Toys within chocolate eggs–an ingestion hazard

Sir, Foreign body ingestion by children occurs commonly. Most ingested foreign bodies are very often well tolerated and pass the intestinal tract with no complications. Some may cause airway obstruction and gastrointestinal perforation or obstruction. The most common complication is entrapment in the oesophagus, and possible sequelae include erosion, perforation and even mediastinitis (1). Coins are the most common item ingested, followed by food and toy parts. Because of the potential for serious complications, all impacted oesophageal foreign bodies should be removed (2, 3). The medical literature known to us is replete with descriptions of foreign body ingestion, but contains no reports of ingested plastic parts packed within a candy. In the present report we describe two children, aged 4 and 5.5 y; in both cases, the ingested toys were lodged in the oesophagus and were removed by flexible endoscopy. A 5.5-y-old boy was referred with hypersalivation and chest pain. On admission he was afebrile, and revealed no abnormal physical findings. A chest X-ray revealed a U-shaped foreign body lodged at the gastroesophageal junction. On reinvestigation, the extremely anxious mother recalled that the child had been seen licking a chocolate egg candy. In view of the child’s cooperation, flexible endoscopy was performed using sedation without general anesthesia. A small plastic toy was removed (Fig. 1, right side). Note also the whole chocolate egg-shaped candy (left side) and the packed plastic toy within an open candy (centre). A 4-y-old boy was admitted with breathing difficulties and chest pain. Half an hour prior to admission he had eaten an egg-shaped chocolate candy. Based on his previous experience, he was aware that this candy contained a plastic toy. Nevertheless, following the chewing of the outer chocolate cover he tried to lick the inside plastic piece, and ingested inadvertently the inside toy and felt it stuck in his chest. Physical examination revealed restlessn ss and hypersalivation. A foreign body was noted on chest X-ray and was removed using flexible endoscopy. Due to extreme agitation, this procedure was conducted under general anaesthesia. The described chocolate candies have been very popular in many European countries, and healthcare providers should be aware of this ingestion hazard. Although these toys are usually blunt, many of them are not smooth and could easily lodge in the oesophagus (4). Oesophageal foreign bodies have traditionally been removed by surgeons with a rigid oesophagoscope utilizing general anaesthesia (3). Recently several reports have a vocated the use of flexible endoscopy for removal of blunt foreign bodies, even without general anaesthesia (5). Other techniques described include fluoroscopic Foley catheter removal (6), and advancement using bougienage (7). For many years we have used flexible endoscopy, and the choice between general anaesthesia and sedation has been determined by the circumstances, including patient’s age and cooperation. However, in all cases including those sedated without general anaesthesia, our rule has been to have an anaesthetist attending, with available resuscitation facilities at hand. The packaging of these candies usually carries a warning, recommending they not be given to children below 3 y of age. Based on the present report and on the medical literature, foreign body ingestion occurs at a wide range of ages. Although median age is usually between 2.5 and 3 y, ages range from 4 months to 16 y (1, 5). Therefore, 3 y of age is not a safe limit. Moreover, adult supervision does not prevent ingestion. In one of the largest series, a caretaker witnessed half of the cases, and Acta Pædiatr 87: 478–81. 1998