Management of Nail Ingestion in Pediatric Patients

Initial Evaluation

In children who have swallowed a nail, clinicians should promptly assess for acute symptoms such as dysphagia, inability to swallow saliva, odynophagia, neck tenderness, retro‑sternal pain, drooling, choking, stridor, or dyspnea 1.
Physical examination must include evaluation for fever, cervical sub‑cutaneous emphysema, or erythema/tenderness that could indicate perforation 1.

Obtain immediate biplanar (anteroposterior and lateral) plain radiographs of the neck, chest, and abdomen to identify the presence, exact location, size, and orientation of the nail 1.
A lateral projection is essential to differentiate an esophageal location from a tracheobronchial position 1.
Perform a CT scan when there is any suspicion of perforation or complications (e.g., mediastinitis, abscess formation, or inability to clearly visualize the foreign body) 1.

Order a complete blood count, C‑reactive protein, and lactate when complications are suspected, to help identify infection or ischemia 1.

Esophageal nail – remove within 24 hours because of a high risk of perforation and fistula formation; therapeutic flexible endoscopy is the first‑line treatment 1.
Gastric or duodenal nail – perform urgent endoscopic removal regardless of symptoms, as sharp, pointed objects pose a significant risk of injury 1.

While 80‑90 % of blunt foreign bodies pass spontaneously, sharp objects such as nails carry an approximate 1 % risk of perforation 1.
Delaying endoscopy beyond 24 hours for esophageal foreign bodies markedly increases the risk of perforation 1.
Avoid barium or gastrografin contrast studies because they can coat the foreign body, impair endoscopic visualization, and raise the aspiration risk in patients unable to swallow 1.

Immediate surgical consultation and likely laparotomy are indicated when the child develops peritoneal signs (guarding, rebound tenderness, rigidity) 1.
Persistent or worsening abdominal pain warrants urgent surgical evaluation 1.
Fever or elevated inflammatory markers suggesting perforation also trigger immediate surgical involvement 1.