Facing the future: standards for children in emergency care settings

Today saw the launch of the new RCPCH ‘Facing the Future’ document – setting standards for paediatric emergency care in the UK. These are a set of standards that should apply to all Emergency Department where children are seen and assessed.

The goal is for all emergency care services to be able to audit themselves against these standards.

It’s a 90 page document and you can read the full version here.

Here is our summary of the key points:

 

1. An integrated urgent and emergency care system

  • The focus is on a whole system approach where all services work together in established clinical networks – including GP services, urgent care centres, acute paediatric services, schools, pharmacy, community services, and ambulance services. They should have shared care guidelines, and evaluation processes across the whole network.
  • Staff in urgent care centres should have appropriate paediatric competence.

 

2. Environment in emergency care settings

  • Provide an appropriate waiting area including refreshments, breast-feeding facilities, and entertainment.
  • Involve children and young people and their parents in service design.
  • Have access to a play specialist.
  • Encourage patient/parent feedback.
  • Provide appropriate discharge information including written and verbal safety-netting.
  • Use patient flow models when planning the use of the environment.

 

3. Workforce and training

  • Every ED treating children should have a PEM consultant and two children’s nurses on a shift.
  • Staff should have professional development training hours for learning events.
  • A member of staff with APLS should be on duty and all staff should have BLS.
  • PEM Consultants should have SPAs in their job plans.

 

4. Management of the sick or injured child

  • Where children are being streamed away from ED this must be done by someone with paediatric competences
  • All children should be visually assessed on arrival by a doctor or nurse and have a clinical assessment (for triage) within 15 minutes. There should be an escalation policy when the triage wait exceed this.
  • All children should have a pain score and vital signs within 15 minutes.
  • Children with abnormal vital signs should have their obs repeated within 60 minutes.
  • Every ED should have an early warning system in place and an escalation policy for critically unwell children
  • The appropriate range of drugs and equipment should be available.
  • Children with moderate and severe pain should have analgesia dispensed within 20 minutes and a reassessment of their pain score within 60 minutes.
  • Health promotion and prevention should be delivered and recorded in the notes.
  • Discharge summaries should be sent to the relevant healthcare professionals within 24 hours.
  • The ED should work with community services to prevent hospital admissions.

 

5. Safeguarding in emergency care settings

  • All staff looking after children should have up-to-date safeguarding training.
  • There should be a lead consultant and nurse for safeguarding.
  • There should be departmental safeguarding guidelines.
  • All staff should have access to 24 hour safeguarding advice from a paediatrician with expertise.
  • All staff should have access to Child Protection Plan information, systems should be in place to identify frequent attenders, and staff should recognise the impact of a carer’s health on the dependent.
  • The primary care team should be informed of each attendance and an approved information sharing system should be in place.
  • There should be a policy for when a child leaves or absconds unexpectedly, and a review of the notes should be undertaken by a senior doctor or nurse for all children who leave before being seen.
  • All children with potential safeguarding presentations should be reviewed by ST4+.

 

6. Mental health

  • All children should have their emotional and mental health needs assessed.
  • Risk and capacity should be documented for all patients with a mental health crisis.
  • Have an appropriate space (including a safe room) for children/families in crisis.
  • Have access to mental health records and crisis plans (can be via CAMHS) and an appropriate escalation pathway.
  • Clinicians should be provided with training on assessing risk, capacity, consent, and parental responsibility.
  • Have 24 hour access to a mental health practitioner.
  • Have a policy for managing the acutely distressed young person.
  • Have a suitable inpatient facility to look after patients requiring an inpatient mental health facility where there is a delay in accessing it.
  • Have a clear pathway to identify a place of safety for those on a Section 136 order

 

7. Children with complex medical needs

  • Have a triage system that considers the prioritising care for children with complex medical needs and provide training on early escalation.
  • Have individual emergency care plans available and ensure any electronic alerts are used to show special instructions.
  • Consider the child with complex needs when designing and planning for the department.
  • Share information about attendances with the relevant professionals.

 

8. Major incidents involving children and young people

  • Ensure that children are specifically considered in planning for a major incident response and involve paediatric staff in incident exercises.

 

9. Safe transfers

  • Each region should have a Paediatric Critical Care transport team managed by the Paediatric Critical Care Operational Delivery Network.
  • Have access to a regional PICU with a 24 hour helpline providing support and advice.
  • Have local facilities and staff for time-critical transfers.
  • Have ED staff trained in patient stabilisation and transfer.
  • Provide information and practical help for families where children are transferred between hospitals.

 

10. Death of a child

  • There should be a local policy for responding to the unexpected death of a child.
  • Children who have died outside hospital should be taken to a hospital with paediatric facilities.
  • All staff should have training on how to support families where there is an unexpected death.
  • There should be co-operation with the Rapid Response team and the Child Death Overview panel.

 

11. Information system and data analysis

  • All ED staff should have an information system providing episode related information and demographics.
  • All health organisations providing emergency care should collaborate with national information centres.
  • All EDs treating children should collect performance data to improve services.
  • All EDs treating children should have discharge summaries compliant with PRSB standards.

 

12. Research for paediatric emergency care

  • All EDs treating children should have a nominated lead for paediatric emergency research with PERUKI membership.
Cite this article as:
Davis, T. Facing the future: standards for children in emergency care settings, Don't Forget the Bubbles, 2018. Available at:
http://doi.org/10.31440/DFTB.16004

The post Facing the future: standards for children in emergency care settings appeared first on Don't Forget the Bubbles.

The 18th Bubble Wrap

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Come along to DFTB18 in Melbourne later this year to participate in our Bubble Wrap Live! session with Arj Rao, Susie Piper and Kylie Stark.

Article 1: The burden of mental health presentations in Victoria

Hiscock H, Neely RJ, Lei S, Freed G. Paediatric mental and physical health presentations to emergency departments, Victoria, 2008-15. Medical journal of Australia. 2018 Apr 23.

What’s it about? 

Anec-data suggests that the number of young people presenting to our our emergency departments with mental health disorders seems to be on the rise. The researchers analysed the Victorian Emergency Minimum Dataset between  – 2008-09 and 2014-25 and looked at all presentations in children and young people (zero to 19 years of age) over that seven year time frame. They then pulled out all of those patients whose diagnosis was of a mental health disorder.

Absolute numbers of mental health presentations increased by 46% between 2008-9 and 2014-15. This representated an increase in the overall proportion from 1.7% to 2.2%. The most frequent reasons for presentation were:- intentional self-harm (22.5% of all mental health cases), and problems related to psychoactive substance use (22.3%) followed by stress/anxiety, mood disorders and behavioural/emotional disorders.

Patients with mental health disorders (compared to young people with physical problmes) are more likely to be admitted and have longer lengths of stay.

There are some problems with the VEMD system. It only allows for a single diagnosis and that relies on the treating doctors being bothered to put it in accurately. If they patient presents with a self-inflicted injury it might not be coded as such.

Why does it matter? 

The mental status examination is one of the most commonly accessed guidelines on the Royal Children’s Hospital website. As someone who routinely deals with mental health challenges in an adult population I am disappointed with the lack iof services available to our younger population. Perhaps this data will highlight the importance of mental health services for younger people.

Reviewed by: Andy Tagg

 

Article 2: Burns and School Performance

Azzam N, Oei J, Adams S, Bajuk B, Hilder L, Mohamed AL, Wright IMR, Holland AJA. Influence of early childhood burns on school performance: an Australian population study. Arch Dis Child. 2018 May; 103(5):444-451

What’s it about? 

The acute impact of burns is obvious to anyone but in this paper the authors took the long term view and assessed the impact a burn may have on a child’s educational performance. They compared those admitted with a burn to those admitted without a burn.

Why does it matter? 

Firstly, the paper provides rich epidemiological data on burns admissions in Australia. The majority being toddlers, TBSA<10% with deep partial thickness. The most common areas affected were the hands and the wrists.

When the team compared national education performance for those admitted with a burn compared to those admitted for other reasons,  they identified that the mean test scores for children with burn injuries were significantly lower (P<0.05) in every test domain although this difference decreased with age.

Associated factors included schooling in a government (public) facility, having a multiparous mother or a mother who smoked during pregnancy and being indigenous. There appeared to be a protective factor in those attending a metropolitan school or with a mother over 35 years of age.

There may be multiple other unmeasured variables that impact on the outcome for example social services input (there no mention if the burns may be a consequence of neglect or physical abuse), maternal mental health, alcohol and drug abuse.

Clinically Relevant Bottom Line:

As emergency clinicians it is easy to get fixated on the managing the acute problem while not appreciating the other factors that may impact the patients quality of life. This study suggests an admission for a burn is an independent variable that may impact educational and economic outcomes for a patient, recommending targeted interventions for these patients. While we may not think we have time should screening for some of these variables be a public health objective in the Emergency Department?

Reviewed by: Stephen Mullen

 

Article 3: What’s in a label?

Vyles D, et al.  Antibiotic Use After Removal of Penicillin Allergy Label. Pediatrics. 2018 May;141(5).

What’s it all about?

The authors had tested children with low risk symptoms after penicillin use and found 100% tolerated penicillin. They hypothesised that prescription practices would change after removal of the childrens’ allergy label.

This article reports the follow-up case series of 100 children investigating the safety and calculating the cost-effectiveness. In 58% of antibiotic prescriptions penicillin derivatives were included. One child developed a rash within 24 hours, but there were no serious adverse reactions reported. They calculated that the practice of removing the label of penicillin allergy from children represents a potential cost saving of nearly 200.000 USD a year for a paediatric ED.

Why does it matter?

Many children present to ED with a history of penicillin allergy. A proportion of these children actually have a history of low-risk symptoms that may be the result of other causes such as viruses or viral-drug interaction. Prescribing alternatives to penicillin for these children may result in antibiotic choices that can place additional burden on the healthcare system including longer hospital admissions, encouraging antibiotic resistance or increasing the likelihood of Clostridium difficile infections.

Interestingly in this study, there was a huge discrepancy between parents who reported that they had informed their primary care provider of the child not being allergic (80%), whereas only 16% of primary care providers reported that they were informed (and 52% of primary care medical records still contained the allergy label). Moreover, 28% of families were not completely comfortable with receiving penicillin treatment for their child despite the label removal.

Clinically Relevant Bottom Line:

This study suggests that reversing the label of penicillin allergy in children is safe and cost saving. More research/guideline development is needed in the optimal dissemination of results after testing. Informing and educating both parents and their child’s primary care providers is likely to be as important as delabeling the child in the first place.

(If you are interested in the topic, this is a nice review, published in the same journal last month: Antibiotic Allergy in Pediatrics. Norton et al. Pediatrics. 2018 May; 141(5).)

Reviewed by: Anke Raaijmakers

 

Article 4: Is it all in the wee?

What’s it about?

The research team at the Children’s Hospital of Pittsburg use a training database of 1686 children under 2years old with fever presenting to ED presentations who had a urine catheter specimen taken between 2007-2013. They created a nested case control study (1:2) to develop a calculator,  ‘UTICalc’ (https://uticalc.pitt.edu) to estimate the probability of UTI both pre-test and post-test (urinalysis). They then go on to demonstrate the effectiveness of UTICalc in 384 children seen between 2015-2016 and compare their calculator as being more effective than the American Academy of Paediatrics algorithm.

The sensitivity of the calculator is over 95%. The team set a pre-test probability of UTI of 2% or higher as recommending urine collection and the Number needed to test with this cut off is 9.8. A post-test probability of 5% was chosen for recommending antibiotics whilst awaiting the formal culture results.

Clinical characteristics  in UTIcalc were

  • Age <12 months
  • Fever >39
  • African American
  • Female or an uncircumcised male
  • Other source of fever.
  • Similar to other studies, the highest risk group was a non-black child over 12 months with a fever over 39 and no other source of fever.

Laboratory characteristics for urinalysis used were:

  • Presence of absence of Nitrites
  • Leucocyte esterase (nil, trace, 1,2,3+)
  • WCC concentration
  • Presence of bacteria on gram stain.

For UTICalc to work, all clinical fields are required however only presence of nitrates and leucocytes were mandatory for the lab portion.

Why does it matter?

Children under 2 often present with minimal history or help with localising of symptoms of a UTI. It is useful to have a greater understanding of the likelihood and risk factors for a UTI to help determine whether it is worth perform a urinalysis as well as whether or not these children should be started on antibiotics before the urine culture result returns. Playing around with the calculator, any combination of leucocytes with nitrates appears to yield a probability of UTI over the 5% threshold for recommending antibiotic treatment. In terms of practically influencing decision making the calculator has some potential in reducing urine testing of infants (the study reports a reduction of 8.1% in a hypothetical group of 1000 children), but I see greater potential in rationalising early antibiotic use in cases where urinalysis results yield nitrates or leucocytes alone or feature trace results. 

The bottom line

UTICalc is a new calculator assessing pre and post urinalysis probability of UTI in infants under 2 year old with fever and suspected UTI. It is based off a larger population group than previous UTI probability calculators and may help inform and guide antibiotic treatment when urinalysis results are available but culture is still pending. The results are based off a training database of children who all had urine collected from one centre in Pittsburgh and future avenues include prospective use and validation in other patient populations.

Reviewed by: Grace Leo

 

Article 5: Should children get a whole body CT after an accident?

What’s it about?

Whole body CT (WBCT) scans have been promoted as the standard for imaging in adult major trauma, and this practice has gradually been extrapolated to children. Often, this was irrespective of the clinical picture, leading many clinicians to question the practice of blanket WBCTs as compared with selective imaging.

In order to determine whether WBCT is associated with improved mortality in injured children (compared with selective CT), the authors analysed 5 years of the US national trauma data bank. They included almost 43000 children between the ages of 6 months and 14 years who received a CT scan within 2 hours of ED arrival for blunt trauma. They replicated (as much as reasonable) the baseline balance in co-variables seen in randomised trials (RCTs). After pragmatically matching for differences in setting, mechanism, injury severity, isolated head injury and interventions (to mitigate the selection bias inherent to database studies), there was no difference in 7 day mortality between children who had WBCT compared with those who had selective CT.

Children who had WBCT spent around 25 minutes less in the ED, but had a longer hospital length of stay.

Why does it matter?

While a RCT has answered the question of WBCT versus selective scanning in adults (no survival benefit, by the way), a similar study in children would be impractical (and perhaps unethical) due to the relative rarity of paediatric major trauma. The value of occult injury identification is also questionable as most are managed conservatively in children anyway. Also, and more importantly, children are more susceptible to the long term consequences of radiation exposure, which adds a key dimension to risk-benefit considerations.

This well designed analysis provides good (perhaps the best so far) evidence that a selective CT strategy is non- inferior to a WBCT approach in paediatric trauma, whilst supporting the principle of ALARA.

Clinically Relevant Bottom Line:

In children with blunt trauma, an approach favouring selective CT imaging (based on individualised clinical assessment) rather than WBCT, avoids unnecessary radiation exposure without missing clinically significant injuries.

Reviewed by: Shammi Ramlakhan

 

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

Cite this article as:
Leo, G. The 18th Bubble Wrap, 2018. Available at:
http://doi.org/{meta_doi}

The post The 18th Bubble Wrap appeared first on Don't Forget the Bubbles.

Ingested Foreign Bodies

Children will put absolutely anything in their mouths and boogers are the least of our worries.

This post accompanies the talk I gave to the Royal Children’s Hospital 2018 Clinical Practice Update. Many thanks to Tom Volkman for the invitation to speak.

Most foreign body ingestions take place in children between 6 months and 3 years of age. It’s that phase of their development where they like to explore absolutely everything and often with their mouths. Whilst earthworms do have some nutritional value*  most of the things that children put in their mouths don’t. From personal experience kids seem to be proud to show you what they have put in their mouths but foreign body ingestion should be suspected if a normally well child has sudden onset coughing or drooling or complains of retrosternal or stomach pain. Fortunately, if it is small, inert and non-toxic then, realistically, caregivers needn’t worry.

 

He swallowed what?

If you look closely at Arana’s 2001 case series of 325 cases you would see that there have been no end of foreign bodies taken by mouth. Here they are, from most common:-

  • Coins
  • Toy Parts
  • Jewels
  • Batteries
  • Needles and pins
  • Chicken bones
  • ‘Large amounts of food’

 

Where do things get stuck?

Given that 80% of things pass through without issue it is worth looking at where they do get stuck.

9% of lodged foreign bodies never make it out of the oropharynx and are amenable to removal with a pair of Magills.

20% get lodged in the oesophagus and points of anatomical narrowing – 70% lodge at the level of cricopharyngeus (C6) in the proximal third, 15% lodge in the middle third (T4) and 15% at the distal third.

60% of foreign bodies are found in the stomach. The majority of these will pass as long as they are less than 6cm in length and 2.5cm in diameter. One case series showed that a third of these may still be in the stomach two weeks later.

11% are caught up in the small intestine by the duodenal sweep around the pancreas or at the ileo-caecal valve.

Transit time is variable with most case series reporting a delay of between 3.8 and 5.1 days before passage. It’s generally not worth your time getting parents to sieve the toilet bowl, however, as up to 50-60% of objects are never seen again (and are not visualized on follow-up x-rays).

So what happens to the things that don’t pass through? 10-20% require endoscopic removal and a very small percentage require an open approach.

 

So let’s take a look at some of these foreign objects.

 

Children are like magpies. They are attracted by bright and shiny objects. What better than that handful of loose change that they found down the back of the couch? Most coins will pass without difficulty once they have made it into the stomach though this can take up to two weeks. The majority of children are asymptomatic and there are a number of case reports of coins being found as a surprise incidental finding on x-rays taken for alternate reasons.

If they do get stuck then they are most likely to get stuck in the proximal third of the oesophagus. These need to be removed as a matter of urgency as they can cause pressure necrosis and erode into the tracheo-bronchial tree. Some advocate the use of a Foley catheter to aid removal – pass it beyond the coin, inflate and then slowly extract – but this might require sedation and the attendant risks. It is also possible to push the coin beyond the level of cricopharyngeus into the stomach and allow it to pass naturally. Glucagon, occasionally used to facillitate foreign body passage in adults, has not been shown to be efficacious in the paediatric population.

Practical Magic

Once I have confirmed coin ingestion via x-ray – often from triage – I go in to see the patient with a 5c coin hidden in the palm of my hand. Children are more worried about being told off than about the potential harms of swallowing a coin and so I like to play a little game.  After taking a history I gently palpate their belly looking for tenderness. As I reach their belly button I allow the palmed coin to fall into my finger tips. As I deftly extract it I ask, “Was this the coin you swallowed?”. If the answer is in the affirmative I can reassure them and then let teh parents in on the truth – nearly all coins will pass without any problem. If it was not the coin then I get the chance to use my favourite Dad joke – “Everything is fine, but come back if there is no change!”

 

 

Number two on the paediatric menu is toy parts. Now, the literature doesn’t actually state what toys are involved but I certainly swallowed at least one piece of Lego. There is is no formal data (yet) on transit time of pieces of Lego. Very occasionally larger toys get swallowed.

Otjen JP, Mitchell RM, Menashe SJ, Perkins JA, Swanson JO. Novel Ingested Foreign Bodies—A Fidget Spinner Case Report. JAMA Otolaryngology–Head & Neck Surgery. 2018 Feb 22.

 

 

Slightly more valuable baubles and their cheaper imitations are next on the list. Most rings and earrings will pass without difficulty if they are small enough (less than 6cm long and 2.5cm wide) though there is a case report of an urgent endoscopy to retrieve a $2000 dollar ring. Imitation jewellery is more of a problem. A number of fake earrings use magnets to hold them in place. If strong magnets, such as the neodynium rare earth magnets, are swallowed in pairs they may be attracted to each other. This leads to potential entero-enteric fistula formation with perforation and peritonitis. Some children, trying to get their belly button pierced before their time, have been known to swallow a magnet to attach to a jewel on the outside. They can be easily detected with plain radiographs though a compass might do in a pinch.

 

 

The fourth most commonly ingested item is the button battery. The number of cases reported to the National Capital Poison Center in the US has been steadily increasing. In 1992 around 2300 cases were reported (in the 7 years prior) with only 0.1% of them leading to adverse events and no deaths. By 2010 this had increased to 8600 contacts with 73 patients (0.8%) suffering from major adverse events. There were 13 deaths (0.15%). This may be due to batteries becoming bigger (and therefore more likely to get stuck) and more powerful. As they lodge in the proximal oesophagus they generate hydroxide radicals in the mucosa. This leads to a caustic injury – a rise in pH, saponification and subsequent liquefactive necrosis. Oesophageal perforation has been noted as early as 6 hours after impaction leading to both tracheo-oesophageal fistula formation and the more dreaded aortoenteric fistula. This was the cause of 7 of the 13 deaths reported.

Unfortunately clinical symptoms correlate poorly with the presence of a battery and so a high index of suspicion is required. If you’ve not yet watched it then you should watch Chantal McGrath’s talk from DFTB17.

Button batteries can look deceptively similar to coins on plain films and so it is worth requesting two views to look for either a step off or a double ring or halo. If they are in the oesophagus they need urgent removal though some controversy remains if they have made it into the stomach. There have been cases of devastating oesophageal involvement without impaction.

The narrow side of the battery, the negative pole, causes the most necrosis.

 

And finally we’ll consider sharp and pointy things – needles and pins. These were the some of the most commonly ingested items in the first half of the last century. As disposable nappies made life easier for countless mothers safety pins also became less of a hazard. Depending on how they are swallowed and where they impact they can perforate and migrate leading to anything from an abscess, fistula formation or penetration into a major organ. Becaused of this they should be removed from the oesophagus regardless of fasting status. Sharp objects are much more likely (15-35%) to lead to morbidity than rounded ones (~1%).

Harry Houdini helped popularise the East Indian Needle Trick at the turn of the last century. If you’ve never seen it then imagine the magician swallowing a packet of 50 needles followed by a length of twine. He then proceeds to bring up the string with the needles threaded along it to the deafening applause of the audience.

Don’t try this at home

A set of threaded needles were already hidden between gums and teeth before the trick began. A small knot on either side of each needle stopped them from falling off. Andt what about that packet of 50 needles? Do you really believe he swallowed them?

 

The Bottom line

Foreign bodies that need emergent removal:-

  • Sharp, long (>5 cm)
  • Rare earth magnet/s
  • Button battery in the oesophagus (also consider if in stomach and symptomatic)

Nearly everything else should pass on its own.

 

*So, what about those worms?

Lumbricus terrestris live for about 6 years in the wild – plenty of time to get juicy and fat.  They are certainly edible and a good source of protein and omega 3 fatty acids.  But we have all heard the saying, “You are what you eat“. Earthworms spend their lives chowing down on compost and soil as well as all of the parasites earth contains.

Perhaps it would be safer to stick with gummy worms – 29 kcals a worm – and much less likely to contain dog roundworm.

 

Selected References

Also head over to RebelEM for another take.

 

Al Shehri GY, Al Malki TA, Al Shehri MY, Ajao OG, Jastaniah SA, Haroon KS, Mahfouz MM, Al Shraim MM. Swallowed foreign body: Is interventional management always required?. Saudi J Gastroenterol 2000;6:84-6

Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. European journal of pediatrics. 2001 Aug 1;160(8):468-72.

Bronstein AC, Spyker DA, Cantilena Jr LR, Rumack BH, Dart RC. 2011 annual report of the American Association of Poison Control Centers’ National Poison data system (NPDS): 29th annual report.

Dehghani N, Ludemann JP. Ingested foreign bodies in children: bc children’s hospital emergency room protocol. BC Med J. 2008 Jun;50:5.

Guelfguat M, Kaplinskiy V, Reddy SH, DiPoce J. Clinical guidelines for imaging and reporting ingested foreign bodies. American Journal of Roentgenology. 2014 Jul;203(1):37-53.

Kay M, Wyllie R. Pediatric foreign bodies and their management. Current gastroenterology reports. 2005 May 1;7(3):2

Kramer RE, Lerner DG, Lin T, Manfredi M, Shah M, Stephen TC, Gibbons TE, Pall H, Sahn B, McOmber M, Zacur G. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. Journal of pediatric gastroenterology and nutrition. 2015 Apr 1;60(4):562-74.

Laya BF, Restrepo R, Lee EY. Practical imaging evaluation of foreign bodies in children: an update. Radiologic Clinics. 2017 Jul 1;55(4):845-67.

Otjen JP, Mitchell RM, Menashe SJ, Perkins JA, Swanson JO. Novel Ingested Foreign Bodies—A Fidget Spinner Case Report. JAMA Otolaryngology–Head & Neck Surgery. 2018 Feb 22.

Paoletti MG, Buscardo E, VanderJagt DJ, Pastuszyn A, Pizzoferrato L, Huang YS, Chuang LT, Millson M, Cerda H, Torres F, Glew RH. Nutrient content of earthworms consumed by Ye’Kuana Amerindians of the Alto Orinoco of Venezuela. Proceedings of the Royal Society of London B: Biological Sciences. 2003 Feb 7;270(1512):249-57.

Spitz L. Management of ingested foreign bodies in childhood. British Medical Journal. 1971 Nov 20;4(5785):469.

Uyemura MC. Foreign body ingestion in children. American family physician. 2005 Jul 15;72(2).

Cite this article as:
Tagg, A. Ingested Foreign Bodies, 2018. Available at:
http://doi.org/{meta_doi}

The post Ingested Foreign Bodies appeared first on Don't Forget the Bubbles.