Children are prone to ingest substances due to their exploratory nature and tendency to put everything in the mouth. Commonly ingested foreign bodies are coins, batteries and buttons. Foreign body ingestion in neonates is a very rare presentation and always needs important consideration as it can be a part of child abuse and can lead to serious life threatening consequence

Aftab, Maryam

Afzal, Badar

Habib, Muhammad Irfan

Kazi, Sayyeda Ghazala Irfan

Khan, Irum Qamar

Siddiqui, Emaduddin

English

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanMarch 2015Nail as a foreign body in a neonate, an unusualpresentation at an unusual ageSayyeda Ghazala Irfan KaziAga Khan UniversityMuhammad Irfan HabibAga Khan UniversityBadar AfzalAga Khan UniversityIrum Qamar KhanAga Khan UniversityEmaduddin Siddiquiemaduddin.siddiqui@aku.edu, emaduddin.siddiqui@aku.eduSee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Pediatrics CommonsRecommended CitationKazi, S. I., Habib, M., Afzal, B., Khan, I. Q., Siddiqui, E., Aftab, M. (2015). Nail as a foreign body in a neonate, an unusual presentationat an unusual age. Journal of Pakistan Medical Association, 65(3), 315-316.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/135AuthorsSayyeda Ghazala Irfan Kazi, Muhammad Irfan Habib, Badar Afzal, Irum Qamar Khan, Emaduddin Siddiqui,and Maryam AftabThis report is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/135AbstractChildren are prone to ingest substances due to theirexploratory nature and tendency to put everything in themouth. Commonly ingested foreign bodies are coins,batteries and buttons. Foreign body ingestion in neonatesis a very rare presentation and always needs importantconsideration as it can be a part of child abuse and canlead to serious life threatening consequences.Keywords: Neonates, Foreign body ingestion.IntroductionIngestion of foreign body (FB) is a common presentationin the paediatric emergency department. It is moreprevalent in children due to their curious nature andpreference to oral explorations.1 Toddlers have asusceptibility to keep everything in the mouth and henceare the most exposed group to such misfortunes.2 Eightypercent of all FB ingestions occur in children. The peakincidence is between the ages of 6 months and 3 years.3The most common FBs ingested by young children arecoins. Among all of the FBs that come for medicalconsideration, 80-90% pass through the gastrointestinaltract without causing any obstruction, 10-20% requireendoscopic elimination, and only about 1% requiresurgical intervention.4 Diagnosis becomes easy whenparents give a history of FB aspiration. X-ray neck, AP andlateral view, is most commonly done for diagnosis.5Oesophageal FB can damage the oesophagus and maylead to perforations and strictures andmay erode the vitalstructures around including trachea and aorta.6 Ingestionof FB is extremely rare in neonates with only a fewreported cases in literature.1 FB ingestion is commonlyseen in a scenario where the elder sibling introduced FBinto the mouth of young one while playing or it may be ahomicidal attempt on an unwanted child.7Case ReportA male neonate age seven days was brought to ouremergency department with insertion of nail in hispharynx by his 3years old elder brother. According to themother, her older child who was 3 years old, informed herthat he put a metallic nail in the mouth of his youngestbrother because he was crying excessively and he wantedto keep him quiet. Initially the child was taken to a privatehospital where his X- ray neck, chest and upper abdomenwas done which showed a nail of about 2 inches in theupper part of the neck (Figure-1). After X- ray the child wasreferred to our hospital for removal of nail. On arrival, thechild was irritable but he was vitally stable with no signsof respiratory distress. Mother complained that he is nottaking feeds since then. General physical examination aswell as systemic examination was unremarkable. Inemergency department, child was immediately taken tothe resuscitation room. As it was revealed on X- ray that itwas impacted in the pharynx, immediate laryngoscopywas done to visualize it in the hypopharynx. It was clearlyvisible on direct laryngoscopy and was immediately takenout with the help of an artery forcep without anybleeding. (Figure-2) The size of the nail was 2 inches(5cm). The procedure was done without anaesthesia. Thechild then kept in emergency for 6 hours, took his feedVol. 65, No. 3, March 2015315CASE REPORTNail as a foreign body in a neonate, an unusual presentation at an unusual ageSayyeda Ghazala Irfan Kazi, Muhammad Irfan Habib, Badar Afzal, IrumQamar Khan, Emaduddin Siddiqui, Maryam AftabDepartment of Emergency Medicine, Aga Khan University Hospital, Karachi.Correspondence: Sayyeda Ghazala Irfan Kazi. Email: ghazala.kazi@aku.eduFigure-1: Plain radiograph showing nail in the neck.comfortably and then was discharged home.DiscussionForeign body ingestion is a common presentation in thepaediatric population; however its occurrence inneonates is very rare with only few reported cases.8Negligence or homicidal attempt for an unwanted childmay also be a reason. Common sites for FB obstructionwithin the oesophagus are cricopharyngeal area, middleone-third of the oesophagus (at aortic arch) and loweresophageal sphincter (above the diaphragm).9 Thepresentation of oesophageal foreign bodies may havetypical manifestations like feeding difficulty, drooling andvomiting with or without respiratory manifestation likecough, respiratory distress, and stridor. Respiratorydistress is the commonest presentation of a FB especiallyin oesophagus in neonates, however, in our case therewas no respiratory symptom. The respiratorymanifestations aremainly due to compression, collapse orerosion of trachea. Various other complications includeerosion of aorta that may lead to life threateninghaemorrhage, oesophageal perforation and abscessformation.10 Proper history and visualization of foreignbody on radiograph of the chest helps in confirming thediagnosis. Diagnosis is easier if a family member providesa leading history, as in our case. In case of negativeradiographs and strong suspicion of foreign body,endoscopy is a preferred way to retrieve radiolucent FBs.CT scan and MRI imaging has been used to recognize theradiolucent FBs,11 however endoscopic removal is apreferred method for oesophageal FBs especially inneonates. In cases of large and impacted FB, open surgeryby cervical exploration is preferred over endoscopicremoval.ConclusionNeonatal FB though rare but can lead to serious lifethreatening events if remain undiagnosed. Counseling ofparents and caretakers should be the first step inpreventing this to happen and should take adequateprecautions in the presence of toddler siblings, thesemishaps may be dangerous and can lead to seriousconsequences.References1. Tansneem Z, Khan MA, Uddin N. Esophageal foreign body inneonate. J Pak Med Assoc 2004; 54:159-61.2. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC,BüyükpamukçuN. Foreign body ingestion in children: An analysisof pediatric surgical practice. Pediatr Surg Int 2007; 23: 755-613. Dahshan A. Management of ingested foreign bodies in children. JOkla State Med Assoc 2001; 94: 183-6.4. Wahebeh G,Wyllie R, Kay M. Foreign Body ingestion in infants andchildren, location. Clin Pediatr 2002; 41: 633-40.5. Singh R, Pandit C, Gupta D, Vajifdar H. Foreign body esophagus ina neonate: Unusual age and unusual presentation. J AnaesthesiolClin Pharmacol 2012; 28: 258-60.6. Jiraki K. Aortoesophageal conduit due to a foreign body. Am JForensic Med Pathol 1996; 17: 347-8.7. Zameer M, Kanojia RP, Thapa BR, Rao KL. Foreign bodyoesophagus: A common occurrence at an uncommon age. Afr JPediatr Surg 2010; 7: 114-6.8. Pujar V, Joshi S, Dhaded S. Unusual Cause of EsophagealObstruction in a Neonate Presenting as Esophageal Atresia. JNeonatal Surg North Am 2013; 2: 47.9. Singh B, Bhagat S, Kataria G, Kaur G, Singh R. Unusual EsophagealTwin Foreign Body (Glass Marble) in a Neonate. J Health Allied Sci2013; 12: 21.10. Singh H, Dhingra B, Yadav D, Aggarwal V. Esophageal ForeignBody in a Neonate: An Unusual Age of Presentation. J NepalPaediatr Soc 2012; 32: 79-80.11. Opasanon S, Akaraviputh T, Methasate A, Sirikun J, LaohapensangM. Endoscopic management of foreign body in the uppergastrointestinal tract: Atertiary care center experience. J MedAssoc Thai 2009; 92: 17-21.J Pak Med Assoc316 S. G. I. Kazi, M. I. Habib, B. Afzal, et alFigure-2: Nail after removal.

Nail as a foreign body in a neonate, an unusual presentation at an unusual age

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Nail as a foreign body in a neonate, an unusual presentation at an unusual age

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