An Uncommon Foreign Body in an Infant

A 3-month-old baby was referred to us from the pediatric department with the accidental diagnosis of ingested foreign body (FB) on X-ray. The child had reported to the pediatric department with the history of drooling of saliva, not accepting mother’s feed and vomiting for the past 7 days. In general, the child was irritable and always crying. The patient had no signs or symptoms of respiratory distress. After a thorough clinical evaluation, no apparent clinical diagnosis could be made. It was during investigations that X-ray chest- postero -anterior (PA) view revealed the metallic FB: a radiopaque FB with sharp edges was seen at the level of C7 to T2 vertebrae (Figure 1). X-ray chest lateral view confirmed the presence of FB in the esophagus (Figure 2). However, the parents of the infant were oblivious of this. The FB zipper hook was removed by rigid endoscopy under general anesthesia: it was lying impacted in the upper part of esophagus 16 cm from the upper incisor (Figure 3). The postoperative period was uneventful and breast feeding was permitted after 24 hours of the endoscopy. Subsequently, the patient was discharged and a regular follow-up was kept in the ENT OPD (ear nose throat out patient department) for 3 months, with no untoward incident to report.

Figure 1.

X-ray chest PA view showing radio-opaque foreign body at the level.

Figure 2.

X-ray soft tissue lateral neck showing the radio-opaque foreign body in upper part of esophagus.

Figure 3.

Removed zipper hook.

The peak incidence of FB ingestion in children is generally seen in the age-group of 6 months to 3 years, when children out of curiosity develop a tendency to insert objects in body cavities. ¹ Foreign body ingestion in infants below 6 months of age is a rare occurrence. ² From our search (Medline/PubMed) of literature we could find very few cases of FB ingestion in children of 3 months of age, namely an impacted ring in a 3-day-old baby, lithium battery in a 17-day-old child, a stone in a 25–day-old child, and a rubber pellet in a 2-month-old baby.^3,4

Moreover, an unwitnessed FB in an infant always poses a diagnostic challenge as no communication with the patient is forthcoming. In this context it would be prudent to note that metallic sharp FB can cause serious complications as esophageal perforations, tracheoesophageal fistula, abscess formation, peritonitis, an aorta-esophageal fistula, and even death.^1,5-7 Foreign body with sharp edges as removed herein, thus warrant immediate removal. A case of ingestion of nail (sharp FB) in an infant is mentioned in the English literature. ⁸ This case presented as a neck abscess at 11 months of age. In this patient there was a history of sibling inserting the said FB 8 months back, when baby was 3 months old, but the patient was asymptomatic. Hence, in view of the aforesaid facts, a possibility of FB ingestion must be given due consideration in infants presenting with drooling, dysphagia, and vomiting in the best interest of patient care.

On further probing this case, it was found that the FB ingestion was also a result of sibling rivalry. The elder brother aged 6 years had inserted the zipper hook into the mouth of the baby just as a prank. This case thus also highlights the importance of adult/parental supervision in children and the hazard of leaving infants unattended.

The dictum of management is very clear: if an esophageal FB is not passed spontaneously within 24 hours, it must be removed considering the possibility of an anatomic anomaly or esophageal perforation.^1,9 Recently, the North American Society for Pediatric Gastroenterology, Hepatology. And Nutrition (NASPGHAN) Endoscopy Committee recommends removal of all symptomatic FB within 2 hours and asymptomatic FB within 24 hours. ¹⁰

In summary, the case in focus merits mention on account of (1) rarity of the occurrence of FB ingestion in age-group less than 6 months, especially sharp objects, (2) Underlining the importance of detection of subtle clinical signs like drooling, not accepting feeds and irritability as important sentinel signs for FB ingestion in the said age-group, and (3) propagation of concept of adult child care, as the most effective preventive management of FB accidents in infants.