A retrospective cohort study on clinical features of foreign bodies in the gastrointestinal tract of children—emergency data from a pediatric regional medical center in eastern China

Introduction

Foreign bodies in the gastrointestinal tract are one of the common emergencies in pediatric emergency care, referring to various objects that cannot be digested and remain in the gastrointestinal tract without being promptly expelled. They are also one of the critical and urgent conditions frequently encountered in gastroenterology (1). Children account for 70–80% of all cases of gastrointestinal foreign body (GIFB) ingestion worldwide, these foreign bodies can lead to severe complications such as gastrointestinal mucosal ulcers, obstruction or perforation, peritonitis, sepsis, and even rupture of major blood vessels, resulting in the child’s death (2). The annual incidence of GIFB in children worldwide is approximately 12–16 cases per 100,000 children. According to a 2022 report by the American College of Emergency Physicians, there were 102,000 cases of GIFB in children under 14 years old, with a complication rate of 8.9%; the multi-center data from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) showed a complication rate of 11.4% (3). In China, single-center reports of pediatric GIFB complication rates range from 9% to 26%, with substantial variability attributed to regional clinical practice differences.

This paper presents a retrospective analysis of cases of GIFB treated in the emergency department of a children’s regional medical center in eastern China. It summarizes the characteristics of these cases and their complications, conducts a statistical analysis of the relevant risk factors, and aims to provide reference for clinical diagnosis and treatment. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0009/rc).

Methods

Study design

This study included case data from the Emergency Department of the Children’s Hospital of Zhejiang University School of Medicine from October 2021 to October 2024, with all data sourced from the hospital’s electronic medical record (EMR) system. Researchers retrospectively extracted data by grouping based on different characteristics such as the child’s age, gender, foreign body risk level (2,4), number of foreign bodies, location of foreign body retention, duration of foreign body retention, method of ingestion, presence of comorbidities, and whether complications occurred. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Medical Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine (No. 2025-IRB-0115-P-01) and individual consent for this analysis was waived due to the retrospective nature.

Setting

The study was conducted in the Emergency Department of Children’s Hospital, Zhejiang University School of Medicine, a tertiary pediatric referral center serving Hangzhou and surrounding regions in eastern China. The study period spanned from October 1, 2021, to October 31, 2024 (37 months). During this period, the Emergency Department maintained standardized protocols for suspected foreign body ingestion including immediate radiographic evaluation and pediatric gastroenterology consultation. Data for all eligible cases were retrospectively extracted from EMRs, with all patients followed until foreign body resolution and hospital discharge as documented in clinical records.

Participants

Eligibility criteria

We included all children aged 0–18 years presenting to the emergency department with confirmed GIFB ingestion supported by clinical history and objective evidence [X-ray, computed tomography (CT), or endoscopic confirmation]. All cases were admitted through the emergency department with documented ingestion history.

Exclusion criteria

We excluded: (I) children with incomplete clinical data precluding analysis; (II) respiratory tract foreign bodies; (III) unconfirmed ingestion cases; and (IV) patients leaving against medical advice (LAMA) before treatment completion.

Participant selection

We identified potential cases from the EMR system using ICD-10 codes T18.0-T18.9 and emergency admission logs. Two researchers (Y.H., J.L.) independently screened records for eligibility. Of 798 initially identified cases, 72 were excluded: 40 due to incomplete data, 18 respiratory foreign bodies, 9 unconfirmed cases, and 5 patients with LAMA, leaving 726 participants for analysis.

Variables

Outcomes

The primary outcome was complication occurrence, defined as any of: gastrointestinal ulceration, perforation, esophagitis, gastritis, bleeding, obstruction, or mediastinitis during hospital stay, diagnosed by clinical findings, endoscopy, or radiography. Secondary outcomes included surgical intervention requirement and hospital length of stay.

Exposures

• Age: categorized as <4 vs. ≥4 years based on clinical significance and previous literature (5-7).
• Foreign body type: classified by risk level—low (coins, smooth plastic, rubber), medium (single magnetic bead, smooth plastic blocks), or high (button batteries, multiple magnets ≥2, sharp metal) per national guidelines (8,9).
• Number: single vs. multiple (≥2) foreign bodies.
• Retention location: upper esophagus vs. other gastrointestinal sites.
• Retention time: time from reported ingestion to removal/expulsion, dichotomized at 24 hours (≤24 h =0, >24 h =1) based on clinical guidelines (8,9).
• Ingestion method: accidental vs. intentional (deliberate ingestion reported by child/caregiver).
• Mental disorder comorbidity: documented psychiatric diagnoses [e.g., trichophagia, developmental disorders, autism spectrum disorder (ASD), intellectual disability (ID)].

Potential confounders

Age, gender, foreign body type, number, retention location, retention time, ingestion method, and mental disorder comorbidity were considered based on literature review.

Effect modifiers

We examined potential effect modification by age group on the association between high-risk foreign bodies and complications.

Data sources and measurement

Data were extracted from the hospital’s Epic EMR system, which includes clinical documentation, imaging reports, endoscopy records, and discharge summaries. Two researchers independently extracted data using standardized forms, with discrepancies resolved by senior author (Y.Z.) discussion. For quality assurance, 10% of records were randomly selected for cross-checking against original medical records, showing >95% agreement.

• Demographics: age, gender, admission date from admission records.
• Clinical presentation: symptoms and ingestion time from emergency notes.
• Imaging: foreign body location, number, type from radiology reports.
• Endoscopy: removal method, mucosal findings from endoscopy reports.
• Outcomes: complications, interventions from progress notes and discharge summaries.
• Mental health: documented psychiatric diagnoses from medical history.

Bias

We identified and addressed several potential biases:

• Selection bias: we minimized selection bias by including all consecutive eligible cases. However, as a tertiary referral center, we may have preferentially included more severe cases, potentially overestimating complication rates compared to primary care settings. This is discussed as a limitation;
• Information bias: to reduce misclassification, we used objective imaging and endoscopic findings rather than relying solely on history. For retention time, we used the earliest reported ingestion time, acknowledging potential caregiver recall bias. Ten percent of imaging studies were independently reviewed by a pediatric radiologist blinded to outcomes to assess diagnostic accuracy;
• Detection bias: all patients received standardized imaging protocols, minimizing differential detection. However, patients with more severe symptoms may have received more intensive monitoring, potentially increasing complication detection in high-risk groups. It should be noted that this study has a significant detection bias: the high endoscopy rate (72.3%) led to a higher diagnosis rate of complications such as esophagitis and gastritis (only diagnosable via endoscopy), while the conservative group could not be diagnosed with these complications, resulting in an overestimation of the overall complication rate (20.9%). In addition, as a tertiary pediatric referral center, our study included more severe cases, which is another reason why the complication rate is higher than that of Western studies (10–15%);
• Confounding: we addressed potential confounding through multivariate logistic regression adjustment for all a priori identified confounders.

Study size

The study size was determined by the available cases during the 37-month study period. Based on previous annual volumes of approximately 250 foreign body ingestions per year, we anticipated 750–800 cases. A post-hoc power calculation with 726 participants (152 with complications, 574 without) indicated >80% power to detect an odds ratio (OR) of 1.5 for common exposures (prevalence >20%) at α=0.05.

Quantitative variables

Age was categorized as <4 vs. ≥4 years based on established clinical relevance. Retention time was dichotomized at 24 hours per clinical guidelines. In sensitivity analyses, we also examined retention time as continuous (log-transformed) and using alternative cutoffs (12, 24, 48 hours).

Statistical methods

Primary analysis

Using SPSS 26.0, we compared categorical variables by χ² test or Fisher’s exact test and continuous variables by t-tests. Multivariate logistic regression identified independent risk factors for complications, adding an interaction term between age group (<4/≥4 years) and ingestion method (accidental/intentional) to the multivariate logistic regression model to account for clinically inseparable factors, and tested the significance of the interaction term with likelihood ratio test, adjusting for all potential confounders. We reported OR with 95% confidence intervals (CI). Two-tailed P<0.05 was considered significant.

Missing data

Missing data were minimal (<5% for all variables). We performed complete case analysis and conducted sensitivity analyses using multiple imputation by chained equations (MICE) with 10 datasets to assess robustness.

Subgroup analyses

We performed stratified analyses by age group (<4 vs. ≥4 years) and tested for interactions between age and each risk factor.

Sensitivity analyses

We conducted four sensitivity analyses: (I) excluding children with mental disorders; (II) using different retention time cutoffs (12, 24, 48 hours); (III) restricting to high-risk foreign bodies only; and (IV) using propensity score matching to balance covariates.

Results

Participants

During the study period, we identified 798 children with suspected GIFB. After applying inclusion and exclusion criteria, 726 children were included (Figure 1). Exclusions were: 45 incomplete data, 18 respiratory foreign bodies, and 9 unconfirmed cases. All 726 included participants were followed until foreign body resolution and discharge.

Figure 1 Flow diagram of participant selection.

General clinical data of patients and univariate analysis

This study included a total of 726 pediatric patients with GIFB admitted to the Emergency Department of the Children’s Hospital Affiliated to Zhejiang University School of Medicine from October 2021 to October 2024. In terms of gender distribution, there were 428 male cases (59.00%) and 298 female cases (41.00%). Regarding age distribution: 397 cases (54.70%) were children under 4 years old, and 329 cases (45.30%) were children aged 4 years or older. Among 726 cases, most patients recovered well after treatment, while 152 cases (20.9%) developed complications. Specifically, 68 cases (44.7% of the complications) presented with gastrointestinal ulcers, commonly occurring at sites where foreign bodies were retained; 28 cases (18.4%) experienced perforation, and 56 cases (36.9%) had esophagitis/gastritis. No deaths were observed in this cohort. The clinical characteristics of complicated pediatric GIFB cases are shown in Table 1.

Types of foreign bodies (classified by risk level)

Low-risk foreign bodies numbered 450 cases (62.00%), the highest proportion, with common types including coins, smooth plastic beads, and rubber products without sharp edges; medium-risk foreign bodies totaled 152 cases (21.00%), such as single magnetic beads and smooth plastic blocks; high-risk foreign bodies were 124 cases (17.00%), mainly including button batteries 114 cases, multiple magnetic beads 7 cases, and sharp metal foreign bodies (such as sewing needles) one case.

Stagnation sites

Among 296 cases (40.80%), foreign bodies were retained in the upper esophagus; the remaining 430 cases (59.20%) were retained in other digestive tract regions outside the esophagus (including the stomach, small intestine, large intestine, etc.). The primary retention site was non-esophageal regions, with the upper esophagus being the most common site of retention within the esophagus. Among all the children, 664 cases (91.50%) had the foreign body removed or naturally expelled from the body within 24 hours of its entry; 62 cases (8.50%) had a retention time exceeding 24 hours, with an average retention time of (14.2±9.6) hours.

Route of intake

Accidental ingestion accounted for 667 cases (91.90%); intentional swallowing accounted for 59 cases (8.13%), mainly among older children, with some related to abnormal mental and behavioral conditions. Among these, 80 cases (11.02%) had comorbid mental disorders. The probability of GIFB complications in children with comorbid mental disorders was 37.50% (30/80), significantly higher than that in children without comorbid mental disorders at 18.89% (122/646).

Treatment methods

Endoscopic removal of foreign bodies via esophagogastroduodenoscopy (EGD) was performed in 525 cases (72.30%), serving as the primary intervention; 192 cases (26.40%) expelled foreign bodies naturally through the intestines after conservative treatment, mostly involving low-risk, small-sized foreign bodies; only 9 cases (1.30%) required surgical intervention due to severe foreign body impaction or combined perforation.

The results of univariate analysis showed that there was no statistically significant difference between the group without complications and the group with complications in terms of gender, type of foreign body, number of foreign bodies, and removal method (all P values >0.05). However, age (P=0.009), location of foreign body retention (P<0.001), retention time (P<0.001), ingestion method (P=0.006), and whether combined with mental disorders (P=0.006) were influencing factors for the occurrence of complications in children with digestive tract foreign bodies, as shown in Table 2.

Multifactorial logistic regression analysis of complications from foreign bodies in the gastrointestinal tract

Taking the occurrence or non-occurrence of complications as the dependent variable (no =0, yes =1), and age (≥4 years =0, <4 years =1), gender (male =0, female =1), foreign body type (low-risk =0, moderate-risk =1, high-risk =2), number of foreign bodies (single =0, multiple =1), retention location (other sites =0, upper esophagus =1), retention time (≤24 h =0, >24 h =1), ingestion method (accidental ingestion =0, intentional swallowing =1), and whether combined with mental disorders (no =0, yes =1) as independent variables, a multiple logistic regression model was used to analyze and screen for factors related to complications from GIFB. A P value <0.05 indicated statistically significant differences, with a two-tailed test and significance level α=0.05.

The results of multivariate logistic regression analysis for risk factors of complications are presented in Table 3. The results of multivariate analysis showed that age (P=0.009, OR =1.77, 95% CI: 1.156–2.710), retention time of foreign body (>24 h) (P<0.001, OR =4.560, 95% CI: 2.38–8.720), location of foreign body retention (P<0.001, OR =3.613, 95% CI: 2.319–5.629), way of foreign body entry (P=0.006, OR =3.450, 95% CI: 1.290–9.230), and comorbidities of mental disorder (P=0.006, OR =3.780, 95% CI: 1.450–9.860) and the interaction between age <4 years and intentional swallowing (P=0.01, OR =2.438) were risk factors for complications.

Discussion

Foreign bodies in the gastrointestinal tract can occur at various age stages of childhood, most commonly during the toddler and preschool periods. The results of this study show that the proportion of male patients (59.00%) is significantly higher than that of female patients (41.00%). Children under the age of 4 years account for more than half (54.7%), indicating that infants and young children under 4 years old are a high-risk group for GIFB. This finding is basically consistent with the results reported in domestic and international literature (10-14). The results of the multivariate logistic regression analysis showed that age (P=0.009, OR =1.770, 95% CI: 1.156–2.710) and way of foreign body entry (P=0.006, OR =3.450, 95% CI: 1.290–9.230) were high-risk factors for complications, similar to the results of previous studies (5,15). The cause is often accidental ingestion. Children are very curious, especially younger children who often try to experience new things with their mouths, which leads to the occurrence of accidental swallowing of foreign objects. Moreover, as society and the economy continue to develop, children’s toys keep evolving, introducing items like LEGO sets, super-absorbent gel beads, and electronic products containing button batteries. These innovations have significantly increased the incidence of foreign body ingestion in the digestive tract. Numerous previous surveys have called on parents to keep button batteries and products containing accessible button batteries (such as remote controls) away from young children, or to secure the battery compartments. Some countries impose certain restrictions on the use of magnets in toys; for example, magnetic toys sold in the United Kingdom should bear warnings, and they are even banned in New Zealand (6). Therefore, it is necessary to strengthen education for children and family supervision to prevent foreign body ingestion. It is recommended to establish family education programs to enhance the promotion of knowledge related to foreign bodies, adopting a combination of online and offline methods to improve parents’ and children’s awareness of prevention against foreign bodies.

In this study, the majority of GIFB were retrieved via endoscopy (72.3%), a smaller portion passed naturally through the intestines (26.4%), and only a tiny minority required surgical intervention (1.3%). This result is inconsistent with findings reported in domestic and international literature. In Western countries, most GIFB pass naturally through the intestines, with 10–20% requiring endoscopic treatment, and only 1% of patients needing surgery (5,6,14). Most domestic literature reports that approximately 80% of foreign bodies in children’s gastrointestinal tracts pass through the intestines and are naturally expelled (7-9,16), but there are also reports indicating that endoscopic removal accounts for the highest proportion of GIFB (13,17). The results of the multivariate logistic regression analysis showed that retention time (P<0.001, OR =4.560, 95% CI: 2.38–8.720) and location of foreign body (P<0.001, OR =3.613, 95% CI: 2.319–5.629) are high-risk factors for complications, which are basically consistent with the results reported in domestic and foreign literature (18,19). Due to the presence of anatomical narrow regions within the gastrointestinal tract, such as the three constrictions of the esophagus, the pylorus, the Treitz ligament, the ileocecal valve, and the rectosigmoid junction, coupled with the naturally smaller lumen of children’s digestive tracts, foreign bodies are prone to become lodged. Additionally, some children with congenital gastrointestinal malformations—such as esophageal stenosis, esophageal atresia, swallowing disorders, and achalasia—or those with a history of abdominal surgery are also susceptible to foreign body retention due to the unique conditions of their digestive systems (1). As the retention time of foreign bodies increases, they exert persistent pressure on the local gastrointestinal mucosa, leading to tissue necrosis and thereby increasing the risk of infection. When a foreign body is lodged in the esophagus, especially at the entrance of the esophagus—the first narrow region of the esophagus—where the area is closely connected to surrounding tissues, the foreign body easily compresses the mucosa, causing ischemic necrosis. This compression may even trigger esophageal perforation, a severe complication that requires immediate treatment. In conjunction with clinical practice, as laryngoscopy, gastroscope, and colonoscopy technologies have become more widespread, and to prevent serious complications, most doctors and patients’ families tend to choose endoscopic removal of foreign bodies. Therefore, considering patient safety, timely diagnosis and prompt medical intervention to remove foreign bodies in a timely manner holds great significance for reducing the occurrence of complications, particularly severe ones.

Unlike adults, where foreign bodies primarily include fish bones, chicken bones, and duck bones, children are more likely to ingest objects such as coins, button batteries, magnetic beads and magnets, fruit pits, hair, sewing needles, screws, and date seeds. The risks posed by each type of foreign body are distinctly different (20). The results of this study show that coins are the most common foreign bodies, accounting for 63.2% (459 out of 726) of all cases. However, only 2 cases presented with ulcers, and 5 cases with esophagitis or gastritis, making them the lowest in terms of complications among various types of foreign bodies. In this study, 114 cases involved button batteries (15.7%), with 3 cases of perforation, 34 cases of ulcers, and 21 cases of esophagitis/gastritis (complication rate: 51.7%), which was significantly higher than the overall complication rate (20.9%). Consistent with existing guidelines, emergency endoscopic removal is recommended for button batteries retained in the esophagus, and close monitoring is required for those in the stomach/intestinal tract.

For high-risk foreign bodies (button batteries, multiple magnets ≥2), we strictly followed the ESPGHAN/NASPGHAN guidelines for removal timing: emergency endoscopy (within 2 hours) for button batteries in the esophagus, and endoscopy within 6 hours for multiple magnets in any gastrointestinal location (21). In our study, 98.2% (122/124) of high-risk foreign bodies were removed within the guideline-recommended time, with a severe complication rate (perforation/mediastinitis) of 4.8%, which was lower than the international reported rate (10–15%), indicating that timely intervention in accordance with guidelines can effectively reduce severe complications. However, in a 2024 survey on pediatric endoscopy training initiated by 58 medical centers across 12 countries by APSPGHAN, it was found that: only 36% of the study programs employed competency-based outcomes for program development, whereas nearly half (48%) used volume-based curricula, the direct observation of procedural skills was the most commonly used assessment method (22). High-risk foreign bodies in children not only require primary physicians to have precise identification and risk assessment capabilities, but also pose higher challenges to the skills of operators performing foreign body removal. Therefore, it is recommended to enhance standardized training for foreign body removal procedures via gastric endoscopy in pediatric regional centers to cultivate medical talents who can better handle clinical situations.

Magnetic digestive foreign bodies also belong to high-risk foreign bodies. When they adhere to each other at different sites within the gastrointestinal tract, the perforation rate can be as high as 50% to 75% (23). A national survey showed that ingestion of multiple magnetic foreign bodies requires more invasive treatment than ingestion of a single one (24). In this survey, there were 78 cases of magnetic bead foreign bodies, among them, 7 cases had multiple magnetic beads (≥2 beads) (all classified as high-risk foreign bodies), and 71 cases had a single magnetic bead (classified as medium-risk foreign body). Among the 7 cases with multiple magnetic beads, 2 cases had perforation, 3 cases had ulcers, and 2 cases had esophagitis/gastritis. The complication rate reached 100%, which was significantly higher than 5.6% (4/71) in the cases with a single magnetic bead. This further confirmed the high-risk characteristic that multiple magnetic foreign bodies easily cause digestive tract damage due to their mutual adhesion. The “Expert Consensus on Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract of China” suggests that multiple magnetic foreign bodies should undergo emergency endoscopy, and even a single magnetic foreign body should be removed via elective endoscopy (25,26). Multiple studies have shown that after accidental ingestion of magnetic foreign bodies, most children initially present with mild or no clinical symptoms for the first few hours or weeks, followed by the gradual onset of persistent or intermittent abdominal pain, nausea, vomiting, and other symptoms (27-29). Therefore, timely diagnosis and effective management of ingestion of multiple magnetic foreign bodies or a single magnetic foreign body along with a metallic foreign body are crucial for reducing the occurrence of complications.

In addition, comorbid mental disorders were identified as a high-risk factor for complications from GIFB in the results (P=0.006, OR =3.780, 95% CI: 1.450–9.860). In this study, there were 35 older children (over 12 years old), and the primary cause of GIFB in this group was intentional swallowing. Among them, one case involved a female child with repeated ingestion of hair, a behavior often associated with the psychiatric condition trichophagia. Literature reviews indicate that trichophagia occurs predominantly in females, and without psychological intervention, it is prone to recurrence (30). Follow-up on children with GIFB revealed that a significant proportion had comorbid mental or psychological disorders, with some experiencing repeated hospitalizations. Therefore, for older children who intentionally swallow foreign bodies, after managing the GIFB, psychological counseling and treatment are also necessary. Parents and healthcare providers should prioritize psychological guidance to help these children address their mental health issues, as this is a key measure to prevent recurrent ingestion of foreign bodies.

Limitations

This study has several specific limitations related to regional clinical practice: (I) the endoscopy intervention rate (72.3%) in our center is significantly higher than that in Western studies (10–20%), which is attributed to three factors: high parental vigilance for pediatric GIFB in China, the characteristics of severe cases in tertiary referral centers, and domestic clinical guidelines advocating active endoscopic intervention to prevent severe complications; (II) as a single-center study in eastern China, the results may not be directly generalized to rural areas or other regions with different healthcare access; (III) the retrospective design may lead to potential recall bias of retention time by caregivers.

Interpretation

Our findings are biologically plausible. Younger children’s smaller gastrointestinal lumens and immature swallowing coordination increase risk. Upper esophageal retention poses greater danger due to anatomical narrowness. Prolonged retention causes progressive mucosal damage. Intentional swallowing and mental disorders likely reflect behavioral issues leading to delayed presentation. The higher complication rate compared to Western studies may reflect healthcare access disparities rather than true population differences. Caution is needed in extrapolating these risk estimates to primary care settings where milder cases predominate.

Generalisability

These results are generalizable to similar tertiary pediatric emergency settings in urban China and other middle-income countries with comparable healthcare systems and foreign body epidemiology. The regional high-risk early warning criterion for pediatric GIFB (age <4 years + upper esophagus retention + retention time >24 h) provides a practical clinical tool for emergency physicians. However, application to rural settings or countries with different foreign body types and healthcare access patterns requires validation. Our findings support region-specific prevention strategies and emergency protocols.

Conclusions

This study retrospectively analyzed 726 cases of foreign body digestion in children in our hospital from 2021 to 2024, aiming to explore their clinical characteristics, the occurrence of complications and related risk factors. By identifying high-risk groups and risk factors, it not only provides a reference for the early intervention of emergency doctors, but also is of great significance for the prevention and health education of children accidentally swallowing foreign objects. It reveals the common types of foreign bodies in the digestive tract among children and the occurrence of their complications, emphasizing the importance of paying attention to high-risk groups and timely treatment. The research results provide an important basis for future clinical practice and have practical application value for improving pediatric emergency rescue and preventive measures. Future research should continue to explore prevention and management strategies for foreign bodies in the digestive tract to reduce their impact on children’s health. Further research can provide a scientific basis for formulating more effective intervention measures and family guidance. At present, there are many retrospective studies on gastrointestinal foreign bodies in children abroad, but most of them are single-center or have limited sample sizes. The research results vary greatly among different regions. In China, especially in regions, large-scale systematic analyses of large samples are still relatively insufficient, and the clinical understanding of risk factors for complications is not yet unified. Therefore, summarizing large-scale case data is helpful to fill the research gap.

Acknowledgments

The authors thank the emergency department and endoscopy unit staff of Children’s Hospital, Zhejiang University School of Medicine for their assistance in data collection and patient care. We also acknowledge the contribution of the medical records department for facilitating access to electronic medical records.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0009/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0009/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0009/prf

Funding: This research work was supported by the National Natural Science Foundation of China (No. 82302486) and Zhejiang Provincial Natural Science Foundation of China (No. LBY22H180013).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0009/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Medical Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine (No. 2025-IRB-0115-P-01) and individual consent for this analysis was waived due to the retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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