ARTICLE Pediatric “Body Packing” Stephen J. Traub, MD; Gary L. Kohn, MD; Robert S. Hoffman, MD; Lewis S. Nelson, MD Background: Recent events in the United States have with a naloxone infusion and aggressive gastrointesti- led to increased security at national borders, resulting in nal decontamination. He ultimately passed 53 packets an unexpected increase in drug seizures. In response, drug of heroin, one of which had ruptured. He recovered un- smugglers may begin using children as couriers, includ- eventfully. Patient 2, a 12-year-old boy, presented to ing using them as “body packers.” the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, Objective: To look at the occurrence of body packing, and he confessed to body packing heroin. He was the concealing of contraband within the human body, treated with whole-bowel irrigation and activated char- which is well documented in adults, in the pediatric coal, and he subsequently passed 84 packets. He also re- literature. covered uneventfully. Patient Reports: Two cases of pediatric body pack- Conclusions: We report the first 2 cases of body pack- ing, in boys aged 16 years and 12 years. Patient 1, a ing in the pediatric literature and review the diagnosis 16-year-old boy, presented with findings consistent with and management of this clinical entity. Pediatricians opioid intoxication after arriving in the United States on should be aware that body packing, regrettably, is not a transcontinental flight. His mental status improved af- confined to the adult population. ter he received naloxone hydrochloride, and he subse- quently confessed to body packing heroin. He was treated Arch Pediatr Adolesc Med. 2003;157:174-177 N THE WAKE of the events of PATIENT REPORTS September 11, 2001, security at border crossings in the United PATIENT 1 States has increased dramati- cally. One of the unintended con- A 16-year-old boy who had recently ar- From the Department of Isequences of this action has been an in- rived in the United States was found unre- Emergency Medicine, New York crease in drug seizures. Faced with this sponsive on a city street. He had arrived that University and Bellevue increase in security, drug smugglers may day after a transcontinental flight from Hospital and Medical Center begin using children as vehicles to trans- Europe. His vital signs were pulse, 138 (Drs Traub, Hoffman, and port their cargo. Recently, a 5-year-old girl beats/min; blood pressure, 130/60 mm Hg; Nelson), and the New York City traveling alone from Colombia to New and respiratory rate, 12 breaths/min and Poison Control Center York was discovered to have more than shallow. The physical examination was (Drs Traub, Hoffman, and 1 Nelson), NY; and the Division 1 kg of heroin in her suitcase. otherwise unremarkable. The patient re- of Pediatric Critical Care, A more dangerous means of smug- ceived 25 g of dextrose, 4 mg of naloxone Department of Pediatrics, gling drugs into the country is by “body hydrochloride, and 100 mg of thiamine hy- Schneider Children’s Hospital, packing.” Body packing is the practice by drochloride, all intravenously. His mental Long Island Jewish Medical which international drug smugglers em- status improved immediately. Center, New Hyde Park, NY ploy human beings to hide cargo in their A urine sample was positive for opi- (Dr Kohn). Dr Traub is now bodies. Cocaine and heroin are by far the ates on toxicologic testing. A routine chest with the Division of Toxicology, drugs most commonly implicated. radiograph indicated abnormal densities Department of Emergency There are no previous reports of body in the stomach, a finding confirmed by Medicine, Beth Israel Deaconess Figure 1 Medical Center, Boston, Mass. packing in the pediatric literature. We de- plain abdominal radiography ( ). Dr Kohn is now with the scribe 2 young body packers, aged 16 years Computed tomography (CT) of the abdo- Division of Pediatric Critical and 12 years, and review the epidemiol- men (Figure 2) demonstrated multiple Care, Morristown Memorial ogy, clinical presentation, diagnosis, and intraluminal foreign bodies. The patient Hospital, Morristown, NJ. management of this condition. admitted to body packing 53 bags of (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 174 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Figure 1. A plain abdominal radiograph demonstrates multiple Figure 2. A computed tomographic scan of the abdomen demonstrates radio-opacities suspicious for foreign bodies. multiple intraluminal foreign bodies. heroin. He was treated with activated charcoal, whole- Body packers may present to health care providers bowel irrigation, and a continuous infusion of nalox- in 3 ways: with signs and symptoms of drug toxicity one. By hospital day 4, he had passed 53 packets rec- owing to leaking or ruptured packets, with symptoms of tally, one of which had ruptured. A second CT scan of gastrointestinal obstruction or perforation, or asymp- the abdomen did not show any intraluminal foreign bod- tomatic, either because they fear the consequences of ies. He was discharged to the custody of law enforce- packet rupture or because they are under arrest. ment authorities. In the stable patient, the initial history and physi- cal examination focuses on ascertaining the type of drug PATIENT 2 and number of packets ingested as well as the presence or absence of gastrointestinal obstruction. Body packers A 12-year-old boy presented to the emergency depart- usually know the exact amount of cargo they carry, but ment with a chief complaint of rectal bleeding. He con- they have reasons to be deceitful, and the history may fessed to body packing 87 packets of heroin and stated therefore be unreliable. The presence of cramping, bloat- that he had begun to pass packets per rectum. He had ing, and abdominal pain suggests obstruction. Rectal no other somatic complaints. His vital signs, including and/or abdominal examination may reveal the presence his respiratory rate, were within reference ranges. His men- of drug packets.6,7 Careful chest and abdominal exami- tal status was normal, and his pupils were midrange and nations in patients who present with gastrointestinal reactive. An abdominal examination revealed normal symptoms may reveal signs of obstruction, or even per- bowel sounds. foration, of the bowel or esophagus.8,9 A plain abdominal radiograph demonstrated mul- In the unstable patient or the patient with altered tiple abnormal opacities consistent with drug packets. mental status, the presence of a “toxidrome” (physical He was treated with whole-bowel irrigation and acti- findings suggesting a particular toxic ingestion) may vated charcoal, and he ultimately passed 84 packets. suggest a diagnosis. Cocaine causes hypertension, Barium-enhanced radiography after the passage of these tachycardia, hyperthermia, dilated pupils, diaphoresis, packets indicated no foreign bodies in the gastrointesti- and agitation. Heroin causes respiratory depression, nal tract, and it was concluded that 3 packets had constricted pupils, decreased bowel sounds, and a passed prior to his initial visit. He was subsequently dis- depressed level of consciousness. These findings can charged. help establish a diagnosis despite a paucity of histori- cal information. COMMENT The plain abdominal radiograph is 75% to 95% sen- sitive for drug packets,3,6 and 3 specific signs should be Body packing is the smuggling of illicit drugs using the sought. Multiple radiodense foreign bodies may repre- human body as a vehicle. Individual packets of 8 to 12 g sent drug packets, but they may also represent normal stool. of a drug (usually cocaine or heroin) are wrapped with The “double-condom” sign is formed when air trapped be- waterproof materials, such as latex glove fingers2 or con- tween layers of condoms renders them more visible.10 A doms,3 then sealed. The body packer (or “mule”) usu- “rosette-like finding” represents air trapped in a knot when ally swallows these packets, sometimes more than 200 a condom is tied.11 Computed tomography is frequently per trip,4 although retrograde packing of the rectum and used to image the abdomen, but the failure of CT to iden- vagina have also been reported.5 The mule then boards tify packets has been described.12 Contrast-enhanced plain a flight to a destination country and sometimes uses con- abdominal radiography, which has a sensitivity and speci- stipating agents to retard bowel motility.3 On arrival, body ficity of 96%, may be a superior method.13 Ultrasonogra- packers pass their contraband, often with the aid of laxa- phy has been suggested as a useful method,14 although sen- tives, cathartics, or enemas. sitivity and specificity have not been established. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157, FEB 2003 WWW.ARCHPEDIATRICS.COM 175 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Secure Airway, Breathing, Circulation. Remove Any Packets From Vagina and Rectum. Consider Regional Poison Control Center Consultation. Asymptomatic Evidence of Drug Toxicity Gastrointestinal Decontamination Gastrointestinal Perforation Activated Charcoal or 1 g/kg (Maximum 50 g) PO or per NG Tube Mechanical Obstruction Administer Every 4-6 Hours × 4 Doses Cocaine Heroin Whole-Bowel Irrigation 500 mL/h (Children); 2 L/h (Adolescents) PO or per NG Tube Until Clear Rectal Effluent Treat Symptoms Treat Symptoms Agitation