Transcription:
Pediatric Recurrent Intentional Foreign Body Ingestion: Case Series and Review of the Literature

Melanie Cole: Welcome to Transformational Pediatrics with Children's Mercy, Kansas City. I'm Melanie Cole, and I invite you to listen as we discuss pediatric recurrent, intentional foreign body ingestion, and here to present case series and review of the literature is my guest, Dr. Christina Low Kapalu, she's a Pediatric Psychologist, Director of the Integrated Care for the section of neuro gastroenterology and motility and Co-Director of the Interdisciplinary Constipation and Incontinence Clinic at Children's Mercy, Kansas City. Dr. Low, it's a pleasure to have you join us today. Although foreign body ingestion is a common pediatric referral concern. Why is intentional or recurrent unintentional foreign body ingestion in youth very poorly defined. Tell us about this intentional ingestion, some characteristics and outcomes, and specifically in a lower socioeconomic population. Tell us a little bit about this phenomenon.

Dr. Low Kapalu: Yeah, so we don't really know a lot about how to manage recurrent and intentional foreign body ingestion in youth. There are only a few case studies in one retrospective or view, but generally speaking, we don't encounter it at a high enough frequency at each hospital to fully understand it. Although it's this lower frequency behavior or presentation, it's high needs, high intensity and high acuity in terms of treatment outcomes and service needs for these patients. And so our project came from this idea that if we can draw from the collective wisdom of case studies, the literature and other institutions, maybe we can come up with a behavioral formulation for how to treat this recurrent phenomenon as implied by the name and help kids to have better outcomes. So, the more we asked about it, the more it came up with other institutions and other colleagues telling us those stories of individuals who had come into their institution, 12, 14, 20, or more times, having ingested something on purpose, like a coat hanger, a fork, a pen, a battery, and then not knowing what to do with these patients. And so we decided to do this literature review to hopefully come up with a plan and there really isn't enough data yet to bear out the outcomes for separate subgroups. So we may see three, four or five of these a year at a big hospital like ours. So we can't really divide it out into socioeconomic groups, but in adults, we know that it happens more often in populations like those that are incarcerated and those with more severe and persistent mental illness.

Host: Wow. It's absolutely fascinating. So what else do you know about recurrent and intentional foreign body ingestion in adults first as children? And are there some guidelines Dr. Low?

Dr. Low Kapalu: Yeah, so in adults, we know the literature basically says that there are two populations of individuals who are most likely to ingest objects on purpose. So those are adults that are incarcerated and those with severe and persistent mental illness, like a thought disorder or obsessive compulsive disorder. We know that it happens more often in males, we know that a small number of individuals account for a large percentage of ingestion. So what that means is you may have one person. So for example, in our case series, one of our individuals over a course of two and a half years had 21 hospitalizations for this same behavior. We also know that with recurrent and intentional foreign body ingestion, which is in contrast to like a two year old swallowing a coin, these are purposeful behaviors that those individuals are more likely to swallow long or sharp objects like knives or pens that cause, or have the potential to cause more harm and need greater medical intervention, which leads to higher medical costs in adults. For youth, we don't know if that same trend then is observed in youth. And then how do we proceed?

One study suggested that there was a second spike in foreign body ingestion. So the first highest rate being in very young children, unintentionally ingesting things like coins or toys. And then you see the second spike between 15 and 19 years of age in one study, that may represent an increase in intentional foreign body ingestion. As you tend to see more psychiatric or cognitive disorders in that population. And while we know there are clear guidelines for how to medically evaluate and treat youth with foreign body ingestion, based on what's ingested their symptoms that presentation the location of the object in their body. We don't really know, and we don't know how to prevent it from happening again in repeated and intentional ingestion. And there are no formalized guidelines about how to keep these kids healthy long-term. So our goals were to prevent or to reduce subsequent ingestion and then provide evidence guided treatment recommendations for both inpatient and outpatient management of this behavior in pediatrics, based on our experiences.

Host: So, as we're going to get into what your study examined and the design and the results, why is it so important that these patients require this nuanced multidisciplinary management approach to address those acute concerns and reduce subsequent ingestions? I imagine that there is not only a psych evaluation, but there's also the ER, I mean, it's got to be so multidisciplinary, tell us a little bit about that.

Dr. Low Kapalu: So, these patients often present to the emergency department as a first point of contact. And the primary goal initially is to get them medically stable and to determine what their treatment should be, their medical treatment should be. And we were finding that these individuals that were coming into our institution were needing additional behavioral health evaluation and treatment, but that was coming kind of at the end of the process after they had been medically managed. But we know that these patients coming in are very psycho-socially complex with other underlying behavioral health conditions and really needed some tailored psychiatric management strategies from the time of presentation to discharge. But the system that was currently in place didn't really allow for that. So we needed to consider multiple factors at presentation to prevent further ingestion. For example, we know that individuals with recurrent foreign body ingestion may actually ingest something else when they're in the hospital.

There's lots of case reports of that and our clinical experiences that happens. And so having a plan from the beginning of presentation until discharge really helps to give us an idea about how to reduce risk of subsequent ingestion. Also, my medical colleagues were requiring additional endoscopic planning and having to take some countermeasures. So for example, the treatment algorithms are based on time of ingestion. So if somebody is presenting and not communicating when they swallowed this object and or they can't communicate about when they swallowed this object, that impacts treatment planning. And then also on top of that, there's these ethical considerations given the patient's age. So in pediatrics an adult is consenting for them. And many of these individuals, at least a subset are presenting from residential treatment homes. And so are in the care of the State. And so who gives consent for those procedures in that case? So all those reasons state that we really needed multidisciplinary care, including social work, psychiatry, psychology, GI and surgery, really from the outset, rather than as an afterthought for care.

Host: What a very complicated and comprehensive approach. Now tell us about your study itself. What was the design you used? Tell us about the results and what does this review of the literature and clinical experience suggest Dr. Low? Because I would imagine this would be a topic of interest to so many clinicians.

Dr. Low Kapalu: Absolutely. Like I mentioned before, even though it doesn't happen very often when it does and it lands in the emergency room, you're in, you need to know how to manage this. So there is, there has been a lot of interest in this. So we conducted a literature review of pediatric recurrent foreign body ingestion, as well as a case series or description of three youth that presented to our institution, given the limited amount of research out there and low rates of occurrence nationally. We also combined the literature view with clinical experience. So this is where I partnered with my medical colleagues to provide a behavioral treatment algorithm for the management of pediatric recurrent intentional foreign body ingestion based on empirically supported behavioral principles. And what our studies showed was that we really don't know a lot about this phenomenon in pediatrics. We may see that there is a mirroring of the underlying predisposing circumstances we see in adults.

For example, youth in residential treatment facilities, or with mood or thought disorders, that's then complicated by the developmental or behavioral immaturity of the patient. And then additional challenges like technical legal and ethical challenges. We also don't have great awareness of the long-term outcomes of recurrent foreign body ingestion in youth. We know that a subset of this population is presenting many times over, but what are some strategies to prevent that and to address that kind of gap in the literature, we really drew from the behavioral literature out there on behavior change. And we found that there were three general behavioral phenotypes of recurrent and intention intentional foreign body ingestion that had somewhat divergent management techniques. So we created this treatment algorithm that really divided groups of RIFBI or recurrent intentional foreign body ingestion into personality disorder traits, or impulse control disorders, thought or mood disorders. So these are the ones that might present with suicidal behavior in the form of ingestion, for example.

And or PICA and trip-telomania, which is further subdivided by cognitive functioning. And so under each of these groupings, we created a list of strategies that could be used by hospitals or institutions to prevent subsequent ingestion. With each pathway, coming with its own prevention strategies that include both the antecedents and the consequences of behavior. We also found that recurrence while hospitalized is possible, if not likely. And so high supervision during hospitalization is required. So, for example, one of our patients required one-on-one supervision while asleep and two on one supervision while awake, just to prevent them from swallowing things like forks, magnets that attach shower curtains to the wall, things like that, and that transferred to psychiatric facility or medication management, which were kind of the first line treatments previously in isolation, don't seem to be sufficient to prevent recurrence of this behavior. And so there needs to be a very planned treatment discharge plan in order to prevent these kids from returning again.

Host: Such a good point, what an interesting topic we're discussing today, before we wrap up, why is identification of antecedents and consequences of ingestion helpful for treatment planning, give us some strategies that may be of help at this time, and what other observations or conclusions did your study help illuminate? What would you like other providers to know about this topic?

Dr. Low Kapalu: So, in behavior management, the intervention is based on the antecedents or the precursors on the consequences or what happens after the behavior. And so you can respond to a single behavior in multiple different ways based on the function of behavior. So if we don't examine why the individual is ingesting the object, you may have the wrong function and your treatment plan may not be appropriate for that particular patient and could actually make the problem worse. So antecedent management strategies they might consider are things like, how are you going to secure items in the room? Do you have the staff to provide one-on-one supervision if these types of patients come into your hospital? When you discharge the patient, how are you going to, where are you going to discharge them to? And how are you going to manage them from the recurrent foreign body ingestion perspective?

You might also think about access to fun activities when they're in the hospital, that's a consequence space strategy. So for example, we know that an adults, the three primary functions of recurrent foreign body ingestion are to escape or avoid a situation. So again, the incarcerated individuals swallow something because they don't want to be in prison. They want to be in the hospital, if it's a preferred setting to inflict self-harm or the behavior could be self-reinforcing that's often in the case of developmental disabilities. So in each of those cases, if you know the function of the behavior, you can provide interventions. For example, if they want to escape her, avoid a situation and they swallow something you want to rapidly evaluate them, treat them appropriately, and discharge them quickly to prevent the accidental reinforcement of being in the hospital.

So, to prevent them from having access to that positive experience, because we don't want them to want that again, we also know we need to have multicenter studies to look at the prevalence and ideology of this behavior. And there need to be concrete processes in place so that we can manage these behaviors, right from the beginning, rather than as an afterthought. What I want pediatricians and sub-specialists to know is that recurrent foreign body ingestion is rare, but you're going to see it. So having a plan at the outset is really important for management of these patients. It's also refractory to treatment as evidenced by recurrence, and there's not really a one size fits all treatment plan that will stop this behavior from happening. Involving psychiatry and psychology and social work from the beginning can often be very helpful because they're the experts in evidence-based behavioral interventions that we can use to decrease this behavior in the future.

Host: What great information and such an informative episode, Dr. Low, thank you so much for joining us today. To refer your patient or for more information, please visit childrensmercy.org to get connected with one of our providers. This has been Transformational Pediatrics with Children's Mercy, Kansas City. Please remember to subscribe, rate, and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.