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

Data of patients <6 years of age who were brought to US EDs for suspicion of FBI between January 1, 1995, and December 31, 2015, were obtained from the National Electronic Injury Surveillance System (NEISS). The CPSC operates the NEISS, which provides data on consumer product–related injuries treated in US EDs. Approximately 100 hospitals, including 8 children’s hospitals, provide data to the NEISS, which then represents a stratified probability sample of the 6100 hospitals in the country that have ≥6 beds and a 24-hour ED. Urban, suburban, and rural hospitals are included. By using a validated method, data from the NEISS are weighted by the CPSC to derive national estimates of product- and sports- and/or activity-related injuries.²⁴ NEISS coders at each of the member hospitals review every ED case with a diagnosis of any type of injury. The coders update the database daily, recording data on patients’ demographics, products involved, and disposition. A brief narrative describing the incident is included. Population estimates from the US Census Bureau were used to determine injury rates per 10 000 children <6 years of age.²⁵ 

All NEISS cases involving injuries identified with a diagnosis code of 41 (signifying an “ingested foreign object”) among children <6 years of age were reviewed (n = 35 957). After a review of a subset of case narratives, case inclusion and exclusion criteria and variable categories were developed. All case narratives were reviewed to confirm that the object in question had been swallowed or ingested. Cases were included in the analysis if (1) the ingested object was within the gastrointestinal tract beyond the mouth and (2) the ingestion was suspected via the use of the words “possible,” “maybe,” and “allegedly” in the case narrative. Any ambiguous cases were reviewed by >1 author, and disagreements were resolved via consensus. Cases that involved (1) ingestions of foods or liquids, (2) the location of the object in the airway or mouth, (3) aspiration, or (4) “choking” (unless specified as having resulted in an ingestion) were excluded (n = 6063), as were case fatalities (n = 1). The final number of actual cases used in the analysis was 29 893.

The following variables provided by the NEISS were coded into categorical variables. Patient age was categorized into 6 groups (<1, 1, 2, 3, 4, and 5 years of age). Disposition was regrouped into 2 categories: (1) hospitalized (ie, admitted, treated and transferred to another hospital, or held for observation) and (2) not hospitalized (ie, treated and released, examined and released without treatment, or left against medical advice). Location of injury was grouped into 2 categories (home or other). On the basis of the most common NEISS product codes, foreign-body product was grouped into 9 main categories: (1) coins; (2) toys; (3) jewelry; (4) batteries; (5) nails, screws, tacks, or bolts; (6) hair products; (7) Christmas decorations; (8) kitchen gadgets; and (9) desk supplies. Two additional categories (not specified and multiple products) were also created on the basis of product codes.

The foreign-body products were further categorized on the basis of the type of object ingested. New variables were created and coded on the basis of keyword searches and review and interpretation of case narratives. Coin type was subdivided into 5 groups: (1) pennies, (2) nickels, (3) dimes, (4) quarters, and (5) other. There were 7 categories for toys: (1) doll pieces, (2) game pieces, (3) balls, (4) blocks, (5) marbles, (6) building sets, and (7) other. Subcategories for jewelry included (1) bracelets, (2) earrings, (3) necklaces and/or chains, (4) rings, and (5) other. Batteries were subdivided into the following categories: (1) button (eg, small or disc batteries), (2) AA, (3) AAA, and (4) other. The category of nails, screws, tacks, or bolts had 8 subcategories: (1) nails, (2) tacks and/or push pins, (3) bolts, (4) screws, (5) hooks, (6) nuts, (7) washers, and (8) other. Magnet ingestion was coded separately as (1) 1 or (2) multiple magnets. If magnet ingestion was not discussed in the case narrative, the number of magnets was set to missing.

Data were analyzed by using SPSS version 21 (IBM SPSS Statistics, IBM Corporation, Armonk, NY) and SAS version 9.4 (SAS Institute, Inc, Cary, NC). A sample weight was assigned to each case by the CPSC on the basis of the inverse probability of selection, and weights were used to generate national estimates. Bivariate comparisons were conducted via Rao-Scott χ² tests, and strength of association was assessed by using relative risks (RRs) with 95% confidence intervals (CIs). Statistical significance was assessed by using α = .05. Trend significance of the rates of FBIs over time was analyzed via linear regression. All statistical analyses accounted for the complex sampling frame of the NEISS. Data reported in this article are national estimates unless otherwise specified as actual unweighted cases. A minimum of 20 actual cases was required for generation of national estimates. This study was exempt from review by the Institutional Review Board at Nationwide Children’s Hospital.

Between 1995 and 2015, an estimated 759 074 (95% CI: 589 323–928 825) children <6 years of age sought care in US EDs for suspected or confirmed FBIs (Table 1). The number of estimated cases increased by 93.3% from 1995, when there were 22 206 ingestions, to 2015, when there were 42 928. The rate of FBIs per 10 000 US children <6 years of age increased by 91.5% over the study period, from 9.4 cases per 10 000 children in 1995 to 17.9 in 2015 (R² = 0.90; P < .001; Fig 1). FBIs most frequently involved children 1 year of age (21.3%) and boys (52.9%). Coins accounted for most of the objects ingested (61.7%). Of patients, 10.3% were hospitalized (Table 2). Of the 58.7% of cases for which location was available, 97.2% of ingestions occurred within the home.

The rate of coin ingestions increased from 6.3 cases per 10 000 children in 1995 to 10.5 in 2015, with a peak rate of 12.1 cases in 2011 (R² = 0.74; P < .001; Fig 2). Coins accounted for 67.0% of all FBIs in 1995 and 58.5% of ingestions in 2015. Of all patients who were hospitalized over the study period, 79.7% ingested coins. When compared with children who ingested all other products, those who ingested coins were 2.43 times as likely to be hospitalized (95% CI: 2.14–2.75). Of the case narratives in which the type of coin could be determined, pennies (65.9%) and quarters (16.0%) were the most common. Quarter ingestions increased with age, from 4.4% of children <1 year of age to 21.9% of children 5 years of age. Children who ingested quarters were almost twice as likely to be hospitalized when compared with those who ingested other coins (RR: 1.87 [95% CI: 1.62–2.12]), and children who ingested pennies were less likely to be hospitalized (RR: 0.52 [95% CI: 0.45–0.59]).

The rate of toy and toy-part ingestions increased from 2003 to 2008 (R² = 0.90; P = .004), declined from 2008 to 2011 (R² = 0.96; P = .020), and again increased from 2011 to 2015 (R² = 0.97; P = .002; Fig 3). The percentage of all FBIs that involved toys or toy parts remained stable over the study period (12.0% in both 1995 and 2015). Three-year-old children most frequently ingested toys or toy parts (21.3%), followed by 4-year-old children (20.2%). Boys were more likely to ingest toys or toy parts compared with girls (RR: 1.31 [95% CI: 1.19–1.44]). When the type of toy could be determined, marbles were most frequently ingested (47.4%).

A total of 7.0% of patients ingested jewelry. The rate of jewelry ingestions increased from 0.7 cases per 10 000 children in 1995 to 1.5 in 2015 (R² = 0.54; P < .001; Fig 3). Girls were 2.5 times as likely to ingest jewelry when compared with boys (95% CI: 2.22–2.81). Children ≤1 year of age accounted for 46.8% of jewelry ingestions. Earrings comprised 33.7% of jewelry ingestions when the type of jewelry could be determined.

A total of 6.8% of children ingested batteries. The rate of battery ingestions increased from 0.01 cases per 10 000 children in 1995 to 1.5 in 2015, with a peak rate of 2.2 cases in 2013 (R² = 0.89; P < .001; Fig 3). Battery ingestions represented 0.14% of all FBIs in 1995 and 8.4% in 2015. Batteries were most frequently ingested by children who were 1 year of age (33.2%). Batteries were the second most common foreign-body product (6.1%) among all patients who were hospitalized. Of all patients who ingested batteries, 9.2% were hospitalized. Of the cases in which the type of battery could be determined, BBs were most frequently ingested (85.9%).

A total of 6.3% of patients ingested nails, screws, tacks, or bolts. Boys (59.7%) and children 1 year of age (31.8%) most commonly ingested items in this group. Screws accounted for the majority of these ingestions (52.7%) when the type could be determined. Hair products represented 2.1% of all ingestions and were more commonly ingested by girls (83.6%). Christmas decorations represented 2.0% of all ingestions, with children ≤1 year of age accounting for 75.6% of them. Kitchen gadgets and desk supplies each represented 1.7% of all ingestions. A total of 2.2% of children were evaluated for suspected magnet ingestion, with 13.3% of them ingesting >1 magnet. Hospitalization was required for 71.1% of children who ingested multiple magnets.

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.

AAP

American Academy of Pediatrics

BB

button battery

CI

confidence interval

CPSC

Consumer Product Safety Commission

CPSIA

Consumer Product Safety Improvement Act

ED

emergency department

FBI

foreign-body ingestion

NASPGHAN

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

NEISS

National Electronic Injury Surveillance System

RR

relative risk