Button battery ingestion is one of the leading causes of death in paediatric poisoning and this has sharply risen from 2016 despite manufacturing warnings and the addition of tape to cover the negative side (not very useful once you’ve removed that to place it in your device). See Poison.org Button Battery stats
What makes button battery ingestion more frightening is the fact that the ingestion may go unwitnessed, the child may have vague symptoms like ‘off food’ and later haematemasis can result from erosion of the battery through the oesophagus and into the thoracic aorta.
Peer reviewer Dr Ruth Barker, Director, Queensland Injury Surveillance Unit and Emergency Paediatrician, Lady Cilento Children’s Hospital, Brisbane.
Mechanism of injury:
The button battery generates hydroxide ions at the negative pole once ingested. This accumulation of hydroxide produces a localised alkaline corrosive injury with tissue liquefactions and necrosis (remember aLkaLine caustics lead to Liquefaction necrosis). Corrosive injury can develop within 2 hours of lodgement. The severity of injury is all dependent on the size of the battery, current produced, length of time it is lodged. Complications include oesophageal perforation, tracheal-oesophageal fistula, aorta-oesophageal fistula and stricture formation.
Remember the 3 ‘N’s – Negative – Narrow – Necrotic.
- The negative battery pole, identified as the narrowest side on the lateral x-ray, causes the most severe, necrotic injury.
- Rarely required.
- Need to consider airway obstruction.
- Delayed presentations may result in cardiovascular collapse from haemorrhage or sepsis and should be managed along conventional lines. Another possibility would be respiratory distress from a trachea-oesophageal fistula.
- Batteries of <20 mm are less likely to lodge in the oesophagus and cause complications (although relatively bigger batteries in small children increases risk despite being <20 mm).
- Batteries >20 mm can cause severe local damage within 2 hours.
- Smaller batteries can also cause localised damage when placed in aural or nasal cavities.
Age and time of presentation
- Age is a risk factor as most fatalities occur in the under 4 year old age group. But consider non-mobile infants can be fed by siblings, patients who are autistic can have a prolonged oral phase and even the elderly can mistake batteries for tablets.
- Delayed diagnosis has a worse outcome.
- A spent battery is less likely to cause as much damage but this should not alter your risk assessment as batteries can still produce a charge for up to 10 years. (A 3v battery when ‘spent’ has 1.5v charge still and research shows damage can be caused at 1.2v).
- Where oesophageal injury is established, perforations and fistulas may not be evident for up to 28 days. Strictures take weeks or months to form.
Clinical features – when to suspect an ingestion:
- Normally asymptomatic as a care giver has noted or suspected an ingestion and brought them to hospital. (shiny object seen in the mouth or batteries missing from a device).
- If unwitnessed or delayed consideration of a button battery ingestion needs to be considered if the presenting complaint is:
- Airway obstruction, drooling.
- Acute stridor or recurrent stridor (including acute or persistent croup).
- Unexplained wheeze.
- Cough, gagging, or choking when eating and drinking.
- Fever (usually indicates oesophageal perforation).
- Dysphagia or sore throat.
- Chest discomfort.
- ‘Off food’ or partial food refusal (while a common complaint there is often a cause identified, if no cause is found consider FB ingestion).
- Vomiting (still possible as can be a partial obstruction).
- Unexplained nasal, ear, rectal, vaginal or eye discharge/bleeding – these batteries can be stuck in many places.
- Haematemsis, melena, haematochezia or epistaxis (all late signs – also epistaxis can be a false positive – unless the battery is up the nose this is likely haematemsis from a battery in the oesophagus, don’t be fooled).
Routine care for the paediatric patient:
- Keep nil by mouth until a full assessment is made.
Update: see controversies below about giving honey or sucralfate suspension to help neutralise the causticity. This may not be in your local protocol but worth discussing with your surgical teams prior to your next button battery ingestion.
- Specific: Plain anteroposterior X-ray of the neck, chest and abdomen (need a lateral chest X-ray if an object is identified above the diaphragm). Skull X-ray if you suspect a nasal placement, abdominal if rectal or vaginal insertion is considered.
- Think ‘neck to bottom’ X-rays for all GI bleeding and suspected FB ingestion, or a history of epistaxis but no bleed point identified.
- Do not mistake a button battery for a coin – (54% of fatalities are due to mis-identification) the battery should have a:
- “Double ring” appearance on PA (most of the time – absence of a double ring does not exclude the diagnosis -see below).
- “Step off” appearance on lateral view (most of the time – see X-rays below for when this may still be absent).
- See an example clinical case below and the differences between a button batteries versus a coin on X-ray. From ‘A second Look at a Coin in the Stomach – Radiology Cases in Paediatric Emergency Medicine Vol 2 Case 9’ (click on images for full link of go to DFTB):
This lineup above shows a radiograph of a series of 6 disc batteries and a dime.
- The first disc battery on the left has the positive terminal facing toward us.
- The second battery from the left has its negative terminal facing toward us. On this second battery, the black plastic insulator is visible in the photograph. However, the radiograph of both the first and the second disc batteries show the internal ring sign of the plastic insulator.
- The fourth battery from the left also shows a plastic insulator, but the radiograph of this battery does not show the internal ring (‘windowing’ on your pacs system may help). It could be absent because the battery casing is thicker than the first and second batteries. Thus, the absence of the internal ring radiographically does not rule out a disc battery since the appearance of the internal ring is highly dependent on the degree of X-ray penetration, the angle of the battery, and the thickness of the battery casing.
- The third and fifth batteries from the left are viewed from the side. On its side view, the battery has a rectangular appearance with a bulge on one end. This bulge represents the negative terminal of the battery as shown in the corresponding photo below it. The radiographic shadow also identifies this bulge which can be described as frosting on the cake (bilaminar appearance).
- However, this radiographic sign may be absent if the battery is oriented obliquely, or if the battery is very thin (see battery on the extreme right). The dime has only be radiographed PA and is the object 6th from the left.
- See radiopedia for more examples.
- Batteries in the oesophagus should be removed within 2 hours of ingestion endoscopically.
- Batteries in the nose or ear require urgent removal, expert advice may be required from ENT.
- DO NOT give aperients (can cause a septic shower).
- Battery in the oesophagus requires urgent endoscopy for removal.
- If the battery is in the stomach, the risk of complication is low, TOXBASE in the UK states that a repeat x-ray should be done in 2 days if the child is asymptomatic (4 days in USA). If it has not moved at this stage, discuss with your upper GI surgeon or endoscopy team, most will remove the battery from the stomach if it has been there for a maximum of 4 days.
- If the battery is beyond the pylorus and the child is asymptomatic, they can be discharged and observed at home for a repeat X-ray in 10 – 14 days if the battery has not been observed in the stool (I think most parents would go for a repeat x-ray as opposed to sifting through 2 weeks worth of poo). Once the battery is beyond the pylorus it is very unlikely they will develop any complications.
- If discharging the patient give parents the advice to return if: they are concerned; the child develops abdominal pain; bloody vomit or faeces; problems swallowing; respiratory distress; or a persistent cough.
System Issues and Prevention
- Protocol for triage and investigation – some departments have set protocols which you may wish to adopt: patients are triage 2 and the radiology form only states ‘?button battery’. This then sets in motion an appropriate X-ray series.
- Educate staff on common pitfalls in image interpretation, presentation and cognitive bias e.g. fixating on epistaxis when no bleed point is seen or assuming because the child is vomiting or eating that there can not be an oesophageal foreign body.
- Find out now who your go to is, can you get an X-ray if you are rural and who can remove the battery (is it ENT or Gastroenterology). These decisions need to be made in advance, ‘no bun’ fights at 0200). Your local ENT/Surgical/Gastroenterology team are a good first start. Finally, it may be worth discussing with your poisons centre (and surgical teams) if there is a potential use for the controversial treatments given local resources and location.
- Devise own local algorithm – see Dr Litovitz’s example below and adapt as approved by local teams.
- See departmental and patient resources below for some excellent videos from Kidsafe QLD.
- See algorithm below from NBIH but their current advice includes honey:
- Pre-hospital: administer 10ml (2 teaspoons) of honey every 10 minutes (max 6 times) if the child is over 12 months of age, less than 12 hours since ingestion and the child can swallow (while getting to the hospital, don’t stop off at the shops).
- In the ED: battery has been determined to be lodged in the oesophagus, they recommend sucralfate suspension (10 mL PO every 10 minutes, up to 3 doses) or honey if less than 12 hours since ingestion.
- In the OR: If no endoscopic evidence of perforation, irrigate injured area with 50-150ml 0.25% sterile acetic acid to neutralise residual alkali.
- Jatana et al also did an interesting study on piglet oesophagus and noted ReaLemon and orange juice applied every 5 minutes had a neutralising benefit. While the study is far from ready to start these treatments ‘prime time’ you may see them coming in a few years.
- While the above treatments may seem a little unorthodox, it may be something to consider in the rural setting with transport delays. Again another reason to talk about these potential cases with your local poisons centre and surgical teams.
from Dr Litovitz who has been monitoring more than 1100 battery ingestion annually
Additional FOAM Resources
- Ingesting Foreign Bodies at DFTB17 – Chantel McGrath – includes podcast
- Ingested Foreign Bodies – Andy Tagg
- Foreign body ingestion – RCH
- LITFL – toxicology library
- Pedemmorsels – button battery ingestion
- Stemlynspodcast – button battery
- Queensland Injury Surveillance Unit – Disc batteries
- ACCC product safety – button batteries
- The Battery Controlled – parental website
- Jatana KR, Litovitz T, Reilly JS et al. Pediatric button battery injuries; 2013 task force update. International Journal of Pediatric Otorhinolaryngology 2013; 77:1392-1399.
- Murray L et al. Toxicology Handbook 3rd Edition. Elsevier Australia 2015. ISBN 9780729542241.
- National Capital Poison Centre Button Battery Ingestion Triage and Treatment Guideline.
- Litovitz T. Whitaker N, Clark L et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168-1177.
DRUGS and TOXICANTS
Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.