Disease burden of pulmonary aspiration and foreign body in airway in Asian children: a review based on Global Burden of Disease data and projections for 2035

Introduction

Pulmonary aspiration and foreign body (PAFB) is one of the most common pediatric emergencies. This condition exhibits a marked age-related distribution, with the highest incidence occurring in children under the age of five years. At this developmental stage, infants and young children are particularly vulnerable due to heightened curiosity, frequent exploratory behaviors, and immature swallowing mechanisms, making them prone to aspirating small objects into the airway (1). Among these, edible plant-based materials are the most frequently encountered obstructions, followed by components of toys made from plastic or metal. The severity of airway PAFB is determined by the size of the object, the site of obstruction, and the duration of the blockage. Partial obstructions may result in recurrent coughing or wheezing, whereas complete obstructions can rapidly lead to asphyxiation and even death (2,3). In addition, prolonged retention of a foreign body may cause secondary infections or long-term complications such as bronchiectasis and atelectasis in some children (4). Consequently, PAFB imposes a significant disease burden on pediatric health (5).

To date, most studies on pediatric PAFB have been limited to single-center, retrospective clinical analyses (6-9), primarily focusing on the types of foreign bodies, age distribution, treatment modalities, and clinical outcomes. While these studies offer valuable clinical insights, their limited representativeness constrains a comprehensive understanding of the epidemiological patterns and overall disease burden at the population level. Globally, the burden of this condition among children has been systematically evaluated using data from the Global Burden of Disease (GBD) study, which reveals an upward trend in global incidence (10). However, these evaluations largely focus on interregional comparisons, with minimal attention paid to intraregional disparities.

Asia, home to the world’s largest child population, may exhibit substantial variability in disease burden due to differences in socioeconomic development, access to preventive measures, and healthcare infrastructure. Despite this, population-based, large-scale national studies focusing on pediatric PAFB in Asia remain scarce. Moreover, most existing global assessments rely on GBD 2019 data (10,11) and lack forward-looking projections, limiting their practical relevance in disease prevention and health resource planning.

In response to these gaps, this study utilizes GBD 2021 data to systematically examine the epidemiological trends, sex- and age-specific distribution, and regional and national disparities in the burden of PAFB among children in Asia from 1990 to 2021. The study also investigates its association with the sociodemographic index (SDI). Furthermore, the Bayesian Age-Period-Cohort (BAPC) model is employed to forecast future trends in disease burden for four representative countries—China, Japan, South Korea, and India. By identifying high-risk populations and priority intervention areas, this study aims to enhance early recognition and emergency response capabilities, ultimately reducing the health losses associated with this preventable condition.

Methods

Data source

The data for this study were obtained from the GBD 2021 database, which comprehensively encompasses epidemiological models and health system assessments. GBD 2021 includes data on 371 diseases, 88 risk factors, and various injuries across 204 countries and territories, stratified by five levels of the SDI. The dataset utilized in this research is publicly available for download from the website (http://ghdx.healthdata.org/gbd-results-tool). As the data are freely accessible to researchers, this study did not require ethical approval or informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Retrieval method

The data collected for this study cover the period from 1990 to 2021 and include the following variables: incidence, mortality, and disability-adjusted life years (DALYs) counts and rates, stratified by age groups (0–14 years), sex, and disease type (PAFB). The data are further categorized by specific regions within Asia, including Central Asia, High-income Asia Pacific, South Asia, East Asia, Southeast Asia, and North Africa and the Middle East, as well as by individual Asian countries.

The SDI, developed by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, serves as a critical tool for assessing and comparing development levels across countries and regions. This composite index integrates income per capita, average educational attainment, and total fertility rate using a weighted average approach. The SDI is quantified on a scale from 0 to 1, with values closer to 1 indicating higher levels of development (12-14).

Statistical analysis

Statistical analyses and data visualizations were performed using R software (version 4.4.1). The burden of PAFB among children in Asia from 1990 to 2021 was analyzed. All estimates of disease burden were expressed as both absolute numbers and rates per 100,000 population, stratified by age group, region, and sex, along with their respective 95% uncertainty intervals (UIs).

Estimated annual percentage change (EAPC) was used to quantify temporal trends in the selected indicators. An EAPC with a 95% confidence interval (CI) entirely above 0 indicates an increasing trend; entirely below 0 indicates a decreasing trend; and a CI including 0 signifies a stable trend with no significant change over the observation period.

Spearman’s rank correlation test was employed to evaluate the linear relationship between the disease burden in Asia and the SDI. Additionally, a BAPC model was applied to forecast the disease burden and mortality rates of PAFB among children in four representative Asian countries—China, Japan, South Korea, and India—for the next 15 years. A P value of less than 0.05 was considered statistically significant.

Results

Incidence, mortality, and DALYs of PAFB in Asian children (Figures 1,2)

Figure 1 Epidemiological trends in the incidence, mortality, and DALYs of childhood PAFB by sex across various Asian regions from 1990 to 2021 (A-I). DALY, disability-adjusted life year; PAFB, pulmonary aspiration and foreign body.

Figure 2 Incidence, mortality, and DALYs associated with the burden of childhood PAFB across different age groups in Asian countries in 2021 (A-C). DALY, disability-adjusted life year; PAFB, pulmonary aspiration and foreign body.

Incidence

In 2021, the estimated number of new cases of PAFB in Asian children was 353,768.724 (95% UI: 252,893.892–490,669.030), corresponding to an incidence rate of 32.457 per 100,000 population (95% UI: 23.202–45.017). Of these, 176,947.696 cases were male (95% UI: 127,428.336–244,509.787) and 176,821.028 cases were female (95% UI: 125,455.877–246,330.069). The number of cases was similar between males and females, though the incidence rate for females (33.951 per 100,000 population) was slightly higher than for males (31.090 per 100,000 population) (Table 1).

From 1990 to 2021, the overall incidence in Asia significantly declined, from 72.021 per 100,000 population (95% UI: 51.076–101.163) to 32.457 per 100,000 population (95% UI: 23.202–45.017), with an EAPC of −2.59% (95% CI: −2.70% to −2.48%) (Figure 1A-1C). The trends for both males and females were similar, with annual percentage changes of −2.59% for males and −2.60% for females.

Age-stratified analysis showed the most significant decline in incidence for neonates under 28 days (EAPC: −3.67%; 95% CI: −3.88% to −3.47%), followed by infants aged 1 to 5 months (EAPC: −3.57%) (Figure 2A).

Mortality

In 2021, the estimated number of deaths due to PAFB in Asian children was 11,159.423 (95% UI: 7,382.655–13,811.106), corresponding to a mortality rate of 1.024 per 100,000 population (95% UI: 0.677–1.267). Of these, 6,003.808 deaths were male (95% UI: 3,058.609–7,712.527) and 5,155.615 deaths were female (95% UI: 3,391.838–6,312.529). The number of male deaths was slightly higher, but the mortality rates for males (1.055 per 100,000 population) and females (0.990 per 100,000 population) were similar (Table 1).

From 1990 to 2021, the overall mortality rate in Asia significantly declined, from 3.250 per 100,000 population (95% UI: 2.378–4.247) to 1.024 per 100,000 population (95% UI: 0.677–1.267), with an EAPC of −3.43% (95% CI: −3.51% to −3.34%). The trends in mortality decline were similar for both genders, with an EAPC of −3.43% for both males and females (Figure 1D-1F).

Age-stratified analysis showed the most significant decline in mortality for infants aged 6 to 11 months (EAPC: −4.32%; 95% CI: −4.47% to −4.17%), followed by children aged 2 to 4 years (EAPC: −4.68%) (Figure 2B).

DALYs

In 2021, the estimated DALY count due to PAFB in Asian children was 992,886.984 (95% UI: 659,445.896–1,225,857.909), corresponding to a DALY rate of 91.094 per 100,000 population (95% UI: 60.502–112.469). The male DALY count was 532,582.967 (95% UI: 273,069.352–682,628.024) and the female DALY count was 460,304.017 (95% UI: 303,638.594–562,748.703). The male DALY count was slightly higher, but the DALY rates for females (88.382 per 100,000 population) and males (93.577 per 100,000 population) were similar (Table 1, Figure 1G-1I).

From 1990 to 2021, the overall DALY rate in Asia significantly declined, from 289.943 per 100,000 population (95% UI: 212.455–377.671) to 91.094 per 100,000 population (95% UI: 60.502–112.469), with an EAPC of −3.44% (95% CI: −3.52% to −3.35%). The trends in DALY rate reduction were similar for both genders, with an EAPC of −3.43% for females and −3.44% for males.

Age-stratified analysis showed the most significant decline in DALY rate for children aged 2 to 4 years (EAPC: −4.66%), followed by infants aged 6 to 11 months (EAPC: −4.32%) (Figure 2C).

Regional disease burden of PAFB in Asian children

Incidence

In 2021, Central Asia had the highest incidence rate (134.723 per 100,000 population), while Southeast Asia had the lowest incidence rate (20.048 per 100,000 population). The region with the fastest decline in incidence was East Asia (EAPC: −4.69%) (Table 1).

Mortality

In 2021, Central Asia had the highest mortality rate (3.129 per 100,000 population), while the high-income Asia-Pacific region had the lowest mortality rate (0.640 per 100,000 population). The region with the fastest decline in mortality rate was the high-income Asia-Pacific region (EAPC: −4.07%) (Table 1).

DALYs

In 2021, Central Asia had the highest DALY rate (278.443 per 100,000 population), while South Asia had the lowest DALY rate (44.736 per 100,000 population). The region with the fastest decline in DALY rate was the high-income Asia-Pacific region (EAPC: −4.07%) (Table 1).

Epidemiological characteristics of PAFB in Asian countries

Incidence

In 2021, significant variation in incidence rates of PAFB was observed across Asian countries. India reported the highest number of cases (125,922.044; 95% UI: 87,661.908–181,570.047), while Georgia had the highest incidence rate (163.453 per 100,000 population; 95% UI: 114.249–222.998), and Indonesia had the lowest incidence rate (16.297 per 100,000 population; 95% UI: 10.816–24.279). China experienced the fastest decline in incidence from 1990 to 2021 (EAPC: −4.74%; 95% CI: −5.66% to −3.81%) (Figure 3A, Table S1).

Figure 3 Incidence, mortality, and DALYs associated with the burden of childhood PAFB in Asian countries in 2021 (A-C). DALY, disability-adjusted life year; PAFB, pulmonary aspiration and foreign body.

Mortality

In 2021, there was considerable variation in mortality rates due to PAFB across Asian countries. China had the highest number of deaths (4,351.224; 95% UI: 2,872.942–5,545.187), while Mongolia had the highest mortality rate (4.467 per 100,000 population; 95% UI: 2.807–6.226), and Bangladesh had the lowest mortality rate (0.006 per 100,000 population; 95% UI: 0.004–0.010). Saudi Arabia experienced the fastest decline in mortality rate from 1990 to 2021 (EAPC: −6.14%; 95% CI: −6.22% to −6.07%) (Figure 3B, Table S2).

DALYs

In 2021, significant differences in DALY rates due to PAFB were observed across Asian countries. China had the highest DALY count (385,589.421; 95% UI: 255,342.267–491,041.728), while Mongolia had the highest DALY rate (396.978 per 100,000 population; 95% UI: 250.298–553.977), and Bangladesh had the lowest DALY rate (1.194 per 100,000 population; 95% UI: 0.887–1.581). Saudi Arabia experienced the fastest decline in DALY rate from 1990 to 2021 (EAPC: −6.19%; 95% CI: −6.27% to −6.11%) (Figure 3C, Table S3).

Correlation between disease burden and SDI

Spearman’s rank correlation analysis was conducted to explore the relationship between the incidence, mortality, and DALYs of PAFB in Asian countries and regions with SDI (Figure 4A-4F).

Figure 4 Relationship between the SDI and the burden of PAFB in Asian countries (A,C,E) and regions (B,D,F) in 2021. PAFB, pulmonary aspiration and foreign body; SDI, sociodemographic index.

For incidence, a significant positive correlation was found between SDI and incidence across Asian countries. The Spearman correlation coefficient was 0.2754, indicating that countries with higher SDI values tend to have lower incidence rates of PAFB.

For mortality, a significant negative correlation was found between SDI and mortality across Asian countries. The Spearman correlation coefficient was −0.2985, suggesting that countries with higher SDI values tend to have lower mortality rates.

For DALYs, a significant negative correlation was observed between SDI and DALYs across Asian countries. The Spearman correlation coefficient was −0.3010, indicating that countries with higher SDI values tend to experience lower DALYs from PAFB.

Forecasting disease burden of PAFB in children of China, Japan, South Korea, and India [2022–2035]

This study utilized the BAPC model to forecast the incidence and mortality rates of PAFB in children in China, Japan, South Korea, and India. Overall, the BAPC model predicts that from 2020 to 2035, both incidence and mortality rates in these countries will continue to decline.

Incidence forecast (Figure 5A)

Figure 5 Projections of the burden of PAFB in children in China, Japan, Korea, and India to 2035. (A) Incidence rate projections for China, Japan, Korea, and India. (B) Mortality rate projections for China, Japan, Korea, and India. PAFB, pulmonary aspiration and foreign body.

• China: it is predicted that by 2035, the incidence will significantly decrease, expected to reach 15.77781 per 100,000 population.
• Japan: Japan’s incidence is expected to decline to 37.47851 per 100,000 population by 2035.
• South Korea: South Korea’s incidence is expected to decline further, approaching 32.99914 per 100,000 population by 2035.
• India: India’s incidence is expected to decline, but it will remain relatively high at 50.5898387 per 100,000 population by 2035.

Mortality forecast (Figure 5B)

• China: it is predicted that by 2035, the mortality rate will significantly decrease to 0.5475445 per 100,000 population.
• Japan: Japan’s mortality rate is expected to decline further, approaching 0.4325384 per 100,000 population by 2035.
• South Korea: South Korea’s mortality rate is expected to reach 0.3304893 per 100,000 population by 2035.
• India: India’s mortality rate, though declining, is predicted to remain at 0.5898387 per 100,000 population by 2035.

Discussion

This study, based on data from the GBD 2021, primarily evaluated the trends in disease burden attributable to PAFB among children in Asia from 1990 to 2021, by analyzing incidence, mortality, and DALYs, along with EAPC. Additionally, Spearman’s rank correlation was employed to assess the relationship between PAFB burden and SDI. The BAPC model was further applied to project the future burden of PAFB over the next 15 years in China, Japan, South Korea, and India.

The results demonstrated a marked decline in the incidence, mortality, and DALYs associated with PAFB among children in Asia since 1990. However, considerable heterogeneity was observed across countries and regions. The findings of this study are expected to provide a valuable epidemiological foundation for the prevention and control of PAFB among children in Asia. Unlike many other infectious diseases (15-18), PAFB does not show a clear negative correlation between socioeconomic development and disease incidence. For example, a global study on the burden of PAFB (10) found that several European countries, such as Italy, the Netherlands, and Iceland, have some of the highest incidence rates worldwide. In contrast, many Asian countries, although reporting lower incidence rates than Western nations, experience higher mortality rates and DALY burdens. Most European countries record DALYs below 200 per 100,000 population. In 2021, approximately 354,000 PAFB cases were reported in Asia, resulting in around 11,200 deaths and nearly one million DALYs. This indicates that PAFB remains a significant public health concern affecting children’s health in the region. In terms of regional distribution, Central Asia bears the heaviest burden, with the highest incidence, mortality, and DALY rates. Southeast Asia and high-income Asia Pacific regions have the lowest burden. In populous countries such as India, Bangladesh, and China, the overall incidence and mortality rates are relatively low, but the absolute number of cases remains high due to large population sizes.

Since PAFB is often caused by the aspiration of hard food items such as peanuts, seeds, and legumes, prevention efforts should focus on educating caregivers to avoid exposing infants and young children to these high-risk foods. Furthermore, when PAFB results in complete airway obstruction, it can be rapidly fatal. This underscores the importance of promoting emergency response training and awareness, including techniques such as the Heimlich maneuver (19). These regional disparities suggest that policy interventions should focus more on countries and regions with limited resources and weak public health education systems, particularly in Central Asia. Age is a critical factor influencing the burden of PAFB. It is well established that children under the age of five are at highest risk for this condition (20), as their swallowing coordination is not yet fully developed and their natural curiosity increases exposure to potential hazards. From a developmental perspective, the high vulnerability of children under three years of age can be partially attributed to incomplete primary dentition; infants and young children lack the mature occlusal contact of deciduous molars required to pulverize hard foods such as seeds and nuts (21). However, few studies have examined the incidence and mortality rates across more specific age subgroups. As shown in Figure 2, this study identified children aged 0–4 years, particularly infants aged 6–11 months and aged 1–2 years, as the most affected groups. Notably, the highest mortality and DALY burdens were concentrated among infants under one year of age. However, it is critical to distinguish between different age windows within the first year of life, as the causes of aspiration differ fundamentally between neonates and older infants. For infants aged 6–11 months and 1–2 years, solid foreign body aspiration predominates, driven by the introduction of complementary foods. In contrast, for neonates (<28 days) and young infants (1–5 months), aspiration predominantly involves liquids or semi-liquids, due to factors such as immature swallowing coordination, gastroesophageal reflux, congenital anomalies, neurological immaturity, or iatrogenic causes (21,22). Furthermore, a suggestive clinical history of choking is present in the vast majority of confirmed cases, reinforcing the principle that a strong history should override normal imaging findings and justify prompt bronchoscopic intervention (21). Therefore, targeted interventions for this high-risk age group, including enhanced parental education, improved caregiving practices, and stricter toy safety standards, are essential strategies to reduce the disease burden associated with PAFB.

At the national level, this study further identified a significant negative correlation between the SDI and the burden of disease, indicating that countries with higher levels of development tend to exhibit lower mortality rates and DALYs associated with PAFB. However, it is noteworthy that at the regional level, the correlation between SDI and disease burden in Asia appears to be weak. As previously mentioned, Western Europe, which possesses the highest overall SDI, paradoxically reports the highest incidence of PAFB (10). The relatively low disease burden in high-SDI Asian countries may be more closely linked to their well-established pediatric emergency care systems and the widespread dissemination of health education. This finding suggested that beyond improving SDI at the national level, establishing a comprehensive emergency service system across society and enhancing public health education regarding the risks of foreign body aspiration in infants may be critical strategies for reducing the burden of PAFB.

Using the BAPC model for predictive analysis, the study further projected that the incidence and mortality rates of PAFB in representative Asian countries such as China, Japan, South Korea, and India are expected to continue declining by 2035. Among these countries, China is projected to experience the most significant reduction. In contrast, although India also demonstrates a downward trend, its projected incidence (50.59 per 100,000) and mortality (0.59 per 100,000) remain relatively high, underscoring the need for strengthened and systematic preventive measures in populous developing nations such as India.

Our findings offer several actionable insights. First, age-targeted prevention is critical: for infants under 6 months, focus on feeding safety; for children aged 6 months to 4 years, avoid high-risk solid foods and enforce toy safety standards. Second, we recommend integrating Heimlich maneuver training into parental education, especially in high-burden regions like Central Asia. Third, countries with high mortality should prioritize pediatric bronchoscopy services and emergency airway teams. Fourth, populous but data-poor countries need prospective registries to validate GBD estimates and guide resource allocation.

Despite relying on the GBD database, a widely recognized and comprehensive global data source, this study is not without limitations. First, the GBD estimation model partially relies on indirect data; for some countries with limited capacity for data collection and management, the resulting estimates may be subject to issues of data quality and representativeness. Second, the GBD database does not differentiate between types of foreign bodies, nor does it capture specific risk factors associated with the condition, thereby limiting in-depth analysis of pathogenesis and high-risk populations. Furthermore, the predictive outcomes of the model may be influenced by national policy changes and unforeseen public health events, warranting cautious interpretation of its forward-looking projections.

Conclusions

Over the past three decades, the burden of pediatric PAFB in Asia has significantly declined, though regional disparities persist, with Central Asia remaining the most affected. The strong inverse relationship between the SDI and PAFB burden underscores the importance of socioeconomic development, public health education, and emergency response systems. Projections based on the BAPC model suggest continued improvements in disease burden across the Asia-Pacific region in the coming years.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0166/prf

Funding: This work was supported by the Joint project of Yunnan Science and Technology Department Kunming Medical University (No. 202101AY070001-217); Kunming Health Science and Technology Personnel Training Project [No. 2020 (Province)-21]; Yunnan Key Specialty of Pediatric Infection (Training and Education Program/Kunming Key Specialty of Pediatric Infection); Key Science and Technology Program of Yunnan Province (No. 202102AA100019); and Medical Science and Technology Leading Talent (Top-ten Program) [No. 2025-SW (Leading)-03].

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0166/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

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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