19 pandemic period we received 44 cases of children with foreign body ingestion for 8.8 cases per year. During 2 years of COVID-19 pandemic we received 21 cases for an average of 10.5 cases per year. Of the 10% of button battery ingestion, we received 0.6 cases per year before the pandemic period and 1.5 cases per year during pandemic period. Conclusion We received more cases of foreign body ingestions in children referred to our institution during pandemic years, but the most important detailed of our study was the increase in button batteries ingestions ,double the number of cases. Keeping the children at home for protection of infection during the lockdown resulted in the increased risk for a potentially dangerous event for this population. Our perception of the increase of cases resulted in a scary truth.

Conservative Management of Acquired Tracheo-Esophageal Fistula after Lithium Button Battery Ingestion

Introduction:Acquired tracheo-esophageal fistula (TEF) is a dreaded complication of lithium button battery (LBB) ingestion in the pediatric population. Traditionally acquired TEFs are managed with surgical interventions. Very few case reports have described successful closure of a TEF secondary to LBB with conservative management. There is no reported literature on the use fibrin glue or laser therapy to enhance closure. Here we describe successful conversative management of TEF secondary to LBB and for the first time, attempted trial of fibrin glue and argon laser therapy. Case presentation: 13-month-old female presented to the emergency department with a 3-day history of croupy cough. Neck X ray demonstrated a radio-opaque foreign body suggestive of a button battery. Patient urgently underwent rigid esophagoscopy and found to have a 20 mm lithium battery in the proximal esophagus. The negative pole was facing anteriorly. Battery was retrieved and inspection revealed a Zagar 2 B grade mucosal injury. Site was washed with 0.25% acetic acid. Direct laryngoscopy and bronchoscopy noted significant posterior tracheal wall edema. Patient was kept NPO overnight and an esophagram obtained next day was reassuring. Therefore, diet was advanced as tolerated and patient discharged next day with plan to repeat esophagram in 2 weeks and endoscopy in 4 weeks. Patient presented 3 days later with drooling, coughing, nasal congestion. She tested positive for SARS Covid 19 PCR on admission. Esophagram at admission noted irregularity and distension of the proximal esophagus with persistent focal outpouching. Patient was kept strict NPO and a repeat esophagram 24 hours later showed large volume aspiration associated with excessive coughing. A nasogastric tube was placed, and tube feedings initiated. Esophogastroduodenoscopy (EGD) was delayed by 1 week due to COVID positive status and upper respiratory symptoms. Initial EGD demonstrated purulent exudates in proximal esophagus and a 6 mm fistulous opening surrounded by ulcerated margins. Bronchoscopy confirmed tracheal end of fistula in addition to posterior tracheal wall ulceration. A fiber-optic scope was used to advance the endotracheal tube so that its distal end was positioned beyond the inflamed mucosa. Patient was kept intubated and sedated, on IV antibiotics and PPI, and on NG tube feeds in the ICU. Repeat scope 7 days post TEF diagnosis showed a 4 mm fistula with healing of the ulcerated mucosa. Fibrin glue was injected into the fistula from the tracheal side in an attempt to close the TEF, but this was unsuccessful and lead to dislodgment of fibrin glue into airway creating a foreign body which necessitated endoscopic retrieval. EGD, 14 days after diagnosis of TEF demonstrated a fistula now ~ 3 mm wide. Argon plasma coagulation (APC) probe (Beamer unit flow of 0.5 L/min,15 W) was directed at the mucosa lining the esophageal end of the fistula with an aim to promote healing by secondary intention. At 21 days post TEF diagnosis complete closure of the fistula was demonstrated on EGD and bronchoscopy and the per-operative esophogram was reported as normal. Patient was discharged 5 days later tolerating an age-appropriate diet. A follow-up esophogram 2 weeks later was reassuring. Patient was asymptomatic on clinical follow up visit 4 weeks from discharge. Discussion(s): Acquired TEF secondary to LBB ingestion is traditionally managened through endoscopic or open surgical repair. However, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula, and mortality. Thus, experts have started to advocate the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. Five pediatric cases to date have reported sustained closure of TEF secondary to LBB with conservative management including strict NPO status and tube feeds/parenteral nutrition. The duration of healing has varied from 4 -11 weeks. We documented successful healing of acquired TEF within 21 days of initial diagnosis making it the shortest recovery period to date. We report the use of argon plasma coagulation at low settings to produce controlled heat coagulation at the fistula site in order to expose the submucosa and enhance healing by secondary intention. Successful closure of congenital TEF have been reported with injection of fibrin glue into the fistulous tract but this technique may not work for acquired TEF because of surrounding inflammation and a patulous tract. We opted to keep our patient sedated and intubated for 2 weeks to minimize movement, and promote healing of the TEF, but risk vs benefit needs to be weighed on a case-to-case basis. In conclusion, conservative management of acquired TEF is a feasible first step and may be considered before opting for surgical repair. Use of APC at low setting may reduce duration of closure of acquired TEF but high-powered, multi-center studies are needed.

Tiny batteries. big danger

Foreign body ingestion is common in the paediatric population, especially in children under five years of age. The most commonly ingested objects are coins, with batteries accounting for approximately 5% of ingestions. Most ingested batteries pass spontaneously through the gastrointestinal tract;however, those lodged in the oesophagus may lead to dangerous complications, such as oesophageal perforation and aorto-oesophageal fistula. There has been a dramatic increase in morbidity and mortality after battery ingestion worldwide in recent years. This is related to the wider use and easier availability of electronic devices and the growing popularity of more powerful 20 mm lithium button batteries, which are more likely to get impacted in the paediatric oesophagus, leading to serious injury if not promptly removed. Ingestion of these larger batteries resulted in death or serious complications in 12.6% of children. An increased incidence of battery ingestion has also been seen during the COVID-19 pandemic due to lockdown restrictions, with children spending more time at home. The main mechanism of injury is the generation of electric current between the poles of the battery. This is facilitated by the oesophagal mucosa being in contact with them and completing the circuit. The resultant caustic reaction leads to liquefactive necrosis of surrounding tissues, with clinically significant damage being reported as early as 2 hours after impaction. The time-sensitive nature of button-battery ingestion requires fast mobilisation of a multidisciplinary team and urgent removal. Clinicians must be able to recognise and manage button battery ingestion as per the latest guidelines. These patients often require anaesthesia for endoscopic battery removal;therefore, anaesthetists must familiarise themselves with the management of battery ingestion and be aware of its potential complications. This review focuses on the anaesthetic considerations and immediate management of ingested button batteries.

Feast or Famine: A National Stay-at-home Order Is Associated with an Increase in Pediatric Foreign Body Ingestions Presenting to Emergency Departments in 2020 Compared to 2011-2019

Background: Foreign body ingestion among children is a wellknown, potentially hazardous injury that can prove fatal. A recent single-center report demonstrated an increased frequency of caustic/toxic ingestions during the pandemic, but the trend in foreign body ingestions has yet to be evaluated. Our study aims to investigate whether the stay-at-home order during the COVID-19 pandemic associated with an increase in foreign body ingestion frequency. Methods: We used the National Electronic Injury Surveillance System (NEISS) database to evaluate the frequency of suspected-foreign body ingestions (FBI) in children ages 0-17 years of age for years 2017-2020. For the purposes of our analyses, we identified 2017-2019 and 2020 as the pre-COVID-19 and COVID-19 periods, respectively. FBI frequencies were then annualized based on the number of years contained within each period. We used the NEISS coding manual to assign classes to the consumer products implicated in FBI including: electronics (including cylindrical and button batteries), magnets, coins, toys, desk supplies, bathroom items, jewelry, fasteners (screws, nails, etc.) and holiday items (Christmas ornaments, holiday décor, etc.). Escalation of care was defined as hospital admission or transfer. All reported values are populations national estimates generated from actual FBI encounters at NEISS sampled emergency rooms and were calculated using the NEISS-supplied weights and variance variables. Rao-Scott Chi-square was used for all categorical comparisons. Results: The majority of FBI occurred in children age 0-5 years. During the COVID period, 57% of ingestions occurred in males. There was no significant decrease in estimated total FBI between the pre-COVID-19 and COVID period (59,933 (95% confidence intervals (95% CI) 42,978-76,888) vs 54,926 (95% CI 39,532-70,319);P=0.06).The estimated number of ingestions occurring in school decreased from pre-COVID-19 (2,678 (95% CI 1,855-3,501)) compared to COVID-19 (1,189 (95% CI 579-1,800), P=0.008). The estimated number of children requiring escalation of care due to FBI increased between the two time periods (6,923 (95% CI 4,605-9,241) vs 8,041 (95% CI 5,305-10,777);p=0.0016). The estimated frequency of magnet ingestions increased significantly between the two time periods (2,891 (95% CI 1,861-3,921) vs 4,816 (95% CI 3,213-6,419), P<0.0001).The number of estimated electronics FBI also increased significantly (5,757 (95% CI 3,833-7,681) vs 6,881 (95% CI 4,417-9,344), P=0.001). Conclusion: While there was no significant increase in the frequency of total foreign body ingestions during the pandemic, the proportion of the most dangerous ingestion subtypes (magnets and electronics) up trended significantly. As expected, the frequency of FBI that occurred at school significantly decreased. The injury patterns described in this analysis, particularly with respect to electronics and magnets, provides an opportunity for targeted advocacy and education of patients, parents, educators, and other caregivers. This should guide future pandemic public health campaigns to increase home safety and prevent future FBI. (Table Presented).

The impact of the first two waves of COVID-19 on the activities of the Estonian Poisoning Centre (EPIC): the need for quick learning

Objective: Coronavirus disease (COVID-19) reached Europe in March, including Estonia (population 1.3 million) with two waves in 2020. Suddenly all citizens needed new information about cleaning and disinfectants including the need for information on safe usage. People remained at home while almost 90% of poisonings occur at home, therefore an increase in poisonings was expected. In addition to advising on toxicity, the EPIC was also expected to provide constant media information to target groups. Previously planned Poisoning Prevention Week (in March) rapidly required new content. The aim is to analyze the effects of the COVID-19 on EPIC's hotline in order to be better prepared for poisoning prevention in the future. Methods: A retrospective study analyzing the data from the EPIC's hotline 2019-2020. We compared the number of monthly calls in 2020, as well the number of yearly calls in 2020/2019. The information collected included: type of caller, age group, reason for exposure (accident, intentional), specific type of exposure. Increases or decreases of 10% in parameters with N > 5 were considered a change. Results: The average number of monthly calls in 2020 was around 325 (an increase of 32% from 2019), with rapid change in 2020 from March compared with February (increased by 65%). The number of calls remained high until the end of 2020. Compared to annual average statistics 2019/2020: there were more calls concerning adults (39%, 1069/1483), while calls regarding children (0-3 years/4-17 years) increased modestly (28%/26%). There was a small change in calls regarding drug poisoning (increasing 17%). Poisoning from chemicals increased 33%, including a marked increase in calls about disinfectants of 505% (22/133 compared 2019/2020), while exposures to mixed chemicals markedly decreased (-97%, 30 poisonings 2019/1 call 2020). Accidents with button batteries increased 76% (38/67 comparing 2019/2020). Many people visited woodland to avoid crowded places and this was associated with an increase in enquiries about mushrooms (149%), snakes (62%), and plants (46%) following the first COVID-19 wave. There was no significant change in the ratio of accidental/intentional poisoning or the ratio of caller type (public/medical professionals), compared 2019/2020. Conclusion: The COVID-19 pandemic impacted the activity of EPIC significantly and trends were identified. It is possible to assume that the EPIC's active role in the crisis with a strategic communication may be related to the higher number of calls through increased awareness. The identified toxicity trends need more precise targeting in the media for subsequent coronavirus outbreaks. (Table Presented).