https://doi.org/10.1177/0009922819829036
Clinical Pediatrics
2019, Vol. 58(5) 571­–577
© The Author(s) 2019
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DOI: 10.1177/0009922819829036
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Article
Introduction
Pediatric patients are prone to foreign body ingestions,
which are frequently evaluated in the emergency department
(ED). These ingestions can cause a wide range of
injuries warranting hospital admission, endoscopy, or
even surgery.1-5
This is best demonstrated in button battery
and magnet ingestions, which can result in serious
injury to the gastrointestinal tract and death.2,6-8
Young
children pose a particularly high risk for foreign body
ingestions and present a unique opportunity for prevention
by limiting access to small objects in the home.9-12
Proper understanding of the epidemiology and potential
harm associated with certain ingestions is crucial for
recognition and prevention.
D’Ippolito et al identified spikes in all types of pediatric
injuries around federal holidays. Injuries occurred
more frequently during the summer holidays (Labor
Day, Memorial Day, and the Fourth of July) and less
frequently during seasonal holidays (Halloween,
Thanksgiving, and Christmas).13
Celebration of the
Christmas holiday varies, but for many people in the
United States, traditions include decorating the house.14
This provides unique and unfettered access to small
objects. Ingestions around the winter holiday season
have been associated with respiratory compromise, gastrointestinal
perforation, gastrointestinal resection with
subsequent short bowel syndrome, sepsis, and death.1,3-
5,11,15,16
Unique Christmas-related injuries have been
documented including ingestions of Christmas bow pins
and even dreidels.17-19
The seasonal risk of foreign body ingestion around
Christmas is unknown. The goal of this investigation is
to determine the trends of pediatric Christmas foreign
body ingestions (CFBIs) presenting to US EDs.
Methods
We used the National Electronic Injury Surveillance
System (NEISS) database to evaluate the frequency of
829036CPJXXX10.1177/0009922819829036Clinical PediatricsReeves et al
research-article2019
1
Brooke Army Medical Center, San Antonio, TX, USA
2
Uniformed Services University of the Health Sciences, Bethesda,
MD, USA
3
Walter Reed National Military Medical Center, Bethesda, MD, USA
Corresponding Author:
Patrick T. Reeves, Department of Pediatrics, Brooke Army Medical
Center, 3551 Roger Brooke Drive, JBSA Ft Sam Houston, TX
78234, USA.
Email: patrick.t.reeves.mil@mail.mil
Pediatric Ingestions of Christmas
Past, Present, and Future: A Review
of Holiday Trends, 1997 to 2015
Patrick T. Reeves, MD1,2
, Jayasree Krishnamurthy, MS2
,
Eric A. Pasman, MD2,3
, and Cade M. Nylund, MD2,3
Abstract
During the observance of Christmas, many families display decorations, which increases the risk of unfettered access
and subsequent ingestion of small objects by children in the home. Our aim was to characterize the epidemiology of
Christmas foreign body ingestion (CFBI) by children. National Electronic Injury Surveillance System data from 1997
to 2015 were obtained for children aged 0 to 17 years who presented to United States Emergency Departments
matching “ingested” for “artificial Christmas trees”; “Christmas tree lights”; “Christmas tree stands or supports”;
“Christmas decorations, nonelectric”; and “Christmas decorations, electric” (excluding tree lights). An estimated
22 224 children (95% confidence Interval = 18 107-26 340) presented to the emergency department for CFBI over
the study period. Children aged 2 years and younger ingested Christmas objects most frequently (P < .001). CFBI
visits demonstrated a seasonal trend (P < .001). Christmas decoration ingestions are a frequent reason for children
to present to the ED, which require dedicated awareness for appropriate diagnosis and care.
Keywords
pediatric, ingestions, Christmas, seasonal, emergency, preventative
572	 Clinical Pediatrics 58(5)
suspected CFBI. Based on the NEISS coding manual
classification, we focused exclusively on Christmas
object product codes (due to absence of other distinguishable
holiday codes such as Hanukkah) and searched
for ingested objects between 1997 and 2015.20
Data Source and Study Population
The NEISS database catalogues ED visits in the United
States for injuries related to consumer products from
urban, suburban, and rural hospitals. Specifically, the
system functions as a stratified national probability sample
of greater than 100 hospitals, including 8 children’s
hospitals. This presents a stratified probability sample of
over 6000 hospitals in the country that boast ≥6 beds
provided in a 24-hour service model. All institutions
included in the database possess the basic capabilities to
treat children.
The NEISS can serve as a public health tool allowing
for correlative conclusions regarding product risks
association with populations to be drawn. Each participating
ED documents data daily into the NEISS, including
information regarding patient demographics,
consumer product codes, diagnosis, affected body
region, type of product involved, and disposition. The
NEISS provides a foundation for researchers to make
population-wide adjusted inferences on various injurious
trends and apply them to a national macrocentric
concept. Specifically, the NEISS facilitates logging of
injury types such as internal (for foreign body ingestions)
as well as coding for the object(s) that caused
injury, such as Christmas decorations.
Inclusion Criteria and Variable Classification
Subjects from 0 to 17 years old were included using a
primary search term for diagnosis of “ingested object”
during the time period of January 1, 1997, to January
1, 2016. A single Christmas year celebratory season
(celebratory season) included temporally linked days
from December to January of follow-on years (ie, the
days in December 2015 leading up to Christmas and
the period following New Year’s Day on January 1,
2016, were reported as Christmas year group 2015).
The inclusion criteria for this study was 3-fold: (1)
age (0-17 years); (2) the injury documented was
ingestion/internal; and (3) the suspected product
involved matched one of the following from the
NEISS coding manual20
: artificial Christmas trees
(1701); Christmas tree lights (1711); Christmas tree
stands or supports (1712); Christmas decorations,
nonelectric (1729); and Christmas decorations, electric
(excluding Christmas tree lights) (1736).
Statistical Analysis
NEISS-supplied strata, primary sampling unit, and
weight variables were used in all analyses with national
estimates and variance estimates as outlined in the
NEISS documentation.21
Taylor series linearization was
used to generate national estimates with 95% confidence
intervals (CIs). This procedure generates population
aggregate incidence rates while accounting for the effect
of sampling variability. Previously validated by Wolter
and Shah, this estimation method remains the gold standard
for approximating population values from complex
samples.22-25
Comparative analysis of the study population proceeded
initially with demographics and case descriptors
including age, race, sex, and ED dispositions.20
Race
was not available for analysis in 10% (N = 80) cases
queried. The analysis of age distributions and case
descriptors occurred using 3 subgroups, which represented
natural stratifications within the dataset: 0 to 2, 3
to 6, and 7 to 17 years to evaluate ingestion frequency by
age. Each subject’s disposition was classified by NEISS
coding as follows: “treated and released or examined
and released without treatment,” “treated and admitted
for hospitalization,” or “transferred to higher facility.”20
A trend analysis across the celebratory seasons was
performed using the Cochran Armitage test of trend.26
This allowed for an evaluation of winter holiday object
ingestion–related ED visit trends across Christmas celebratory
seasons. These analyses were performed using
NEISS national estimate data as the numerator and the
national age-specific population per year (supplied by
the US Census Bureau) as the denominator.27
Last, the
seasonality of CFBIs was tested using the X-12 procedure,
an adaptation of the US Census Bureau’s X-12
Seasonal Adjustment program.28
A combination of 3
F-tests of seasonality were used: the stable seasonality
test, moving seasonality test, and the Kruskal-Wallis test
for stable seasonality.29,30
Our team additionally focused
on two 7-week periods leading up to and after December
25 (November 12 to February 12) to analyze ingestions
frequencies documented as they related to the actual calendar
marked holiday.
A P value <.05 was considered statistically significant.
This study was reviewed and deemed exempt by
the Uniformed Services University of the Health
Sciences Institutional Review Board as subjects were
de-identified and the data are publicly available online.
Results
From 1997 to 2015, there were an estimated 22 224 children
(95% CI = 18 107-26 340) who presented to the
Reeves et al	 573
ED for CFBI, for approximately 1235 encounters per
year (generated from 821 ED visits catalogued into
NEISS; Table 1). Of those patients reported, children
aged 2 years and younger accounted for 84% of ingestions
(estimated N = 18 762; 95% CI = 15 207-22 317),
P < .001. The majority of CFBI occurred in males
(59.58%, 95% CI = 10 591-15 759) and among
Caucasians (56.09%, 95% CI = 8236-14 340). By comparison,
there were 1 127 112 (95% CI = 928 514-1 325
709) national estimated childhood ED visits for suspected
foreign body ingestions (total foreign body ingestions
[TFBI]) during 1997 to 2015 (estimates derived
from 43 809 reported ED visits for ingestions). Figure 1
demonstrates the incidence of suspected CFBI and TFBI
during the study period.
An increase in CFBI occurred in the 7-week block
surrounding Christmas, with peak ingestion rates for the
product codes of interest noted in the days prior to
Christmas (median = 13 days before or after Christmas;
interquartile range = 4-23 days; Figure 2). Although
there was an uptrend in TFBI during the study years (P
< .001), there was no significant change in TFBI during
the 7-week holiday block. Conversely, there was no
annual trend in CFBI ED visits during the study years
from 1997 to 2015 (Figure 1).
During the 7-week block before and after Christmas,
CFBI represented 12.6% of TFBI. When the CFBIrelated
ED visits were separated by month, a significant
seasonal trend was demonstrated (P < .001; Figure 3).
In contrast, the annual proportion of CFBI to TFBI
remained stable throughout the study period (minimum
1.2%, 2013; maximum 3.5%, 2001, encompassing all
ingestions from January to December of a single calendar
year; Figure 1). The most common type of CFBIs
were in the category of nonelectric Christmas decorations
(ie, ornaments, bells, candles, snow globes, and
others; Table 1). Approximately 85.2% TFBI are treated
and released from the ED annually, including 82.5%
TFBI treated and released during the 7-week Christmas
timeline. By comparison, CFBI demonstrated a lower
percent requiring escalation of care, with approximately
95.8% treated and released from the ED over the timeline.
Of 601 children, 2.7% (n = 27 subjects) required
escalation of care (ie, either hospital admission or
Table 1.  Pediatric Christmas Foreign Body Ingestion–Related ED Visits in the Unites States, 1997 to 2015a,b
.
Variable Actual Sample National Estimate 95% CI % of CFBI
Total 821 22 224 18 107-26 340  
Age, year
 0-2 683 18 762 15 207-22 317 84.4
 3-6 115 2752 1645-3859 12.4
 7-17 23 709 320-1099 3.2
Sex
 Male 468 13 175 10 591-15 759 59.3
 Female 353 9049 6686-11 412 40.7
Race
 White 406 11 288 8236-14 340 57.5
 Black 59 1081 660-1503 5.4
 Other 276 8029 5258-10 801 37.2
Location
 Home 646 17 879 17 808-26 639 80.5
 Disposition
Treated and released or examined and released without
treatment
780 21 279 16 935-25 624 95.8
Code, product
  1729, Christmas decoration (nonelectric) 549 14 096 11 314-16 878 66.9
  1711, Christmas tree lights 234 6979 5426-8531 28.5
  1736, Electric decorations (excluding Christmas tree lights 31 1003 468-1766 3.8
  1701, artificial Christmas trees 6 75 7-143 0.7
  1712, Christmas tree stands or supports 1 72 0-215 0.1
Total 821 22 224 18 107-26 340  
Abbreviations: CI, confidence interval; CFBI, Christmas foreign body ingestion.
a
The table depicts basic epidemiology for Christmas foreign body ingestions by children. % CFBI = (Christmas Foreign Body Ingestions of the
variable described/Total number of Christmas foreign body ingestions identified).
b
Ten percent (N = 80) cases did not include data regarding the subject’s race.
574	 Clinical Pediatrics 58(5)
transfer from the ED to another facility; 95% CI = 153-
1049) from 1997 to 2015.
Discussion
Our study is the first in the literature to describe multiple
types of holiday ingestions, in a multicenter setting, with a
specific focus on Christmas foreign bodies and trends of
ingestion. We found the presence of seasonality associated
with the frequency of CFBI concentrated in the months
leading up to and following Christmas compared with the
remainder of the year. In a more detailed review of the
time period around Christmas, we found an increase in
CFBI in the days leading up to Christmas, with peak ingestion
rates noted in the 13 days before or after Christmas.
Additionally, the data were consistent with similarly
designed studies that showed that younger children were
more likely to ingested foreign bodies, and in this instance,
CFBI.9,11,12
Finally, the study did not reveal any annual
trend of CFBI during the time period examined.
Figure 1.  Christmas foreign body ingestions (CFBIs) versus total foreign body ingestions (TFBI) by children, 1997 to 2015.
Frequencies of TFBI and CFBI by children, over the study years. While TFBI was demonstrated by Cochrane Armitage Trend
to have a significant uptrend (P < .001), CFBI did not demonstrate a significant trend.
Figure 2.  Christmas foreign body ingestions (CFBIs) by
children, seasonality histogram in weeks. Frequency of CFBI
during the holiday period across the study years, 1997 to
2015.
Figure 3.  Christmas foreign body ingestions (CFBIs) by
children, monthly seasonality plot. Seasonality plot showing a
significant increase in CFBI during the winter/holiday months
with maximum ingestion frequencies correlating with the
Christmas holiday.
Reeves et al	 575
Due to the large variety of Christmas object types,
CFBI can present medical teams with a multitude of
clinical quandaries. A presenting symptom for this
type of injury may be oropharyngeal mucosal bleeding
or nonspecific gastrointestinal bleed.31
Our investigation
showed that Christmas decorations
(nonelectric items with multiple subtypes including
ornaments, bells, candles, snow globes, etc) constituted
the largest percentage of suspected CFBI on a
national scale and present a risk for perforation or
impaction. This trend is consistent with Kimia’s single-center,
case-series description of ornament ingestion
in 81% (n = 35) of children.31
In addition to
electrically enhanced ornaments, Christmas tree
lights and other electrical decorations present the
unique risk of burn and tissue erosion when
ingested.32,33
This risk is compounded by the advent
of light emitting diodes and the use of button batteries
as a power source. Our study revealed that Christmas
tree lights (code 1711) or other electrical decorations
(code 1736) constituted 29.5% and 4.7% of the CFBI,
respectively. The description of bulb ingestions has
been limited previously to small case reports. The frequency
of this specific ingestion subtype has been
described by Kimia et al (18%, n = 8), Norberg and
Reyes (100%, n = 1), and Trout and Towbin (50%, n
= 3), with each investigation having documented at
least one patient requiring surgical intervention.31,34,35
Last, Maas et al described the risk for lead toxicity in
patients following extended contact with, or ingestion
of, older artificial Christmas trees secondary to the
breakdown of lead-based structural stabilizers contained
within the polyvinyl chloride branches.36
This
investigation demonstrated that approximately 1% of
CFBI is attributed to the ingestion of artificial trees in
the days following Christmas (possibly linked to the
decoration takedown phase). Given to the Center for
Disease Control and Prevention’s goal for children to
have an undetectable serum lead level, the use of
older artificial trees as decorations in the home may
warrant caution.37
While our study cannot report on management strategies
employed using NEISS data, the available literature
indicates that escalation of care beyond the emergency
room (ie, hospital admission or transfer) can occur in as
high as 5.2% of CFBI cases, and that the care of these
patients can be complex.31
Skilled radiologists employing
2-view chest radiograph, multidetector row computed
tomography, or providers using handheld metal
detectors each appears to play an emerging role in the
diagnosis and care of these patients.38,39
Our data
revealed that an estimated 2.7% (n = 601) of children
with CFBI required escalation of care. By comparison,
14.8% TFBI required escalation of care in our dataset.
Our team posits that the higher admission and transfer
rates for TFBI are likely related to the propensity for
children to swallow coins, small toys, jewelry, chicken/
fish bones, and other metallic objects (ie, magnets, button
batteries, and screws), which require more dedicated
observation and management.12,33
Although we have characterized both injury mechanisms
and injury trends, a step toward improving injury
prevention will be key to health maintenance in pediatric
patients. Previously, D’Ippolito and colleagues recommended
that future prevention efforts for holiday
injuries should focus on general complaints (musculoskeletal,
burn, and concussion).13
While we agree with
this foundational model, the data in our study support
the use of additional, targeted holiday-specific injury
prevention efforts. Anticipatory guidance during visits
with primary care providers in the weeks leading up to
Christmas may help prevent CFBIs. These could focus
on avoiding risk factors such as leaving young children
(age = 0-2 years) unattended around decorations of all
types during the holiday season. Potential educational
resources that may prove beneficial include the
American Academy of Pediatrics choking prevention
brochure and the Injury Prevention Program age-based
handouts.40,41
Finally, even though the Consumer
Product Safety Commission established a small parts
regulation for toys in 1980 and furthered regulation with
the Consumer Product Safety Improvement Act in 2008,
there does not yet exist a regulation to safeguard children
against the risks for small Christmas decoration
ingestion.42,43
Future advocacy efforts might focus on
improving social awareness, parental education, or even
federal oversight with regard to these possibly dangerous
decorations.
The NEISS database has several limitations, which
include data collection from EDs only. This potentially
underestimates rates of foreign body ingestion by children
who might otherwise present to primary care clinics,
urgent care facilities, were counseled (through their
caregiver) via telephone by Poison Control Centers, or
never sought care. All foreign body ingestions recorded
were “suspected,” and confirmed ingestions and management
strategies were not reported. In addition,
because the NEISS product codes specify Christmas
objects, we could not define Christmas versus other holiday
(eg, Hanukkah) versus other winter ornament or
decoration ingestions.
CFBIs are a documented reason for children to present
to the ED. It is reassuring that many of these children
are able to be evaluated and released. Children
younger than 2 years of age are at the highest risk for
ingestions. In the weeks leading up to Christmas, there
576	 Clinical Pediatrics 58(5)
is an increase in the number of Christmas decoration
ingestions. Medical professionals who care for children
need to be aware of CFBIs to provide effective, preventive
care and timely anticipatory guidance. By empowering
families with the knowledge of the risk for
decoration ingestion, the overall number of ingestions
may potentially be decreased and the risk or need for
invasive procedures mitigated.
Authors’ Note
This work was prepared as part of the official duties of Drs
Reeves, Pasman, and Nylund, who are employed by the
United States Army, Navy, and Air Force, respectively. The
views expressed in this article are those of the authors and do
not reflect the official policy or position of the United States
Army, Air Force, Department of Defense, or the United
States Government. Title 17 U.S.C. 105 provides that
“Copyright protection under this title is not available for any
work of the United States Government.” Title 17 U.S.C. 101
defines a United States Government work as a work prepared
by a military service member or employee of the United
States Government as part of that person’s official duties.
Author Contributions
PTR: Conceptualized the study, interpreted the data analysis,
drafted the manuscript, and approved the final manuscript.
JK: Acquired and organized the data, performed the data analysis,
and revised the manuscript.
EAP: Contributed to study design, developed the data analysis
plan, interpreted the data, and revised the manuscript.
CMN: Contributed to study design, oversaw the statistical
analysis, interpreted the data, revised the manuscript, and
served as subject matter expert and project manager.
All authors approved the final version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Patrick T. Reeves https://orcid.org/0000-0002-1217-9795
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