Inhalation of a Foreign Body by a Child

[Badri]

A 3-year-old boy was brought to the Emergency Department of a Private Hospital by his mother reporting that he swallowed a little plastic building brick. They brought a similar piece with them. He was seen by doctor “A” who documented that the child exhibited no respiratory distress. He was then checked by auscultation and had a chest x-ray done. The radiologist and doctor “A” considered the results to be normal and the child was discharged home.

Two months later the child became unwell with a cough and high temperature. He was brought back to the Emergency department where the x-ray suggested right lower lobe pneumonia. The mother mentioned to the doctor that the child had been seen earlier in the ED when foreign body ingestion was ruled out. All this was documented.

Over the next two years the child suffered recurrent episodes of pneumonia and attended the ED 5 times. He was seen by different doctors every time and had x-ray done on each visit. All of them were reported as right lower lobe pneumonia with collapse and some pleural fluid. There was no mention in the notes that previous x-rays were compared.

In view of recurrent chest infections the family doctor referred him to the paediatric team for further investigations. The Paediatric Consultant looked at all the x-rays and became suspicious of the presence of a foreign body. An urgent bronchoscopy was done when a large piece of plastic was seen and removed. The child required further surgery as the FB had caused fibrosis of the pulmonary parenchyma that required excision.

The mother sued the private hospital and all the doctors involved during those two years.

Experts opinion was that when there was a history of possible foreign body inhalation, you must follow the child very closely. Even when there was no definite history of FB inhalation, it should be suspected in children when recurrent pneumonia and x-ray changes are noted.

The case was deemed indefensible and was settled for a moderate amount.

Learning Points.
• A careful history with details about the Foreign body would help
• There should be high suspicion when there is stridor, wheezing or difficulty breathing
• Many plastics are radiolucent. If you have a similar plastic brought by parents, x-ray that with the child to see if it is radiolucent.
• If the child has recurrent symptoms, review all old notes and x-rays and refer the child to an expert.

Report exracted from the Case Book of Med Protection Society - Oct 2017.

[uamohammed]

Hi Badri
A very interesting case. Here the mother was very sure that child got aspirated a plastic piece into the chest. That is enough for the suspicion. As pointed out sometimes the aspirated materials may be radiolucent. Even otherwise when it gets lodged at the junction of bifurcation of trachea and a bronchus that means it is behind the mediastinum the major structures of which might mask this small piece. A careful examination of breath sounds would have also helped. When the patient comes with a repeated episodes of respiratory distress, a CT scan would have helped. It is very unfortunate.

UA Mohammed

[Badri]

Yet another illustration of the need for good history taking. Also when a patient or parent gives you a reasonably accurate account of what happened, take the story seriously even when you can't find anything positive. Bring the patient back to re examine fairly soon.