A 21-month-old male presented to the Emergency Department after several weeks of intermittent dry cough. One week earlier, he had been seen in the ED, diagnosed with a viral URI, and discharged home. Now, a CXR was performed that demonstrated hyperinflation of the left lung and a flattened hemi-diaphragm. When questioned, parents recalled a coughing and choking episode while eating peanuts 3 weeks earlier. On rigid bronchoscopy, we found a peanut fragment surrounded in granulation tissue and obstructing the left mainstem bronchus. After both were removed, he remained in the PICU until extubation on hospital day 3.
This scenario is not uncommon. My co-fellows and I regularly evaluate children for possible foreign body aspiration (FBA). The literature reports approximately 12,000 children presenting to U.S. EDs annually, resulting in 2,000 hospitalizations (costing $12 million) and a mortality rate between 1% and 4%, with a similar incidence of anoxic brain injury. Not surprisingly, 80% of foreign body aspiration cases involve children under the age of 3. These children often explore their surroundings by placing objects in their mouths, but they lack well-developed aerodigestive skills to protect their airways. Small, round, and hard, peanuts and other seeds are particularly problematic until children are able to grind food, after their molars erupt around age 2 or later.
Many aspirations are witnessed, but still, up to 20% of children are misdiagnosed following FBA. Patients with aspirated foreign bodies may have minimal, vague symptoms after the initial choking episode, and X-rays are frequently inconclusive. As a result, they may present several times before receiving the correct diagnosis. In addition to increased healthcare utilization, delayed diagnosis of FBA may result in pneumonias, abscesses, bronchiectasis, and permanent lung damage. It is critical that FBA remain on any primary care provider’s differential for children presenting with cough or noisy breathing. It is especially helpful to elicit a history of choking from the parent or caregiver.
Warnings are mandated for choking hazards related to toys and other nonfood items, but no legislation requires similar warnings for food, highlighting the importance of anticipatory guidance for parents. Many parents of our patients are unaware of the risks from some solid foods they feed their children.
Recent developments in allergy research complicate discussions about peanuts. Previously, the American Academy of Pediatrics recommended delaying the introduction of highly allergenic foods like peanuts and fish until children had reached 3 years of age. However, the 2015 LEAP study showed that introducing peanut early helped decrease the development of allergy in children at high risk. Now, the AAP encourages parents to add peanut-containing foods—but not whole peanuts—when their children begin to eat solid foods.
References and suggested readings
Kim IA, Shapiro N, Bhattacharyya N. The national cost burden of bronchial foreign body aspiration in children. Laryngoscope. 2015;125(5):1221-1224.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Policy Statement—Prevention of choking among children. Accessed March 7, 2018.
Chapin MM, Rochette LM, Annest JL, et al. Nonfatal choking on food among children 14 years or younger in the United States, 2001-2009. Pediatrics. 2013;132(2):275-281.
Sidell DR, Kim IA, Coker TR, et al. Food choking hazards in children. Int J Pediatr Otorhinolaryngol. 2013;77(12):1940-1946.
DuToit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J of Med. 2015;372(9):803-813.
DuToit G, Katz Y, Sesieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol. 2008;122(5):984-991.