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Management of Button Battery Ingestion

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Why are we worried about button batteries?

Young children enjoy exploring the world, playing with toys, and, even with the best supervision, eating things that they really shouldn’t! This is why we often see most foreign body ingestions in younger children and toddlers. A button battery is one of the most dangerous things a young child can ingest. Ingestion of these can cause significant morbidity and mortality. 

Button batteries are disc-shaped long-life batteries that can look very similar to small coins. They are found in almost every household and often in games, toys, and even light-up shoes, which are particularly appealing to a young child.

Between 7 and 25% of all foreign body ingestions in children are due to button batteries. A systematic review, which had the big data advantage of including 136,191 children, found that over 75% of button battery ingestions occurred in children under six, and toddlers were the most vulnerable. In this population, 61.8% of button batteries were obtained directly from a device, 29.8% were loose, and the remainder were obtained from the packaging. Unfortunately, younger children are even more at risk of harm from button battery ingestion. The batteries are more likely to stick due to their smaller anatomy. The ingestion is more likely to be unwitnessed and undisclosed, resulting in a delay in diagnosis. You need a high index of suspicion in younger children. 

Button battery ingestion is a life-threatening condition. It can cause severe complications and can be fatal. Damage can occur within two hours of ingestion. Because many ingestions are unwitnessed in young children, there may be a delayed diagnosis, putting children at risk of these life-threatening complications.

How do button batteries cause injury?

1. Mechanism of the injury

The main mechanism of BBI is liquefactive necrosis secondary to electrical injury (electrolysis). Other mechanisms include local pressure necrosis and corrosive damage due to content leakage. 

Electrolysis occurs once the battery is lodged in the tissues, causing a complete electrical circuit that generates an electrical current. This subsequently increases hydroxide ion production, causing the pH to rise. The highly alkaline environment leads to liquefactive necrosis.

2. Timing of the injury

The risk of severe complications, such as perforation, occurs within 2 hours of the battery lodging in the tissue. However, the tissue injury occurs within 15 minutes.

3. Site of the injury

If a battery passes through the oesophagus, it often goes through the GI tract without causing problems. Therefore, most complications of button battery ingestion occur in the oesophagus, with only 7% in the stomach and 1.3% in the small intestine.

Once the battery is lodged in the oesophagus, both poles come in close contact with the mucosa, causing electrical current and electrolysis. This is anatomically less likely to occur in the stomach or the small intestine. 

There are three main sites for being lodged and causing caustic injury in the oesophagus.

There have also been case reports of BBI causing spondylodiscitis. This can happen if the battery is lodged in the posterior wall of the oesophagus.

4. Severity of injury

5. Types of injury

How should we manage button battery ingestion?

Different guidelines exist for managing button battery ingestion in children. We will focus on the ESPHGAN 2021 guidelines.

Clinical Picture

Button battery ingestion may present with respiratory or gastrointestinal symptoms. However, unwitnessed ingestion can lead to delayed presentation. Therefore, children are more likely to present with complications of ingestion, leading to delayed diagnosis.

Imaging

Imaging is one of the fundamental elements of managing button battery ingestion because the treatment depends on the battery’s site. Although CT or an MRI following removal might be needed, X-ray remains the first-line imaging technique to identify the battery and guide management. 

CT with contrast is sometimes needed before any intervention if severe oesophageal complications, such as aorto-oesophageal fistula, are suspected. MRI can only be used after battery removal.

Treatment

A. If endoscopy is available 

Treatment depends on the site of impaction and time since ingestion. Early diagnosis is crucial as oesophageal batteries should be removed within two hours to avoid complications.

After battery removal, irrigation with acetic acid may be used to neutralize the hydroxide ion accumulation. This should only be considered if there is no suspicion of perforation. This can be done by irrigating 50 to 150 ml of 0.25% acetic acid immediately after endoscopic battery removal.

B. If endoscopy is not readily available 

The aim is to reduce the severity of the injury until an endoscopy is available or the patient is transferred to a centre where one can be performed.

Post Endoscopic Removal

Long-term follow-up

Unfortunately, oesophageal strictures can occur weeks after ingestion, depending on the extent of the injury. Therefore, the contrast oesophagogram should be repeated to look for any oesophageal stricture. Sometimes, the endoscopy needs repeating as well. Although early dilatation is the key to management, waiting for the oesophageal tissues to heal is essential. It usually takes four weeks for the tissues to heal. 

Serial imaging (CT or MRI) should be considered if there are suspected complications, severe mucosal damage, delayed diagnosis, or removal that occurred more than 12 hours after ingestion.

What discharge advice should be given?

Parents should be aware of possible complications and how they present, especially signs of GI bleeding and oesophageal stricture. They should be asked to present to the emergency department if their child has any blood-stained vomiting, melena, or abdominal pain, if they change their eating pattern (refusing food or fluids), or has features of intestinal obstruction (persistent vomiting, abdominal distension).

How to prevent BBI?

The best way to prevent ingestion is to secure device batteries, e.g., in screw-secured compartments. The other element is increasing public awareness of the seriousness of button battery ingestion. Parents should be encouraged to discard old batteries, securely fasten the button battery compartment, and put the batteries out of reach for children. They should seek urgent medical help after any case of suspecting BBI within the first 2 hours.

References

Jatana KR, Chao S, Jacobs IN, Litovitz T. Button Battery Safety: Industry and Academic Partnerships to Drive Change. Otolaryngol Clin North Am. 2019;52(1):149-161. https://doi.org/10.1016/j.otc.2018.08.009 

Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. Laryngoscope. 2017;127(6):1276-1282. https://doi.org/10.1002/lary.26362 

Mubarak A, Benninga MA, Broekaert I, et al. Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. Journal of Pediatric Gastroenterology and Nutrition. 2021;73(1):p 129-136. https://doi.org/10.1097/MPG.0000000000003048 

Newman RK, Dijkstra B, Gibson J. Disk Battery Ingestion. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. https://www.ncbi.nlm.nih.gov/books/NBK470298/ 

Park S & Burns H. Button battery injury: An update. Australian Journal for General Practitioners. 2022;51(7). http://doi.org/10.31128/AJGP-03-21-5873 

Pugmire BS, Lin TK, Pentiuk S, et al. Imaging button battery ingestions and insertions in children: a 15-year single-center review. Pediatr Radiol. 2017;47, p:178–185. https://doi.org/10.1007/s00247-016-3751-3 

Sethia R, Gibbs H, Jacobs IN, Reilly JS, Rhoades K, Jatana KR. Current management of button battery injuries. Laryngoscope Investig Otolaryngol. 2021;6(3):549-563. Published 2021 Apr 15. https://doi.org/10.1002/lio2.535 

Tan A, Wolfram S, Birmingham M, et al. Neck pain and stiffness in a toddler with history of button battery ingestion. J Emerg Med. 2011;41(2):157-60. https://doi.org/10.1016/j.jemermed.2010.02.027 

Varga Á, Kovács T, Saxena AK. Analysis of Complications After Button Battery Ingestion in Children. Pediatr Emerg Care. 2018;34(6):443-446. https://doi.org/10.1097/PEC.0000000000001413

Authors

  • Moustafa Eldalal is a Peadiatric Trainee in West Midlands, currently at University Hospitals of North Midlands. He has a postgraduate diploma in Preventive Cardiovascular medicine, University of South Wales. Interested in Teaching and Neonatal medicine.

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  • Owen Hibberd is an Emergency Medicine Trainee in Cambridge, currently studying on the QMUL PEM MSc. Interested in Paediatric Emergency Medicine, Pre-Hospital Emergency Medicine and Medical Education. He/him.

    View all posts
  • Costas Kanaris is a Paediatric Intensive Care Consultant in Cambridge and an Associate Editor of the Journal of Child Health Care. He has a PhD in Medical Ethics and Law and is an Honorary Senior Lecturer at Queen Mary University of London.

    View all posts

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