Everything is Awesome: Don’t Forget the LEGO

Tagg A. Journal of Paediatrics and Child Health 2018; doi:10.1111/jpc.14309

Clinical Question

• In adult subjects who ingest a small toy part, compared to historical controls of children who have ingested coins, is there a difference in object transit time and complication rate?

Background

• Children in their developmental years will explore their environments, often by ingesting objects with no nutritional value
• The most commonly ingested object (coins) has been shown to pass safely within 3-5 days with no ill effects (Spitz et al 1971)
• There is a paucity of data regarding the second most commonly swallowed object – “toy parts”
• The lead author wanted to get a study into the Christmas BMJ

Design

• Prospective, observational, non-blinded cohort study
• Standardised toy part of uniform dimensions (Lego Head) used
• Foreign object ingested at the same time of day (0700-0900)
• Bowel habit standardised between participants through the use of the Stool Hardness And Transit (SHAT score) – an average of Bristol Stool Chart scales over 3 days; with higher score indicating looser motions
• SHAT score compared pre ingestion  (pre SHAT) and post ingestion ( SHAT)

Setting

• 5 centres -3 in UK, 2 in Australia
• Unspecified 2 week period in 2018

Population

• Inclusion: Healthcare professionals working within paediatric hospital care
• Exclusion:
  • previous gastrointestinal surgery
  • inability to ingest foreign objects
  • An aversion to searching through faecal matter 
    
• 6 adult patients
• 50% male
• Mean age 36.2 (27-45)

Intervention

• Ingestion of standard Lego mini figure head

Control

• Historical controls from previous studies of ingested coins (Spitz, 1971)

Outcome

• Primary outcome: The Found and Retrieval Time (FART) score
  • 5/6 figures retrieved
  • Mean bowel motions to retrieval =2 (range 1-3)
  • Average FART score 1.71 days (1.14 to 3.04 days)
  • One participant searched 13 stools unsuccessfully over a 2 week period, with this figure yet to be located
• Secondary outcome: Comparison of SHAT and FART scores
  • Pre study SHAT score (n=6) range 3 o 5.67
  • Post study SHAT score (n=5) range 2.96 to 7.76
  • No significant difference noted between pre and post study SHAT scores
  • No correlation noted between SHAT and FART scores

Authors’ Conclusions

• Small objects, such as those followed by children, are likely to pass between 1 and 3 days without complication

Strengths

• Important research question
• Standardisation of toy object and stool scoring
• Male-female balance
• The courage and determination of the authors must be lauded; many researchers lack the constitution to undergo such self-experimentation

Weaknesses

• Non-randomised
• Non-blinded
• Small numbers- the true complication rate cannot be estimated from this study
• An adult population was studied, which is different from the population of interest (children)
• The authors SHAT themselves- this would have covered them in difficult to remove bias
• Search technique and searcher not standardised- exemplified by one item not being found
• Unvalidated scoring methods used in the study- the SHAT score is arguably crap and the FART score is arguably a load of hot air
• One head was lost to follow up (follow through?) – the authors should have tried/pushed harder to locate it

The Bottom Line

• In this trial of 6 adults ingesting a standard Lego head, 5 of them were found within 3 days
• This adds to years of data and human experience before that have already confirmed that swallowing small objects are safe for the vast majority of large and small humans
• I will not feel strained by human ingestion of small objects, and will feel under no pressure to furrow through faeces to find them

External Links

• [article] Everything is Awesome: Don’t forget the Lego
• [Blog Post] Don’t forget the Bubbles: Everything is Awesome- Don’t forget the Lego
• [further reading] Em Lit of Note: That Lego is gone
• [News interview] BBC: These doctors pooed out Lego to stop parents worrying
• [further reading] The successful Christmas BMJ article. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial

Metadata

Summary author: Segun Olusanya
Summary date: 23rd December 2018
Peer-review editor: Adrian Wong