Foreign Body Ingestion in Children: The Role of X-ray

I read with great interest the retrospective review of foreign body ingestion among Omani children published in the November 2018 issue of the Oman Medical Journal.1 Of the 585 patients reviewed, 385 were enrolled based on the inclusion criteria, and they were managed solely by pediatricians. In our center, in Malaysia, such cases are managed by otolaryngologists, for both children and adults. Among those studied in the series, 11 patients (2.9%) were diagnosed without any X-ray. Were those cases diagnosed based on the history of observed ingestion alone, or were there any other reasons that meant the X-ray was not performed? Doing imaging on children is relatively difficult, especially if we are dealing with a small not-so-opaque foreign body; thus, any suggestion is very much appreciated. There are many cases of foreign body ingestions with unreliable history but positive findings on imaging following persistent symptoms2 (e.g., vomiting minutes after swallowing, unresolved dysphagia, or respiratory symptoms), especially in small children with unwitnessed ingestion.3 Are these cases included in the series? Negative findings on X-ray despite persistent symptoms may warrant further computed tomography or other contrasted imaging, especially for cases that involve radiolucent foreign bodies such as peanuts.4 In conclusion, foreign bodies in children are mostly straightforward cases, but misdiagnosis can occur due to a lack of clinical suspicion.