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Three Part Question

In [children with nasal foreign bodies] will [parent's kiss / mouth to mouth positive pressure technique] help [reduce the need for use of instruments / sedation / general anaesthesia]

Clinical Scenario

A 3-year-old boy presents to Emergency Department having pushed a nut in to right nostril. The foreign body is easily visible in his nose but the child is very uncooperative for you to remove it. While you are about to refer the child to ENT, your colleague asks you to try parent’s kiss and you wonder whether it will work?

Search Strategy

Medline and Embase using National library of health interface

Medline: [(exp nose AND exp foreign bodies) OR “nasal foreign bod*”.ti,ab OR nasal obstruction/th (th=therapy)] AND [“parent’s kiss”.ti,ab OR pressure OR “positive pressure”.ti,ab] LIMIT to children and English language

EMBASE: [(exp nose AND exp foreign bodies) OR “nasal foreign bod*”.ti,ab OR nasal obstruction/th (th=therapy) AND [“parent’s kiss”.ti,ab OR pressure OR “positive pressure”.ti,ab] LIMIT to children and English language

Medline and EMBASE duplicates filtered

Search Outcome

11 papers found of which 1 paper directly answers the question (reducing the need for instruments / sedation / general anaethesia) and 3 papers indirectly relates to the same clinical question (measures success rate of the technique).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Neeraj Purohit; Shalina Ray; Tom Wilson; OP Chawla; July 2008 UK	All Children under the age of 5 years presenting with nasal foreign body to A&E and ENT - 31 patients included in the study	Prospective observational study from 0ct’04 to Mar’05 Compared with data from Mar’04 to Oct’04	Successful removal of foreign body	64.5% (20/31) success - 13/17 small/regular FBs & 7/13 large/irregular FBs	Time since insertion ranged from 30 minutes to 7 days – no data on the success rate of the technique and the time of the insertion 14 children had prior attempts to remove the FB before presentation to A&E. No mention of number of attempts of the technique and the success rate.
			Reduction in the number of general anaesthetics following introduction of the technique	3% (1/31) required GA compared to 32.5% (13/40) in the preceding 6 month period (before introduction of the technique)
			Successful removal with instruments after failure of the technique	10/11 compared to 27/40 in the preceding 6 month period
D.Alleemudder; A.Sonsale; S.Ali August 2007 UK	Child of any age group presented with nasal FB from Feb’06 to Oct’06 – 8 patients	Prospective observational study conducted by single SHO	Successful removal of foreign body	62.5% (5/8) success with maximum of 4 attempts (1 pt-first attempt, 2 pts-second attempt, 2 pts-third attempt). Recommends semi-recumbent position. Failures mainly because of hollow FBs	Small number of patients for the success rate to be significant
Marissa Botma; Roxana Bader; Haytham Kubba August 2000 UK	Children presenting to A&E with unilateral nasal FB – 19 patients recruited after consenting parents	Prospective observational study	To determine the efficacy, safety and acceptability of the positive pressure technique	79% success (15/19). Median age-24 months. Age 2 or less – 7/9, Age>2 – 8/10. 4/19 removed with instruments. No GA. None refused to participate. None of the children showed signs of distress. No complications	In 10 children, a previous attempt made at instrument removal. Unable to identify any factors which predicted failure.
Samuel A Backlin September 1994 Canada	Paediatric patients who attended ED with a diagnosis of nasal FB over 2 year period	Retrospective study – review of computer charts. Total 64 cases were identified - PPT was used in 8 cases	To describe the successful use of positive pressure technique	100% success (8/8). All children except one – immediate presentation to ED. Local agent used in 2 cases (1-Otrivine, 1-Saline lubricant)	Small number of patients for the success rate to be significant. No mention of number of attempts.

Comment(s)

In 1965, Ctibor first described mouth-to-mouth positive pressure technique for removal of unilateral nasal foreign bodies in children. It involves the parent positioning the child in supine or semi recumbent position and exhaling in to their mouth while occluding the other nostril. Though all the studies were done on small group of patients, they showed a satisfactory success rate between 62.5% and 100%. One paper reported no effect on results by time since insertion or age of the child, better success at removing small regular nasal foreign bodies. Another paper reported that hollow objects are resilient to PPT. No complications occurred in any studies. It has been mentioned that the PPT cause no distress to child and well accepted by parents.

Clinical Bottom Line

Positive pressure technique or Parent’s kiss is simple, safe and effective and could be tried in Emergency Departments. Though there is theoretical risk of barotraumas and infections, there are no reported cases. Use of this technique initially does not preclude invasive methods for treatment if required later.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Purohit N; Ray S; Wilson T; Chawla OP The “parent’s kiss”: an effective way to remove paediatric nasal foreign bodies Annals of the Royal College of Surgeons July 2008, vol./is.90/5(420-2)
2. Alleemudder D; Sonsale A; Ali S Positive pressure technique for removal of nasal foreign bodies International Journal of Pediatric Otorhinolaryngology November 2007, vol./is. 71/11(1809-11), 0165-5
3. Botma M; Bader R; Kubba H 'A parent's kiss': evaluating an unusual method for removing nasal foreign bodies in children Journal of Laryngology & Otology August 2000, vol./is. 114/8(598-600), 0022-2151
4. Backlin SA Positive-pressure technique for nasal foreign body removal in children Annals of Emergency Medicine April 1995, vol./is. 25/4(554-5), 0196-0644