Comparison of pediatric airway foreign bodies over fifty years.

Abstract: Prevention and early recognition remain critical factors in the treatment of foreign body inhalation in children. Accidental inhalation of both organic and nonorganic foreign body material continues to be a cause of childhood morbidity and mortality. The University of North Carolina Department of Otolaryngology has collected foreign bodies acquired from the airways of young children since its inception in 1954. The authors reviewed 26 foreign bodies removed bronchoscopically from the airways of children during the years 1955 to 1960, and compared these to 27 foreign bodies collected from 1999 to 2003. Findings showed remarkable similarities in the types of foreign bodies aspirated. Organic foreign bodies were most commonly found. Differences existed in the type of organic foreign body aspirated, with popcorn being retrieved in 15% of cases during the later time period. Also, an increase in bronchoscopically removed small toy parts was found in the later group.

Key Words: bronchoscopy, foreign body, pedicatric airway

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Foreign body aspiration continues to be a common cause of accidental death in infants and young children. (1) In the past, North Carolina had a disproportionately high rate of deaths among children related to foreign-body aspiration. (2) Techniques for the removal of foreign bodies from the airways have improved dramatically, and the incidence of complications has markedly diminished. Before Chevalier Jackson introduced the ventilating bronchoscope with distal lighting, the mortality among those diagnosed with foreign body aspiration approached 50%, and now it is estimated to be 1%. (3) Because foreign body aspiration continues to be a potentially life-threatening occurrence in early childhood, the authors carried out a comparison of foreign bodies removed at University of North Carolina hospitals in order to identify whether trends could be observed in the nature of objects being aspirated. If a changing pattern of childhood aspiration could be detected, directed preventive measures could be instituted.

Materials and Methods

Airway foreign bodies have been removed with rigid bronchoscopes and foreign body forceps by otolaryngologists at the University of North Carolina since the mid-1950s. Foreign bodies are displayed in a collection assembled by the Department of Otolaryngology (Fig. 1). A retrospective study was undertaken to compare the most recently removed 26 airway foreign bodies (1999-2003) with the first 27 airway foreign bodies (removed during the years 1955-1960) from the collection. A descriptive study of the foreign bodies was done without review of patient age, procedure, or complication rate.

Results

The results of the comparison showed remarkable similarities between objects from the two time periods studied. Organic foreign bodies represented 89% of foreign bodies collected from 1955 to 1960, and 69% of those removed from 1999 to 2003. In both cases, peanuts were the most common organic foreign body (54% in the earlier time period and 42% in the later period). Furthermore, a minority of foreign bodies were found to be radiographically opaque: 19% and 15% respectively.

Interestingly, the type of organic foreign body appears to have changed (Table 1). Whereas watermelon seeds represented 11% of foreign bodies found from 1955 to 1960, and no sunflower seeds or popcorn remnants were retrieved during that time, from 1999 to 2003, 8% of the foreign bodies removed were sunflower seeds and 15% were popcorn. It is likely that this represents a changing dietary trend among young children in the surrounding geographic area between the two time periods studied.

[FIGURE 1 OMITTED]

The incidence of aspiration of toy parts has increased over the roughly 50 years studied in this series. Whereas no small toy parts were found from the bronchoscopically-removed collection from 1955 to 1960, small parts of toys represented 15% of the foreign bodies removed between 1999 and 2003. Examples were bits of Lego, a plastic bullet, and plastic beads used in making jewelry.

Discussion

Food products and other organic substances continue to be the objects most commonly aspirated into the airways of children. Better public education is necessary to reduce the exposure of children to high-risk foods (ie, peanuts) during high-risk ages (under 3 years of age). In spite of federal regulations and increasing public education, aspiration of toy parts may be more common now than fifty years ago. (4) This is particularly important because other studies indicate that the proportion of all aspiration deaths due to nonfood objects is increasing. (1,5) In addition, physician awareness is extremely important in light of findings showing that 45% of airway foreign body diagnoses are delayed by more than 24 hours. (6) One third of these are due to initial misdiagnosis by physicians.

Conclusion

Aspirated foreign bodies are a potentially fatal hazard to children. When pediatric airway foreign bodies removed nearly 50 years ago are compared with foreign bodies removed recently, there are both similarities and differences. Small toy parts appear to be more commonly aspirated in recent times. Also, although peanut fragments are still the majority of aspirated organic foreign bodies, popcorn and sunflower seeds are more commonly found in recent times. Prevention through public education has proven effective in reducing fatalities. Continued education about and regulation of nonfood choking hazards may reduce incidences further.

Table 1. Aspirated organic foreign bodies: changing dietary trends?

Organic
    1955-1960     89%
    1999-2003     69%
Peanuts
    1955-1960     54%
    1999-2003     42%
Watermelon seeds
    1955-1960     11%
    1999-2003      0%
Sunflower seeds
    1955-1960      0%
    1999-2003      8%
Popcorn
    1955-1960      0%
    1999-2003     15%

Accepted November 12, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9705-0434

The best way to make your dreams come true is to wake up.

--Paul Valery

References

1. Lifschultz BD, Donoghue ER. Deaths due to foreign body aspiration in children: the continuing hazard of toy balloons. J Forensic Sci 1996;41:247-251.

2. Drake AF, Smith TL, Fischer ND. Foreign body aspiration in North Carolina children. NC Med J 1994;55:83-85.

3. Rovin JD and Rodgers BM. Pediatric foreign body aspiration. Ped Rev 2000;21:86-90.

4. http://tlc.discovery.com/fansites/babystory/articles/choking_24_01.html.

5. Mittelman, Am J Forensic Med Pathol, 1984;5(3):201-210.

6. Baker SP, Fisher RS. Childhood asphyxiation by choking or suffocation. JAMA 1980;244:1343-1346.

RELATED ARTICLE: Key Points

* Organic and food products continue to be the most common objects aspirated by children.

* Of the organic foreign bodies, a decrease in watermelon seeds and an increase in popcorn and sunflower seeds were found.

* The incidence of aspiration of toy parts has increased during the last half-century.

* Better public education is necessary to reduce the exposure of children to small toy parts and high-risk foods such as peanuts during high-risk years (under 3 years of age).

David R. White, MD, Carlton J. Zdanski, MD, Amelia F. Drake, MD

From the Departments of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.

Reprint requests to Amelia F. Drake, MD, UNC Department of Otolaryngology/Head and Neck Surgery, 1114 Bioinformatics Bldg., CB# 7070, Chapel Hill, NC 27599-7070.