Caustic ingestion in children—A review
Introduction
Preventive measures have made significant impact on reducing caustic injuries in many countries. It is, however, still a goal that needs to be realised by many developing countries. Most caustic injuries are seen in countries where prevention is still lacking due to social, economic and educational variables. Half to 80% of the injuries are seen in children.1, 2 These are typically accidental in nature. This is in contrast to ingestion by adults which is often suicidal and frequently life-threatening. True prevalence of caustic injuries in children is not known but limited data available supports the large scale of the problem, which is a major public health issue.
The aim of this article is to discuss impact of caustic injuries and its sequelae, particularly in low and middle income countries (LMIC), to describe well-established treatment modalities and to look into the controversial management options.
Section snippets
Epidemiology
Ingestion of highly alkali or acidic substances is a major cause of morbidity and mortality worldwide, especially in developing regions. Victims are largely unsupervised preschool children.1, 2 Most taste or drink household cleaning agents due to curiosity or while searching for food or drink. Toddlers are most at risk, averaging 3 years of age at ingestion.3 Risk factors for caustic ingestion in children include male gender,4, 5, 6 attention-deficit/hyperactivity disorder symptoms,4 lower
Pathophysiology
The depth of injury depends on the tissue concentration of the caustic substance, which is difficult to assess from the history, even if the causative agent and its concentration is known.28 An acid usually forms an eschar of burnt tissue from protein coagulation (coagulation necrosis) which may protect against deeper tissue penetration. Their sour taste may also limit accidental intake. Alkaline agents disrupt both proteins and fats, combining with them and destroying cell architecture, a
Primary prevention
Nearly all paediatric injuries are due to accidental ingestion6 with 86–90% occurring within the home environment or in directly adjacent surroundings.8 Containers are frequently found unmarked and within reach of children, without child-proof seals.6, 8 Legislation banning domestic retail of sodium hydroxide-based cleaning agents25 or limiting concentration of strong bases in domestic preparations,1 has significantly reduced incidence and severity of injuries in some countries. Legislated
Presentation
A history of substance ingestion is the most common presentation. Symptoms depend on the form, amount and strength of the caustic substance. Crystal and solid forms tend to cause oropharyngeal burns. Conversely liquids tend to be swallowed and create oesophageal injury.
Half to two-thirds of children are asymptomatic after reported caustic ingestion.39 Absence of signs is regarded by some as indicative of no or minimal injury, with no need for diagnostic endoscopy,5, 13, 39, 40, 41 although
Home first aid measures
The causative agent should immediately be removed and identified if possible. A poison telephone help-line may aid identification of caustic contents. Vomiting should never be induced, as it can increase caustic exposure,5 but can occur spontaneously due to gastric irritation. A neutral liquid (preferably water, but milk may be considered) should be given to drink if possible to help neutralise the agent,47 taking care not to stimulate vomiting. Urgent medical attention should be sought,
Acute phase treatment
The majority of children with a history of caustic ingestion (up to 70%48) are asymptomatic and can be observed for 12–48 h, depending on the nature of the substance ingested.
Those with airway symptoms may require supplementary oxygen. Temporary endotracheal intubation was reported necessary in up to 18%.6 Long-term tracheostomy may be required in about 1%.49
Symptomatic patients are kept nil per mouth until further investigations have been performed, on intravenous maintenance fluid.
Broad
Definitive treatment
Most patients suffer from mild injuries and these grade 0–IIa injured patients should be observed in hospital until full oral feeds are tolerated. Patients with grade IIb and III injuries will require further evaluation and management of potential stricture development once their acute management is complete. Initial hospitalisation of 2–4 weeks is typically required in these cases before oral intake is optimal. A liquid diet, either orally or via nasogastric tube as tolerated, may initially be
Proton pump inhibitors (PPIs)
Reduction of stomach acid with PPIs or histamine H2-receptor antagonists is hypothesised to protect healing oesophageal mucosa and reduce stricture formation. Routine use of PPIs after caustic ingestion is widespread practice.53 Our observation of the positive effect of gastric fundoplication in radiologically proven reflux on resistant stricture healing is supported by others64 as well as observations of abnormal pH, manometry, and impaired oesophageal transit, in children with caustic
Oesophageal strictures
Caustic ingestion is the most common cause of oesophageal stenosis in children in LMIC.72 Early oesophagoscopy findings of a grade IIb or III injury, oesophageal stenosis on contrast oesophagogram5 (Figure 1) and persistent dysphagia at 3 weeks after injury51 may be used for early identification of children who require stricture dilation. Some centres report symptomatic treatment only within the first 2–3 weeks after presentation, without early endoscopy. Early dilatation (starting between 10
Animal (rat model) research
Pirfenidone, an anti-fibrotic drug and anti-inflammatory drug used to treat pulmonary and liver fibrosis as well as external scarring, has shown promise in reducing stricture formation when applied topically to the oesophagus at the time of burn.121 Other systemic anti-fibrotics (e.g., 5-fluorouracil)122 and anti-oxidants reduced histological evidence of damage after caustic injury.123, 124, 125 Bingol-Kologlu reported that subcutaneously injected systemic heparin for 48 h after injury decreased
Conclusion
Caustic oesophageal injuries remains a major public health issue particularly in the lower and middle income countries. Implementation of preventative measures is the only long-term solution. Management of caustic strictures is well established. New management modalities for strictures such as topical mitomycin C application are promising but require larger trials with long-term follow-up.
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