Preventing Self-Harm From Repeat Foreign-Body Ingestion

Abstract

Mental health disorders in adolescents present some of the most challenging of all ethical dilemmas. This is particularly true when they lead to self-injurious behavior that can only be prevented by either limiting the freedom of the adolescent or forcing treatments on them that they do not want. Intentional and repeated foreign-body ingestion (FBI) in youth is a poorly understood self-injurious behavior that can be life-threatening. It poses unique clinical and ethical challenges. Ingestion of sharp or magnetic objects increases the need for endoscopic retrieval or surgical intervention with associated risks, including perforation and anesthesia-related adverse events. When behavior modification efforts fail to prevent recurrent FBI, the cumulative risk of medical intervention mounts. Sometimes, as a last resort, doctors consider surgical procedures that limit jaw movement and may physically prevent recurrent FBI. In this Ethics Rounds article, we present a case in which doctors consider whether it is in the best interest of a teenager with this behavior to undergo orthodontic jaw wiring as a next step in treatment of repeated FBI. Doctor commentary on the ethical decision-making process is provided.

Endoscopist experience with pediatric recurrent and intentional foreign body ingestion (RIFBI): Management considerations and future directions

“…3 While rare, behavioral recommendations are emerging regarding preventative efforts to reduce subsequent ingestions. 14,15 We have previously published a behavioral treatment algorithm for the management of pediatric RIFBI, 14 dividing ingestions by behavioral phenotype and providing unique treatment pathways for each. Some evidence of a similar decision-making pathway in hospitalized or incarcerated adults exists, with outpatient management suggested if medically and psychiatrically stable.…”

“…Palta et al advocated for the need for behavioral interventions to decrease intentional ingestion in patients with psychiatric comorbidities to prioritize resource utilization 3 . While rare, behavioral recommendations are emerging regarding preventative efforts to reduce subsequent ingestions 14,15 . We have previously published a behavioral treatment algorithm for the management of pediatric RIFBI, 14 dividing ingestions by behavioral phenotype and providing unique treatment pathways for each.…”

Inpatient Pediatric Foreign Body Ingestion

“…A concomitant psychiatric condition was, however, associated with an increased LOS for FBI admissions. This may be related to the fact that some FBI associated with psychiatric conditions may be intentional, more dangerous, and require longer LOS (9)(10)(11). Due to the inherent limitations of administrative claims data that we used for this study, we cannot evaluate the specific reasons for this association.…”

Perforaci´ón gástrica por espina de pescado. Reporte de un caso y revisión de literatura

“…En niños, es muy común que los cuerpos extraños se localicen a nivel de vía aérea; de acuerdo con la ubicación del cuerpo extraño, se presentan los síntomas que pueden ir desde tos hasta dificultad respiratoria. En estos casos se justifica la realización de broncoscopia, por tratarse de un procedimiento diagnóstico y terapéutico, y que a la vez es seguro, por lo que se convierte en el estándar de oro para remover cuerpos extraños en niños; y su retraso podría aumentar el riesgo de complicaciones (12)(13)(14).…”

“…Se considera que la existencia de una perforación es una contraindicación absoluta para realizar exploraciones endoscópicas, tanto altas como bajas. Al tratarse de un procedimiento desafiante y de alto riesgo, sobre todo cuando son objetos afilados que pueden causar perforación y sangrado; otro factor de riesgo es la falta de ayuno, que puede generar complicaciones como la broncoaspiración, lo que complica el estado del paciente (12); sin embargo, el tratamiento conservador de las perforaciones pequeñas está bien documentado, siempre y cuando no haya perforaciones abiertas o peritonitis. Con el paso del tiempo se han perfeccionado las técnicas endoscópicas y, en este sentido, cobra importancia, ya que no solo permiten hacer el diagnóstico, sino también la extracción.…”