Residency · Residency · Pediatrics

Drowning, Foreign Body Ingestion, and Toxic Exposures

Introduction

Unintentional injuries are a major cause of morbidity and mortality in children, with drowning, foreign body ingestion, and toxic exposures representing three of the most common and preventable emergencies seen in pediatric practice. These conditions share a common theme: they disproportionately affect young children due to developmental curiosity, oral exploration, and limited hazard awareness. The pediatrician must be skilled in acute management, anticipatory guidance, and prevention counseling.

Drowning

Epidemiology

Drowning is the leading cause of unintentional death in children aged 1-4 years in the United States and the second leading cause of injury-related death for children aged 5-14 years. Toddlers are most at risk in residential swimming pools and bathtubs, while adolescents are more commonly affected in open water (lakes, rivers, ocean). There is a male predominance of approximately 80% of drowning deaths. The highest risk populations include children with epilepsy (15-19 times increased risk), autism spectrum disorder, and limited swimming ability.

Pathophysiology

Submersion leads to hypoxemia, which is the primary mechanism of injury and organ damage. Laryngospasm occurs initially but eventually relaxes, leading to aspiration. The distinction between "wet" and "dry" drowning is no longer clinically relevant. While there are theoretical differences between fresh and saltwater aspiration regarding surfactant washout and osmotic shifts, clinical management is identical. Hypothermia may be protective in cold water immersion by slowing metabolic demand, and this "cold water protective effect" is most pronounced in children.

Clinical Assessment and Management

Scene safety and rescue breathing in the water should be initiated if possible, with CPR begun immediately if the victim is pulseless. The patient should be treated as a potential cervical spine injury if the mechanism involves diving or is unknown. All submersion victims should be evaluated in a medical facility, even if initially asymptomatic. Assessment includes ABCs, oxygen saturation, chest radiograph, and arterial blood gas. Pulmonary management ranges from supplemental oxygen to CPAP or BiPAP for moderate hypoxemia to mechanical ventilation with lung-protective strategies (low tidal volume, PEEP) for severe cases. Neurologic prognostication should avoid premature conclusions; GCS, pupil reactivity, and neuroimaging guide assessment, and therapeutic hypothermia is not routinely recommended for drowning. Asymptomatic patients with normal examination and SpO2 should be observed for 4-8 hours before discharge.

<image>Illustration depicting the drowning timeline showing the progression from submersion through laryngospasm, aspiration, hypoxemia, loss of consciousness, and cardiac arrest, with intervention points marked along the timeline including rescue breathing, CPR, and hospital-based resuscitation</image>

Prevention

Four-sided pool fencing with self-closing, self-latching gates reduces drowning risk by 50-70%. Constant adult supervision with "touch supervision" for children under 5 is essential. Swim lessons starting at age 1 year are recommended by the AAP. Life jacket use is required for boating and open water activities. Bathtub safety requires that children never be left unattended, even for moments.

Foreign Body Ingestion

Epidemiology

Foreign body ingestion has peak incidence in children aged 6 months to 3 years, with over 100,000 cases reported annually in the United States. Most ingested foreign bodies pass spontaneously; approximately 10-20% require endoscopic removal, and less than 1% require surgery.

Types of Foreign Bodies and Management

Coins are the most commonly ingested foreign body in children. Esophageal coins most commonly lodge at the upper esophageal sphincter (thoracic inlet, level of the clavicles). On radiograph, coins in the esophagus appear en face on the AP view, while coins in the trachea appear en face on the lateral view. Asymptomatic esophageal coins may be observed for 12-24 hours in reliable patients, as some pass spontaneously. Symptomatic or persistent coins require endoscopic removal within 24 hours.

Button batteries lodged in the esophagus represent a true emergency, as they cause liquefactive necrosis within 2 hours by generating hydroxide radicals through an external electrical circuit with the esophageal mucosa. Complications include esophageal perforation, mediastinitis, tracheoesophageal fistula, and aortoesophageal fistula (which can be fatal). Immediate endoscopic removal is required without observation or induced vomiting. If there will be a delay to endoscopy beyond 12 minutes, honey (10 mL every 10 minutes, up to 6 doses; not in infants under 12 months) or sucralfate should be instilled to mitigate injury. Button batteries that have passed beyond the esophagus into the stomach generally pass without intervention and are followed with serial radiographs.

A single magnet generally passes without complication. Multiple magnets (or a magnet plus a metal object) can attract across bowel walls, causing pressure necrosis, perforation, fistula, volvulus, and obstruction. Endoscopic or surgical removal of multiple magnets is mandatory. High-powered rare-earth magnets (neodymium) are particularly dangerous even in small sizes.

Sharp objects (needles, pins, fish bones) should be removed endoscopically if in the esophagus or stomach, as there is a greater than 25% perforation rate if sharp objects pass beyond the stomach. Superabsorbent polymers (water beads) can cause bowel obstruction and should be removed endoscopically if accessible. Objects greater than 6 cm in length or greater than 2.5 cm in diameter are unlikely to pass the pylorus or ileocecal valve, and endoscopic removal is recommended.

<image>Radiographic examples showing anteroposterior and lateral chest views of common pediatric foreign body ingestions: esophageal coin (en face on AP), button battery (double-ring sign or halo on AP), and multiple magnets in the abdomen with arrows indicating points of bowel wall apposition, alongside a management algorithm for each type</image>

Toxic Exposures (Poisonings)

Epidemiology

Over 1 million toxic exposures in children under 6 years are reported annually to US Poison Control Centers. Unintentional ingestion is the most common scenario in young children (peak age 1-3 years), while intentional ingestion predominates in adolescents (self-harm). The most common agents are cosmetics and personal care products, cleaning substances, analgesics, foreign bodies, and vitamins.

General Approach

ABCs and stabilization take priority over identification of the toxin. The Poison Control Center (1-800-222-1222) should be contacted for all exposures. Key information to determine includes the substance, amount, timing of ingestion, symptoms, and the child's weight. Physical examination should focus on toxidromes (constellations of signs suggesting a class of agent).

Key Toxidromes

The anticholinergic toxidrome is characterized as "hot as a hare, dry as a bone, blind as a bat, mad as a hatter, red as a beet," with fever, dry skin, mydriasis, delirium, tachycardia, and urinary retention. The cholinergic toxidrome follows the SLUDGE/BBB mnemonic: salivation, lacrimation, urination, defecation, GI distress, emesis, bradycardia, bronchospasm, and bronchorrhea. The sympathomimetic toxidrome presents with tachycardia, hypertension, hyperthermia, mydriasis, diaphoresis, and agitation. The opioid toxidrome features miosis, respiratory depression, CNS depression, and bradycardia. Serotonin syndrome manifests with agitation, hyperthermia, clonus, hyperreflexia, and diaphoresis.

Decontamination

Activated charcoal (1 g/kg, maximum 50 g) is most effective within 1 hour of ingestion and is not useful for metals (iron, lithium), alcohols, hydrocarbons, or corrosives. Whole bowel irrigation with polyethylene glycol is used for sustained-release preparations, iron, lead, and body packers. Gastric lavage is rarely indicated and only within 1 hour of life-threatening ingestion. Syrup of ipecac is no longer recommended by the AAP, as the risk outweighs the benefit.

Critical Ingestions in Pediatrics ("One Pill Can Kill")

Calcium channel blockers (especially extended-release) cause bradycardia, hypotension, and hyperglycemia. Sulfonylureas cause delayed hypoglycemia that may present hours after ingestion, requiring admission for glucose monitoring for 24 hours. Opioids (methadone, buprenorphine) cause respiratory depression, and naloxone may require repeat dosing or infusion. Tricyclic antidepressants cause QRS widening, sodium channel blockade, and seizures, treated with sodium bicarbonate. Clonidine causes bradycardia, hypotension, CNS depression, and miosis (mimicking opioid toxicity). Camphor causes rapid-onset seizures. Iron causes direct GI mucosal injury, metabolic acidosis, and hepatic failure, treated with deferoxamine for significant ingestions.

<image>Table-format illustration of the five major toxidromes (anticholinergic, cholinergic, sympathomimetic, opioid, serotonin syndrome) with columns showing pupil size, heart rate, blood pressure, temperature, skin findings, mental status, and prototypical causative agents for each syndrome</image>

Clinical Pearls

Drowning outcomes are determined by the duration and severity of hypoxemia, and early bystander CPR is the most important modifiable prognostic factor. Button battery ingestion in the esophagus is a true emergency requiring immediate removal, as tissue damage begins within 2 hours. Multiple magnet ingestion requires emergent removal due to the risk of bowel perforation and fistula formation. Activated charcoal is most effective within 1 hour and does not bind metals, alcohols, or corrosives. Several common medications ("one pill can kill") can cause life-threatening toxicity in toddlers from a single pill or dose. Prevention counseling regarding pool fencing, safe medication storage, and poison-proofing the home is a core responsibility of the pediatrician.

References

1. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. New England Journal of Medicine. 2012;366(22):2102-2110.
2. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. Journal of Pediatric Gastroenterology and Nutrition. 2015;60(4):562-574.
3. Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clinical Toxicology. 2016;54(10):924-1109.
4. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning. Pediatrics. 2010;126(1):e253-e262.

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