Risultati

Objectives

to collect relevant, up-to-date, representative, accurate, systematic information, related to foreign bodies (FB) injuries.

Methods

The "Susy Safe" registry, a DG SANCO co-funded project gathering data on choking in all EU Countries and beyond, was established in order to create surveillance systems for suffocation injuries able to provide a risk-analysis profile for each of the products causing the injury. Main findings after 4 years of activities are resumed here.

Results

16,878 FB injuries occurred in children aged 0–14 years have been recorded in the SUSY SAFE databases; 8046 cases have been reported from countries outside EU. Almost one quart of the cases involving very young children (less than one year of age) presented a FB located in bronchial tract, thus representing a major threat to their health. Esophageal foreign bodies are still characterizing injuries occurred to children younger than one year, in older children the most common locations are the ears and the nose. FB type was specified in 10,564 cases. Food objects represented the 26% of the cases, whereas non-food objects were the remaining 74%. Among food objects, the most common were bones, nuts and seed, whereas for the non-food objects pearls, balls and marbles were observed most commonly (29%). Coins were involved in 15% of the non-food injuries and toys represented the 4% of the cases.

Conclusions

this data collection system should be been taken into consideration for the calculation of the risk of injuries in order to provide the EU Commission with all the relevant estimates on FB injuries.

The present study presents 441 cases of foreign bodies (FB) injuries collected in Argentina, in the framework of the Susy safe program, a web-based surveillance registry for foreign body injuries in children aged 0-14. The analysis was carried out on hospital cases recorded for foreign bodies' injuries, registered in the Susy Safe database and validated as proper for quality and consistency of data.

The current analysis is carried out on FBs located in ears, nose, pharynx and larynx, trachea, bronchi and lungs, mouth, oesophagus and stomach. Injuries occurred most frequently in children older than 3 years Four-hundred-forty-four cases were treated: female patient's incidence was lower than males' one, with a 1:1.24 proportion (44.7% of female, and 55.3% males).

Analyzing the outcomes, hospitalization was required in 218 cases (49.5%), most frequently when the injury occurred in trachea, bronchi and lungs (36.4%).

Complications were recorded in 49 patients (11.1%), the majority of which (5.7%) presented to the ENT departments with a FB in the respiratory system.

An adult was present in 77.8% of the cases testifying that primary prevention has a key role in avoiding those kinds of injuries. Particularly, active strategies that promote behavior change seem to be necessary. A communication initiative is under development in Argentina, aimed at informing parents and supervisors of the risks posed by common objects to their children's health.

Rationale and aim

The purpose of this study is to acquire a better understanding of Food Foreign Bodies (FFB) injuries in children characterizing the risk of complications and prolonged hospitalization due to food items according to patients' characteristics, circumstances of the accident, Foreign Body (FB) features and FB location, as emerging from the SUSY Safe Web-Registry.

Methods

The present study uses data provided by the SUSY Safe Project, a DG SANCO co-funded project started in February 2005, which was aimed at establishing an international registry of cases of Foreign Bodies (FB) injuries in children aged 0–14 years. The analysis was carried out on injuries due to a food item. FB location was reported according to ICD9-CM code: ears (ICD931), nose (ICD932), pharynx and larynx (ICD933) trachea, bronchi and lungs (ICD934), mouth, esophagus and stomach (ICD935). Age and gender injury distributions were assessed. Data regarding adult supervision and activity before injury were also evaluated. FBs which most frequently cause complications were identified. The association between children age, adult presence, object characteristics and hospitalization/complications was computed using unweighted odds ratios and the related 95% confidence intervals.

Results

16,878 FB injuries occurred in children aged 0–14 years have been recorded in the SUSY Safe databases. FB type was specified in 10,564 cases; among them 2744 (26%) were due to a food item. FB site was recorded in 1344 cases: FB was located in the ears in 99 patients, while 1140 occurred in the upper and lower respiratory tract; finally, 105 food items were removed from mouth, esophagus and stomach. Complications occurred in 176 cases and the most documented was pulmonary or bronchial infections (23%) followed emphysema or atelectasis and by and asthma (7%). Bones were the commonest retrieved FFB encountered in this study, while nuts seem to be the FFB most frequently associated to complications.

Conclusions

On the basis of this study we make the strong recommendation that parents should be adequately educated and provide age-appropriate food to their children and be present in order to supervise them during eating especially during a critical period ranging from 2 to 3 years of age.

Rationale and aim

The aim of the present study is to acquire a better understanding of Non Food Foreign Bodies (NFFB) injuries in children with particular regard to the quantification of the risk of complications and hospitalization associated with patient characteristics, FB features, FB location and circumstances of the accident, as emerging from the SUSY Safe Web-Registry.

Methods

The present study uses data provided by the SUSY Safe Project, a DG SANCO co-funded project which was aimed to collect as many scientific data as possible regarding Foreign Bodies (FB) injuries in children aged 0–14 years and to serve as a basis for a knowledge-based consumer protection activity in the Europe market. FBs were characterized by size, shape and consistency. Descriptive statistics (absolute and relative number or median, I and III quartile according to the categorical or continuous variable, respectively) were calculated for each considered non food item characteristics; FB features distribution by children class age and site of obstruction were assessed. Two different outcomes were considered: hospitalization and complication. FBs which most frequently cause complications were identified. The association between children age, adult presence, object characteristics and outcomes was computed using crude odds ratios and the related 95% confidence intervals.

Results

16,878 FB injuries in children aged 0–14 yrs have been recorded in the Susy Safe databases. FB type was specified in 10,564 cases; among them 7820 (74%) were due to a non food item. Almost two thirds of injuries occurred in patients 3 years or more old. 53% of patients were males, while 47% were females. When injury happened, the great part of children (86%) was playing. Almost 30% (2339) of injuries happened under adults’ supervision. Complications occurred in 299 cases and the most documented was infections (10% of cases) followed by perforation (5%).

Conclusions

The inhalation/aspiration of a FB, as well as the ingestion and the insertion in the orifices of a FB may result in significant morbidity. Particularly, long-standing or hazardous foreign bodies can cause extensive damage. Some objects, because of their composition, contour, or location, are particularly hazardous: for instance, objects with sharp edges pose a significant risk of laceration and perforation, while fragments of toys have been found only in 2 cases. Parents are frequently unconscious of hazard related with some objects and they are not adequately able to promptly recognize dangerous objects and risky situations. Moreover, also clinicians seem to pay little attention to adult role in the dynamic of the accident: in fact in case series descriptions, data regarding adult presence are often under-reported. On the contrary, since many injuries to children cannot be prevented without some degree of active behavior on the part of parents, the dissemination of information regarding safe behaviors and the implementation of educational strategies aiming to improve parent's attention toward this issue could be fundamental in preventing injuries and need to be promoted by family pediatricians and health practitioners.

Foreign body (FB) inhalation, aspiration or ingestion are relatively common events in children. Despite many efforts made in several countries to achieve acceptable safety levels for consumer products devoted to children, small toys or toy parts are still frequently mentioned among risky foreign bodies. The aim of the present study is to characterize the risk of complications and prolonged hospitalization due to toys inhalation, aspiration or ingestion according to age and gender of patients, FB characteristics, circumstances of the accident, as emerging from the Susy Safe Registry. The Susy Safe Registry started in the 2005 to collect data to serve as a basis for a knowledge-based consumer protection activity. It is actually one of the wider databases collecting foreign body injuries in the upper aero-digestive tract in pediatric patients. It is distinguished by a deep characterization of objects which caused the injuries and a multi-step quality control procedure which assures its reliability.

Preventive strategies imposing a regulation of industrial production, even if fundamental, are not sufficient and need to be integrated along with other intervention addressed to make aware caregivers toward a proper surveillance of children.

Rationale and aim

Foreign body (FB) injuries are a relatively frequent event in young children. Clinical picture can be evidently affected from different variables. Among those size, shape, type and FB location cover an important issue. Increased attempts have been made in order to encourage normative interventions for products devoted to children's care and entertainment, reaching acceptable safety level; on the contrary, fewer efforts have been devoted to investigate the risk associated to objects that – even if not expressly created for children – are easy accessed by children, like stationery. The aim of the present study is to characterize the risk of complications and prolonged hospitalization due to stationery items according to age and gender of patients, FB characteristics and FB location, circumstances of the accident, as emerging from the Susy Safe Registry.

Methods

From 2005 to 2010 case were collected from 70 centers in 32 different countries. Details on the injuries, identified by means of the International Classification of Diseases, Ninth Revision (ICD-9) codes listed on hospital discharge records, were gathered through a standardized case report form, that provides a full set of information on injuries, with specific details on age and gender of the child, location, shape, volume, consistency and ellipticity of the foreign body, behavioral aspects linked to the injury, like the supervision of the parents or the activity concomitant to the accident, any complication occurred, length of hospitalization.

Results

In the years 2005–2010 a total of 17,205 FB injuries in children aged 0–14years were registered in Susy Safe Database. Among them 425 (2.5%) were due to a stationery item. The majority of FBs were retrieved in the nose (179, meaning 42.1%) and in the ears (176, 41.4%) only 5 cases were observed in children younger than 1year, while most of the cases, 80.6%, were recorded in children older than 3years. 193 patients (45.4%) were female, while 232 (54.6%) were male. Adult supervision was indicated in 212 cases. In 143 of these accidents the adult was present (33.6% of the whole group). The most frequent stationery retrieved was rubber, counting for 209 cases (49.2%). According to the FBs types, mostly all cases reported a 3D volume and a rigid or semirigid consistency (49.3%). Looking to the outcomes, 31 (7%) children needed hospitalization and complications were seen in 38 children (8.9%). No significant associations were seen between the outcomes and the FBs' characteristics, excluded those between the consistency of the FB (rigid) and the necessity of hospitalization and the shape (2D) and the presence of complication.

Conclusions

Injuries are events that in many cases can be prevented with appropriate strategies. Passive environmental strategies, including product modification by manufacturers, are the most effective. However, regulation regarding small parts of potentially dangerous objects covers products addressed to children use but objects not projected for children, such as stationary items, are excluded. Our study testifies that stationary is involved in a non-negligible percentage of FB injuries, mainly due to insertion in the ears. Frequently, injuries happen under adult supervision. These results confirm the fact that when passive preventive strategies are not practical, active strategies that promote behavior change are necessary and information about this issue should be included in all visits to family pediatricians.

Background

Ingestion and/or aspiration of foreign bodies (FB) are avoidable incidents. Children between 1 and 3years are common victims for many reasons: exploration of the environment through the mouth, lack of molars which decreases their ability to properly chew food, lack of cognitive capacity to distinguish between edible and inedible objects, and tendency to distraction and to perform other activities, like playing, whilst eating. Most FBs are expelled spontaneously, but a significant percentage impacts the upper aerodigestive tract. Approximately 80% of children's choking episodes are evaluated by pediatricians. The symptoms of aspiration or ingestion of FBs can simulate different paediatric diseases such as asthma, croup or pneumonia, delaying the correct diagnosis.

Symptoms

There are three clinical phases both in aspiration and in ingestion of FBs: initial stage (first stage or impaction or FB) shows choking, gagging and paroxysms of coughing, obstruction of the airway (AW), occurring at the time of aspiration or ingestion. These signs calm down when the FB lodges and the reflexes grow weary (second stage or asymptomatic phase). Complications occur in the third stage (also defined as complications' phase), when the obstruction, erosion or infection cause pneumonia, atelectasis, abscess or fever (FB in AW), or dysphagia, mediastinum abscess, perforation or erosion and oesophagus (FB in the oesophagus). The first symptoms to receive medical care may actually represent a complication of impaction of FB.

Locations and management

Determining the site of obstruction is important in managing the problem. The location of the FB depends on its characteristics and also on the position of the person at the time of aspiration. Determining the site of obstruction is important in managing the problem. Larynx and trachea have the lowest prevalence, except in children under 1year. They are linked with the most dangerous outcomes, complete obstruction or rupture. Bronchus is the preferred location in 80–90% of AW's cases. Esophageal FBs are twice more common than bronchial FBs, although most of these migrate to the stomach and do not require endoscopic removal. Diagnosis of FB proceeds following the traditional steps, with a particular stress on history and radiological findings as goal standards for the FB retrieval. The treatment of choice for AW's and esophageal FBs is endoscopic removal. Endoscopy should be carried out whenever the trained personnel are available, the instruments are checked, and when the techniques have been tested. The delay in the removal of FBs is potentially harmful. The communication between the endoscopist and the anaesthesiologist is essential before the procedure to establish the plan of action; full cooperation is important and improves the outcome of endoscopy.

Conclusions

Ingestion and or aspiration of FB in children are multifactorial in their aetiology, in their broad spectrum of different resolutions for the same FB and in the response of each patient to the treatment. Prevention remains the best treatment, implying an increased education of parents on age-appropriate foods and household items, and strict industry standards regarding the dimensions of toy parts and their secure containers.

Rationale and aim

This paper has the object to present the impact of nuts' and seeds' injuries withdrawing data from the Susy Safe registry, highlighting that as for other foreign bodies the main item efficiently and substantially susceptible to changes to decrease the accidents’ rates is the education of adults and children, that can be shared with parents both from pediatricians and general practitioners. Indeed labeling and age related warnings have also a fundamental relevance in prevention.

Methods

The present study draws its data from the Susy Safe registry. Details on injuries are entered in the Susy Safe Web-registry through a standardized case report form, that includes information regarding: children age and gender, features of the object, circumstances of injury (presence of parents and activity) and hospitalization's details (lasting, complications and removal details). Cases are prospectively collected using the Susy Safe system from 06/2005; moreover, also information regarding past consecutive cases available in each centre adhering to the project have been entered in the Susy Safe registry.

Results

Nuts and seeds are one of the most common food item retrieved in foreign bodies injuries in children. In Susy Safe registry they represent the 38% in food group, and almost the 10% in general cases. Trachea, bronchi and lungs were the main location of FB's retrieval, showing an incidence of 68%. Hospitalization occurred in 83% of cases, showing the major frequency for foreign bodies located in trachea. This location was also the principal site of complications, with a frequency of 68%. There were no significant associations between these outcomes and the age class of the children. The most common complications seen (22.4%) was bronchitis, followed by pneumonia (19.7%). Adult presence was recorded as positive in 71.2% of cases, showing an association (p value 0.009) between the adult supervision and the hospitalization outcome. On the contrary there was a non significant association between adult presence and the occurrence of complications. In 80.7% of cases, the incident happened while the child was eating. Among those cases, 88.6% interested trachea, lungs and bronchi.

Conclusions

Food-related aspiration injuries are common events for young children, particularly under 4 years of age, and may lead to severe complication. There is a need to study in more depth specific characteristics of foreign bodies associated with increased hazard, such as size, shape, hardness or firmness, lubricity, pliability and elasticity, in order to better identify risky foods, and more precisely described the pathogenetic pathway. Parents are not adequately conscious and aware toward this risk; therefore, the number and severity of the injuries could be reduced by educating parents and children. Information about food safety should be included in all visits to pediatricians in order to make parents able to understand, select, and identify key characteristics of hazardous foods and better control the hazard level of various foods. Finally, preventive measures including warning labels on high-risk foods could be implemented.

Context

While several articles describe clinical management of Foreign Bodies injuries in the upper air tract, little epidemiological evidence is available from injury databases.

Objective

This article aims to understand the burden of airway FB injuries in high-, low-, and middle-income countries as emerging from scientific literature.

Data Sources

One thousand six hundred ninety-nine published articles 1978–2008.

Study Selection

A free text search on PubMed database ((foreign bodies) or (foreign body)) and ((aspiration) or (airways) or (tracheobronchial) or (nasal) or (inhalation) or (obstruction) or (choking) or (inhaled) or (aspirations) or (nose) or (throat) or (asphyxiation)) and ((children) or (child)).

Data Extraction

Information on reported injuries according to country, time period, children sex and age, FB type, site of obstruction, symptoms, signs, diagnostic and therapeutic procedures, delay at the diagnosis, complications, number of deaths.

Results

Serious complications occur both in high-income and low-middle income countries in a considerable proportion of cases (10% and 20%, respectively). Similarly, death is not infrequent (5–7% of cases).

Conclusions

Few countries have good systematic data collection and there's a lack of sensibility in parents and clinicians in terms of acknowledge of the choking risk. On the contrary, international surveillance systems able to collect information in a standardized way need to be implemented. Pediatr Pulmonol. 2013; 48:344–351. © 2012 Wiley Periodicals, Inc.

Risk Assessment is the systematic study of decisions subject to uncertain consequences. An increasing interest has been focused on modeling techniques like Bayesian Networks since their capability of (1) combining in the probabilistic framework different type of evidence including both expert judgments and objective data; (2) overturning previous beliefs in the light of the new information being received and (3) making predictions even with incomplete data. In this work, we proposed a comparison among Bayesian Networks and other classical Quantitative Risk Assessment techniques such as Neural Networks, Classification Trees, Random Forests and Logistic Regression models. Hybrid approaches, combining both Classification Trees and Bayesian Networks, were also considered. Among Bayesian Networks, a clear distinction between purely data-driven approach and combination of expert knowledge with objective data is made. The aim of this paper consists in evaluating among this models which best can be applied, in the framework of Quantitative Risk Assessment, to assess the safety of children who are exposed to the risk of inhalation/insertion/aspiration of consumer products. The issue of preventing injuries in children is of paramount importance, in particular where product design is involved: quantifying the risk associated to product characteristics can be of great usefulness in addressing the product safety design regulation. Data of the European Registry of Foreign Bodies Injuries formed the starting evidence for risk assessment. Results showed that Bayesian Networks appeared to have both the ease of interpretability and accuracy in making prediction, even if simpler models like logistic regression still performed well.

Ingestion of foreign bodies is an avoidable accident that is seen mainly in children under 3 years-old. Most of them pass through the digestive tract without causing clinical manifestations or complications, but a significant percentage is impacted in the esophagus causing vomiting, sore throat, dysphagia and drooling. The most common foreign bodies are coins. Complications usually occur when there is a delay in diagnosis or with large, sharp or potentially toxic objects, as the button battery. It is essential to make differential diagnosis between coin and button battery, since the latter requires urgent removal due to the earliness of the injury caused. We report 115 cases of foreign bodies in the esophagus, and we alert the pediatrician in recognizing and preventing this problem.

Aspiration of foreign bodies is an important and preventable cause of morbidity and mortality in childhood. The early diagnosis and treatment are essential for risk of mortality in the acute and complications arising from the continuance of a foreign body in the airway. The clinical presentation may mimic different diseases, delaying the correct diagnosis. Pediatricians should be aware of the possibility of foreign body in children with persistent respiratory symptoms, even in the absence of a history of choking. Bronchoscopy is indicated in all patients with suspected aspiration, even when the physical and radiological examination is inconclusive. We evaluate in 90 cases the time between the aspiration of foreign body and the removal, and emphasize the need for preventive measures and greater dissemination of knowledge in the community and health professionals about this problem.

Rationale and aim

Foreign bodies (FB) aspiration, ingestion, insertion or inhalation can be a serious occurrence, resulting in fatality if not promptly recognized and solved. The aim of the current paper is to present foreign body ingestion's cases observed at the Children's Hospital Gutierrez in Buenos Aires in 5 years of ORL activity and to compare main findings with data coming from other well known already published case series.

Methods

A prospective study was realized on children having ingested, inhaled, aspirated or introduced FBs, with regard to age and sex distribution, FB's type, dimensions and consistency, FB's location, clinical presentation, removal and occurrence of complications.

Results

FBs retrieved amounted to 2336 cases. The most common location was the nose (66.7%), where the most frequent FBs retrieved were inorganic (72.7%) and occurred in children younger than 3 years old (54.2%), the only position where children younger than 3 years are a majority in respect to the older ones. The presence of the adult was seen in the preponderance of cases (88.4%). Symptoms varied between the different anatomical systems, with cough as predominant when concerning aspiration, local pain or inflammation in inhalation and insertion, and vomiting in for the FBs ingestion cases. All the foreign bodies retrieved were clustered in categories, due to necessity when extremely various and with low absolute frequency. The most common FBs retrieved were pearls (20.2%), followed by stationery products (mostly rubbers) and coins. Complications had a low rate in all the studies.

Conclusions

The study stresses the importance of primary prevention, seen as the active care of adults toward children manipulating foreign bodies potentially dangerous. This presence may not avoid the event, but in case of FBs aspiration, ingestion, insertion or inhalation, it could be the main factor leading to a faster and correct treatment. Prompt removal of the foreign body decreases the risk of complications, resulting in a lower length of hospitalization.

Symptoms were various and differed in all the studies, showing that their wide amount indicates the importance of registries to early recognize and therefore treat a pathology that might be mistaken for something different due to unspecific signs. Secondary prevention with specific training of doctors on clinical post-trauma guidelines for treatment and active participation of doctors to the broadening of the current registries seem to be other ways for lowering the outburst of FBs injuries.