Foreign body injury in children in the twentieth century: a modern comparison to the Jackson collection.

OBJECTIVE: To compare two databases of foreign body (FBs) objects causing injury in children (>20 years of age) and record differences in size, shape and material for children at risk over a 70-year period of time. STUDY DESIGN: Retrospective analysis of the Jackson collection (JC) of FBs (1920-1932) and a 12-year modern study (MS) of data taken from 25 children's hospitals in North America over the period 1988-2000. Digital images were obtained of the JC collection. METHODS: Identify age, sex, and type of products, size, shape, and consistency of material from the injury-producing FBs. Statistical Processing for Social Sciences was used for analysis of JC versus MS. RESULTS: 5528 children were evaluated from the MS, and compared with 1238 from the JC. Boys remain at greater risk than young girls (53% versus 47%) over the 70-year period of study. Coins have replaced safety pins (31% versus 15%) as the most common offending FBs. Although 99% of FBs causing injury are less than 1.25 in. in greatest diameter in both the JC and MS, 100% of FBs are eliminated when the test size is greater than 1.75 in. CONCLUSIONS: Boys remain at greater risk of injury over the last 60 years. However, coins have now emerged as the leading cause of injury in children. Children achieve greater protection from risk by modification of the Small Parts Test Fixture (SPTF) from 1.25 to 1.75 in. diameter.

The South African experience with ingestion injury in children.

INTRODUCTION: The Red Cross Children's Hospital is the only children's hospital in South Africa. It has a dedicated trauma unit for all children under the age of 13 and serves a population of approximately 2 million inhabitants. As part of the Child Accident Prevention Foundation program we have kept a database of all children treated for trauma in our hospital since 1991. Presently, we have over 88,000 entries in our database. AIM: To study our experience with ingested foreign bodies in children. MATERIALS AND METHODS: A retrospective study was performed using the CAPFSA database of a total of 3677 patients presenting with foreign bodies. The hospital folders were searched using a standardised data extraction form. Only foreign bodies aspirated or ingested were included. RESULTS: To date, 241 folders have been analysed. DEMOGRAPHICS: Both sexes were equally affected (boys 49%). Age ranged between 0 and 12 years, although there was only one child under the age of 1. At the age of 3 years there was a peak in incidence (24% of all cases). Nature of ingested object: Although the objects were from a range of materials, most were metal (40%) or plastic (23%). The most commonly ingested object was a coin (28%), a ball (20%) or bone (8%). The size ranged from 0.1 to 3 cm (as measured by virtual ring), the most common size of an ingested foreign body was 0.5 cm. Anatomical site: The most common anatomical site of impaction was the nose (41%), followed by the oesophagus (20%), the stomach (14%) and bowel (11%). Other anatomical sites included hypopharynx, nasopharynx, bronchus, larynx and oral cavity. Severity of symptoms: Only 0.4% of our cases were assessed as being severe, 14% as moderate, and 44% as mild. Forty-two percent (42%) had no symptoms. Removal: Fifty-seven percent (57%) of ingested foreign bodies were removed surgically, 19% were left in situ, 14% spontaneously dislodged and only 1% was removed by Foley catheter manipulation. CONCLUSION: A presentation with a foreign body is quite common in our patient population, representing approximately 4.2% of all our cases. The majority of ingested foreign bodies produced mild or no symptoms, needed surgical removal and had no complications.

Application of data for prevention of foreign body injury in children.

BACKGROUND: To develop design criteria for consumer products, based on foreign body injury and fatality data, to prevent airway obstruction injuries to children. METHOD: Beginning in 1988, RAM Consulting has created a worldwide database of foreign body injuries. This ongoing project now includes approximately 7000 data points from 51 children's hospitals in 15 countries located on five continents. Statistical analysis of these data, especially in terms of size, shape and consistency of the object and obstruction location and severity of injury for the patient has allowed the creation of an injury prevention criterion. RESULTS: Analysis of these data reveals that adoption of an injury prevention criteria based on the use of a 1.50 in. (38.10 mm) diameter gauge for non-spherical objects and a 1.75 in. (44.50 mm) diameter gauge for spherical objects would greatly reduce airway obstruction injuries to children. Furthermore, the data show that this criterion is independent of country and culture. However, the data suggest that a child's exposure to the "mix" of objects that may cause airway obstruction varies with the country and culture of the child. For example, coins are well represented in the database, however, some countries make more coins than other countries and the exposure level may have made the difference in the occurrence of incidents. CONCLUSIONS: Airway obstruction injuries from consumer products could be greatly decreased by the adoption of the presented injury prevention criteria that is founded in a statistical analysis of known objects that have caused injury. This criteria is dependent on object characteristics and is independent of the country or culture of the child.

Prevention of accidental childhood strangulation. A clinical study.

Accidental strangulation is a preventable problem, and there is limited scientific understanding of its mechanism in children. If the amount of external pressure that occludes the airway can be determined, design changes may be made to allow for production of household objects that would break apart at safe pressure levels. A force gauge was applied to the suprahyoid region in 90 children under standardized anesthesia. Three blinded observers performed the study. The anesthesiologist maintained the airway and used a stethoscope to auscultate for breath sounds and monitor the CO2 curves to evaluate obstruction. The recorder noted the numbers from the gauge. A single observer applied the force gauge. Age was the most significant variable in occluding the airway. Obstruction appears to occur at the level of the larynx. Increased knowledge regarding the external pressure required for airway occlusion would allow for the design and manufacture of products with a reduced potential for accidental strangulation.

Prevention of accidental childhood strangulation: where is the site of obstruction?

BACKGROUND: Accidental strangulation is a preventable problem with limited scientific understanding in children. Children's clothing and household furniture have the potential to cause strangulation. Localizing the site of obstruction would provide understanding and insight to preventing this unfortunate event. METHODS: While undergoing the application of pressure to the submental and suprahyoid region in eight patients flexible endoscopy was performed to evaluate the location of obstruction. RESULTS: Submental pressure occluded the nasopharynx and oropharynx. Suprahyoid pressure occluded the larynx. CONCLUSIONS: In suspension strangulation, airway obstruction appears to occur at the level of the larynx involving the epiglottis and the arytenoids. Increased knowledge regarding site of airway occlusion may help to decrease the hazard of accidental strangulation.

Human factors project: development of computer models of anatomy as an aid to risk management.

Behavioral studies and reports in the pediatric medical literature suggest that children, particularly those younger than 4 years, frequently place foreign objects such as toys and small parts of consumer products in their mouths, nasal cavities and ear canals. These actions not infrequently lead to injury or death. Accurate models of the anatomical areas most often severely injured by foreign body impaction (oral cavity, orbit, ear canal and nasal passages) would greatly facilitate assessment of the risks of impaction. Because models of these anatomic regions in children of the ages when they are most at risk are not widely available, Intertek Testing Services, Risk Analysis and Management (ITS RAM), in association with faculty at the University of Pittsburgh and the Pittsburgh Supercomputing Center at Carnegie Mellon University, developed computerized models of these anatomical areas of interest in children at the critical stages of child development. Computer models were also developed of proposed or existing products and of objects represented in the ITS RAM Small Parts Aspiration and Ingestion Database (comprised of data from 17 children's hospitals) and fatality data from the Consumer Product Safety Commission. The computer models of products and computer anatomical models can be used to assess the possible hazards inherent in the product designs and to communicate the risks associated with product designs to manufacturers and marketing groups.

Prevention and management of aerodigestive foreign body injuries in childhood.

Pediatricians have a critical role in the evaluation of children who experience a choking episode and foreign body injury. Familiarity with important symptoms and signs improves diagnostic skills and complements radiographic evaluation. Further reduction in injury prevention is assisted by parental education and avoidance of objects and foods that produce the greatest risk. Design modifications of toys and other products for children's use is the next important step in this safety process.

Characteristics of objects that cause choking in children.

OBJECTIVE: To characterize the types, shapes, and sizes of objects causing choking or asphyxiation in children and to compare these characteristics to current standards. DESIGN: To evaluate morbidity, retrospective 5-year medical record survey; to evaluate mortality, data reanalysis. SETTINGS: Pediatric hospital and consumer product testing laboratory. PATIENTS: All children (n = 449) who underwent endoscopy for foreign body aspiration or ingestion at Children's Hospital of Pittsburgh (Pa) between 1989 and 1993 and children (n = 449) whose deaths due to choking on man-made objects were recorded by the Consumer Product Safety Commission (CPSC) between 1972 and 1992. MAIN OUTCOME MEASURES: Objects removed from children's aerodigestive tracts were characterized by location, procedure for removal, and type. Objects causing death were characterized by type, shape, and consistency. Three-dimensional objects that had caused asphyxiation were analyzed by computer-simulated models. RESULTS: Of the 165 children treated by endoscopy, 69% were 3 years of age or younger. Foreign bodies most often ingested or aspirated were food (in 36 children) and coins (in 60 children). Of 449 children whose deaths after aspirating foreign bodies were reported to the CPSC, 65% were younger than 3 years. Balloons caused 29% of deaths overall. Conforming objects such as balloons caused a significantly (P < .001) higher proportion of deaths in those aged 3 years or older (60%) vs those younger than 3 years (33%). Of the 101 objects causing deaths that we could analyze, 14 met current standards for use by children of any age. CONCLUSIONS: Balloons pose a high risk of asphyxiation to children of any age. Changes in regulations regarding products intended for children's use might have prevented up to 14 (14%) of 101 deaths in this study.