To help children understand where things go after being ingested, these doctors swallowed 6 Lego blocks themselves

Don't worry, like a grain of corn, they will come out.

Written by | Xiaoye

How long does it take for a tiny Lego human head brick to enter the mouth, go down, pass through the winding intestines, and finally be excreted smoothly? This is a practical question, because children often swallow foreign objects. Obviously, it is impossible to let children do such an experiment, but six pediatric experts stepped forward and bravely experienced the magical journey of Lego's intestines.

Lego minifigure head | Source: Andrzej Rembowski

Start with a lecture

It all started at an academic conference, when Dr. Andrew Tagg, an emergency physician in Australia, decided to give a lecture on foreign body swallowing. He had a special interest in pediatrics, and emergency cases of children swallowing foreign bodies were common. In a 2001 review study [1], coins ranked first among the most commonly swallowed objects, followed by plastic toys. Tagg recalled that when he was a child, he would try to bite two Lego blocks that were firmly stuck together to separate them. He was sure that he had swallowed blocks himself.

Tagg made full preparations before the meeting and read through all the primary literature. However, the final effect was mediocre. Of the 300 people who originally participated in the meeting, only 15 attended Tagg's report, and only 10 people were left at the end. He didn't want to waste his previous efforts, so he thought of using the power of the Internet.

In 2013, he co-founded the Don't forget the bubbles website[2] with Dr. Henry Goldstein, a pediatrician at the Queensland Children's Health Center, Dr. Tessa Davis, a consultant in pediatric emergency medicine at the Royal London Hospital and a senior lecturer at Queen Mary University of London, and Ben Lawton, a pediatric emergency physician, to provide professional pediatric medical and nursing information to child caregivers. At regular editorial meetings, Tagg discussed the issue of swallowing foreign objects with them, which resonated with them - they often encountered anxious parents holding their children and telling doctors that they couldn't find out what their children had swallowed. At present, many doctors in the academic community have studied how long it takes for a coin to be excreted after being swallowed[3-5], but no one has studied how long it takes for a plastic toy to travel around the body. So Tagg said to everyone, "I have a strange idea."

For them, most of the medical knowledge comes from clinical practice, not just from papers, so they decided to experiment in person and soon formed an international team. Three other pediatricians were also eager to try, including Dr. Katie Knight, consultant in pediatric emergency medicine at Middlesex Hospital, Dr. Damian Roland, honorary professor and consultant in pediatric emergency medicine at the University of Leicester Hospital, and Grace Leo, a joint lecturer at the University of New South Wales and a pediatrician at Sydney Children's Hospital. The latter two are also members of the Don't forget the bubbles core team.

Knight believes this experiment may become a legendary story in the medical world.

Eat Lego!

After the team was assembled, the doctors began to discuss specific plans. The first question was what to eat? Tagg proposed the most common Lego plastic building blocks. In fact, in routine diagnosis and treatment, doctors ask patients to swallow pill-sized cameras (capsule endoscopes), which are even larger than small Lego blocks, so Goldstein believes that Lego blocks are feasible. Professional doctors who have received pediatric training are very clear about what size of foreign bodies can or cannot pass through which areas of the body. For example, if the foreign body is larger than 2.5 cm in diameter and longer than 6 cm, it cannot pass through the duodenum; if the foreign body has sharp corners or thorn-like protrusions, there is a risk of puncturing the internal organs.

The researchers had considered Lego bricks with a size of 2x4 (that is, 2 studs wide and 4 studs long), but because of the rectangular right angles, there was a risk of puncture. Later, they thought of the Lego mini-man head accessory, which is larger than a corn kernel and is round, so it is not easy to damage the internal organs.

The next most important thing is to find it in your own feces!

The size of the Lego figurine head used in the experiment, in millimeters. Source: Reference [6]

Normally, people's bowel movements range from three times a day to once every three days, so the team unified the time of eating, and three days before the experiment, everyone made a bowel movement record. In order to ensure the rigor of the experiment, Roland proposed the "stool hardness and excretion" (SHAT) and "finding and retrieval time" (FART) scores. The former assesses the participants' bowel movements. Specifically, the softer the stool, the more frequent the bowel movement, and the higher the SHAT score, and vice versa. FART evaluates the time from the entrance to the discharge of foreign matter.

After an online meeting, everyone decided that no matter where they were, they would eat the Lego heads between 7 and 9 a.m. Unfortunately, Lawton decided to withdraw because he had to take a 30-hour flight back to his parents' home during the experiment, go to the toilet at an altitude of 10,000 feet, and then search for Lego, which was inconvenient. In the end, the experimental members happened to be 3 men and 3 women.

I have been looking for it for thousands of times.

In fact, no one felt anything special when they swallowed the Lego head. Everyone continued to live their daily lives, but it took a little longer to go to the toilet. Everyone created an online channel to share their progress. Everyone was looking forward to who would be the first to poop out, and the mood was like searching for Easter eggs.

Team members were filmed swallowing Lego at the start of the experiment. Source: Henry Goldstein's Twitter

Of course, this process is not comfortable. Even if they are used to stool examinations, it is the first time for them to search for it themselves. These pediatric medical professionals did not reach a unified strategy on how to find Lego, but each of them showed their own skills.

Knight used a medical vomiting basin and a sealed transparent plastic bag. She and Leo both found the vomit on the same day after swallowing it, which made them feel relieved. Dr. Davis followed closely behind. She used a medical paper bowl and successfully found it after her second bowel movement. Tagg found the Lego head with a medical tongue depressor during his three bowel movements.

Dr. Goldstein also found Lego the next day, and he looked for it three times in total. Especially during work, no one knew what research this senior pediatric attending physician in the hospital was doing. He was seen wearing a suit and carrying a vomit bag into a remote toilet, and then went straight to the medical waste disposal area after coming out... He even summed up his experience in the search process and reminded other experimental subjects to pay attention to early defecation, "It is much faster than expected."

The situation of the last person, Roland, was not optimistic. He had been unsuccessful for several days. The team initially estimated that the longest reasonable retrieval time might be about 14 days. Therefore, it was speculated that Roland's Lego was still in his body. So Roland searched for two weeks in a row, but unfortunately found nothing. Where did his Lego go? Maybe it had been excreted long ago. Roland reflected that the reason for his failure was that he did not "search carefully" and missed the best time to retrieve it. Tagg said humorously, "Maybe one day many years later, a gastroenterologist will find Lego staring at him during a colonoscopy."

Despite this, the experimental results were quite satisfactory to everyone. Based on the FART score statistics, the researchers calculated that it takes an average of 1.71 days for a small Lego head to enter an adult's mouth and be excreted; and the time it takes for the bricks to pass through the female body is faster than that of the male body (note that this is not statistically significant). In addition, the researchers compared the SHAT scores before and after swallowing and found that the difference in stool hardness was not significant, indicating that for adults, swallowing foreign objects like Lego heads does not significantly affect gastrointestinal activity and defecation. There is no significant correlation between the SHAT score and the FART score after swallowing, which means that it is not necessarily the case that the softer the stool and the more frequent the bowel movements, the shorter the time it takes for the bricks to pass through the human body. After retrieving the bricks and reaching conclusions, everyone logged into the online document at the same time and typed out the paper together.

Individual data of 6 participants, related data such as detection and retrieval time, stool consistency and transit time score, source: Reference [6]

Who will win the research?

At the beginning of the discussion, everyone’s common goal was the Christmas issue of the British Medical Journal (BMJ). This annual special issue publishes some light-hearted but thought-provoking medical papers, and is also a treasure trove of resources for the Ig Nobel Prize. For example, the 2017 special issue published an article on the behavior of general practitioners, and the case analyzed by the author was Dr. Brown, the bear in the cartoon Peppa Pig[7]. If a doctor can publish an article in the Christmas issue of BMJ, his experience will become more legendary. Dr. Davis even made it his long-term goal to publish a paper here.

Unfortunately, BMJ rejected the paper directly for a simple reason: they do not allow the publication of autologous experimental studies. Their submission process was not smooth, and they were rejected 6 times in total. Goldstein felt that rejection was very common in paper submissions and was quite indifferent, while Roland was a little worried that this paper might not be published. Everyone felt that such content was still worth making public, so they decided to put the article on their own Bubbles website as a blog post for readers to read.

Davis was the main author of the paper and was responsible for the submission. She was very persistent and believed that she would be able to find a journal willing to accept and publish it. In the end, they found the Journal of Paediatrics and Child Health. The editors liked this interesting article very much and it was officially published in November 2018. The article was also honored to become the most read article of the year [6].

After the paper was published, the author created a topic on social media. Many people shared their childhood experiences of accidentally swallowing Lego toys. Source: Twitter

Bruce Y. Lee, professor of health policy and management at the City University of New York School of Public Health, pointed out the limitations of this interesting paper. On the one hand, the subjects were adults, whose gastrointestinal tracts are very different from those of children aged 6 months to 3 years, so it is not possible to say whether the time it takes for Lego to pass through the body of children is consistent with the results of this study. [7] On the other hand, the authors mentioned that the results showed that the time it took to expel Lego was shorter than that of earlier coin studies, but they could not explain why. At the same time, they also admitted that the SHAT score does not perfectly reflect the bowel movement pattern of the intestine. [6]

Other academic experts admired the team's courage in devoting themselves to research, but also pointed out several flaws in the research method, which affected the study's status as a strictly evidence-based medical study. The Journal of Pediatrics and Child Health published a "response" [8], proposing an improvement plan. The author pointed out that the original study clearly lacked a control group and multiple test verifications, and suggested conducting a randomized longitudinal placebo or foreign body passage (POOP) trial to replicate the experimental results; the uncertainty caused by a failed retrieval case may confuse the interpretation of the results, so it is recommended that subsequent trials can mark the objects with safety tags that are easy to track.

After this study, the six doctors have developed an indissoluble bond with Lego, and now they all carry a Lego head with them as a souvenir. When Dr. Knight encounters a patient who swallowed a Lego plastic head, she can firmly tell the parents not to worry too much, and that it will come out in two days. Roland, the only one who did not find Lego, received a variety of Lego building block toys as a comfort gift. He strung the heads together to prove his small contribution to medical research.

If not expelled, where would the foreign body get stuck?

While the Lego figure head can pass through the human body without any problems, other foreign objects can have serious consequences. Most cases of foreign object swallowing occur in children between the ages of 6 months and 3 years old. Children at this developmental stage are the most active in exploring the outside world. They are more likely to put things within reach into their mouths than to explore in other ways.

Data show that in 2015, 17.9 out of every 10,000 children in the United States had foreign bodies in their digestive tracts[9]. In my country, according to data on cases of foreign bodies in children’s digestive tracts from 2016 to 2021, the number of cases was as high as 17,000, and children under the age of 5 accounted for as high as 75% of the patients[10]. For children who have no safety awareness, the types of foreign bodies that are swallowed by mistake are complex and numerous, ranging from the most common coins to magnetic foreign bodies, hair, pins, plastic toys, electric toothbrush heads, thumb tacks, date pits, chicken bones, screws, etc.[11].

According to the different locations of swallowed foreign bodies in the body, they are generally divided into three categories: tracheal foreign bodies, esophageal foreign bodies and gastrointestinal foreign bodies. Among them, tracheal foreign bodies are the most dangerous, while gastrointestinal foreign bodies can usually be left for children to expel on their own. Taking coins as an example, most coins can pass through children's esophagus without difficulty and fall into the stomach, and often do not show any discomfort symptoms. If coins are accidentally stuck, they often get stuck in the nearly one-third of the esophagus, which may cause tissue pressure necrosis and then invade the tracheobronchial tree structure. This is an emergency and requires immediate medical attention. Tagg also pointed out that there are three types of objects that need to be removed immediately: sharp and long objects (greater than 5 cm), rare earth magnets, and button electricity in the esophagus. These objects can cause damage to the esophagus or intestines, and even form intestinal fistulas and cause death. [12, 13]

A case of swallowing a fidget spinner reported in JAMA Otolaryngology. Source: Reference [12]

According to Tagg's survey, 9% of foreign bodies are stuck in the oropharynx and need to be removed with medical forceps when they cannot be spit out; 20% of foreign bodies are stuck in the esophagus and narrow anatomical sites; 60% of foreign bodies fall all the way down into the stomach, and as long as the object is less than 6 cm in length and less than 2.5 cm in diameter, it will continue to enter other organs. Another one-third of foreign bodies can stay in the stomach for up to two weeks. The remaining 11% of foreign bodies are blocked by the duodenum or ileocecal valve. According to reported case data, the time it takes for foreign bodies to pass depends on the specific situation, and the average time may be between 3.8 and 5.1 days. Of all cases that cannot be discharged, 10%-20% can be removed by endoscopy, and only in very rare cases do open surgery require.

Figure caption: The possible position of a foreign object in a child’s body after the object is swallowed by the child. Source: Reference [12]

The "Guidelines for the Management of Foreign Bodies in the Digestive Tract of Children in my country"[10] published in 2021 provides specific handling procedures for dangerous foreign bodies that enter the digestive tract and cannot be excreted on their own (including sharp objects, button batteries, etc.): First, perform X-ray and CT examinations, and then, based on the location of the foreign body, clinical manifestations and other indicators, endoscopic surgery, surgical surgery and other measures can be taken to prevent further deterioration of the child's health and possible complications.

In addition, we have also heard of some "folk remedies" to help defecation, such as eating sesame oil, which may aggravate digestive tract damage and should be evaluated by a doctor. Professor Liu Haifeng, deputy director of Shanghai Children's Hospital and chief physician of the Department of Gastroenterology, once said that if a child is found crying and crying after swallowing a foreign object, or has difficulty swallowing or stomach pain, it is best to go to the hospital first and make a decision after the doctor's evaluation. [14]

Six adults carried forward the curiosity for exploration that humans have maintained since childhood and let Lego experience a journey inside the human body, but their research also serves as a timely reminder to parents: Exploring the world is wonderful, but be careful not to let your children put everything in their mouths.

References

[1] https://link.springer.com/article/10.1007/s004310100788

[2] https://dontforgetthebubbles.com/

[3] https://jamanetwork.com/journals/jamapediatrics/article-abstract/517427

[4] https://journals.lww.com/co-pediatrics/Abstract/2006/10000/Management_of_esophageal_coins.17.aspx

[5] https://www.e-ce.org/journal/view.php?doi=10.5946/ce.2018.039

[6] https://onlinelibrary.wiley.com/doi/10.1111/jpc.14309

[7] https://www.bmj.com/content/359/bmj.j5397

[8] https://onlinelibrary.wiley.com/doi/10.1111/jpc.14403

[9] https://publications.aap.org/pediatrics/article/143/5/e20181988/77066/Foreign-Body-Ingestions-of-Young-Children-Treated?autologincheck=redirected

[10] Guidelines for the management of foreign bodies in the digestive tract of children in China (2021)

[11] https://www.mdpi.com/1648-9144/55/10/686

[12] https://dontforgetthebubbles.com/ingested-foreign-bodies/

[13] https://www.mdpi.com/2413-4155/4/2/20

[14] https://www.thepaper.cn/newsDetail_forward_1620185

This article is supported by the Science Popularization China Starry Sky Project

Produced by: China Association for Science and Technology Department of Science Popularization

Producer: China Science and Technology Press Co., Ltd., Beijing Zhongke Xinghe Culture Media Co., Ltd.

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