Nasal foreign bodies are a common problem in children, most frequently occurring between the ages of 2 and 5 years, and their removal can be challenging.1,2
Children in this age group have a natural fear of the unknown, and providing care to them can be difficult, especially if previous attempts to remove the foreign body have been painful.
Potential complications, most notably the risk of aspiration of the foreign body, mean that objects should be removed from the nasal cavity in a timely fashion. Various techniques have been described: instrumental extraction (using a hook or nasal forceps), suction, balloon catheters,3
and various positive-pressure techniques, the simplest of which is to ask the child to blow his or her nose while occluding the unaffected nostril. However, this technique is only possible for older children.5
Alternatively, a bag valve mask can be applied over the child’s face, the bag then squeezed to apply a puff of air into the child’s mouth;6
a male–male tube adaptor can be attached to an oxygen or air outlet via oxygen tubing placed in the unaffected nostril;7
or the “mother’s kiss” or “parent’s kiss” technique can be used.
The mother’s kiss was first described in 1965 by Vladimir Ctibor, a general practitioner from New Jersey.8
The mother, or other trusted adult, places her mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation. While occluding the unaffected nostril with a finger, the adult then blows until they feel the resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the unoccluded nostril and, if successful, results in the expulsion of the foreign body. The procedure is fully explained to the adult before starting, and the child is told that the parent will give him or her a “big kiss” so that minimal distress is caused to the child. The procedure can be repeated a number of times if not initially successful. A modified mother’s kiss technique has been described,9
which involves the adult blowing into a straw in the child’s mouth. We did not include this technique in our review.
Although the mother’s kiss technique has been sporadically mentioned in the literature in case reports and case series, it has yet to gain widespread acceptance. It is not a suitable intervention for evaluation using a randomized controlled trial, because there is no appropriate control group: nontreatment is unacceptable, and there is no gold standard for comparison.
Randomized controlled trials are considered to be the best trial design, but some treatments result in a dramatic effect that may not require randomized trials.10
The mother’s kiss technique falls into this category, because the foreign body will not usually move without intervention. Hence, case reports are sufficient to show that the technique sometimes works. However, a systematic review is needed to clarify how often it works and under what circumstances.
We sought to examine the existing evidence for the efficacy and safety of the mother’s kiss technique, to help clinicians understand this evidence and to confirm or refute the appropriateness of current practice.
Although systematic reviews of randomized controlled clinical trials are now common, it is rare to see a report of a systematic review of case reports or case series, and the methods for performing such a review are less clearly defined and tested. The principal elements of a systematic review are the location, appraisal and synthesis of individual studies; however, there are pitfalls to traditional systematic reviews of clinical trials that can introduce bias and inaccuracy in the results, which must be avoided. For this systematic review of case reports and case series, we were ever mindful of the rationale behind the stages in systematic reviews of clinical trials and endeavoured to apply the same principles to reduce bias and improve accuracy.