Button batteries were recognized as hazardous to kids as early as 3 decades ago.1 Over the recent years, increasing miniaturization of electronic devices has expedited the widespread use of button batteries in household appliances and children’s toys. As a result, button batteries with smooth and shiny appearance are more appealing and accessible to young children.2 In parallel, the annual incidence of button battery ingestion has been reckoned to be 6.3 to 15.1 per million.3
Between 1997 and 2010, an estimated 40,400 children aged younger than 13 years in the United States visited hospital emergency departments for treatment of battery-related injuries (BRI), including confirmed or possible battery intake. Nearly 75% of the BRI cases involved children aged 4 years or younger and 10% required hospitalization.4 Although these data have posed a health concern over accidental BRI in family caregiving in the United States, less attention to these injuries was aroused in China, another largest toy consumer and manufacturer worldwide. So far, in this country, epidemiological data regarding both the incidence of BRI and a treatment observation protocol remain limited. Here, we presented 6 cases of button battery intake as foreign body, with review of related literatures about BRI in Chinese children.
Between July 2009 and February 2013, there were 6 consecutive pediatric cases of button battery intake treated in the Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Guangzhou Medical University. The diagnosis of button battery intake in these children was based on history, clinical manifestations, and imaging studies. Data on the patient age, time to first treatment, route of button battery intake (ingestion or inhalation), length of hospital stay, imaging findings, and medical outcomes were reviewed (Table 1).
Furthermore, we conducted a thorough search for case series of injuries related to button battery intake as a foreign body among Chinese children. The search was limited to English- or Chinese-language articles by authors from the mainland China. Four databases (PubMed, Web of Knowledge, Scopus, and ProQuest) were used for searching of English-language articles. For Chinese-language articles, we used China National Knowledge Infrastructure, Wanfang Database, and VIP Journal Integration Platform, the first 3 largest global databases of academic full-text articles in Chinese language online. The date of target publications was from January 1979 up to December 2012. The terms used for the literature search were “button battery” and “foreign body” and “Chinese” and “children,” or where applicable, “Niukou Dianchi” (“button battery” in Chinese) and “Yiwu” (“foreign body” in Chinese) and “Ertong” (“children” in Chinese). The full text of resultant articles was read to exclude any irrelevant studies. To obtain additional literature that was not indexed, a secondary manual search was performed by checking all the reference lists from within the retrieved articles.
Of the 6 children (4 boys and 2 girls) in this study, the patient age ranged from 11 months to 6 years. The mean time from button battery intake to treatment was 18.33 hours (range, 6 hours-3 days). The mean length of hospital stay was 18 days.
BRIEF PRESENTATION OF 3 TYPICAL CASES
A 2-year-old boy was admitted to the Department of Otolaryngology-Head and Neck Surgery within 2 hours of foreign body ingestion, presenting with sore throat and dysphagia. Esophagography showed a round opacity in the upper esophagus that seemed to be a button battery (Figs. 1A, B). About 6 hours after the ingestion, he received endoscopy under general anesthesia for the retrieval of the button battery. During the procedure, a deformed button battery was found to have caused corrosion of the proximal esophageal mucosa. The patient’s symptoms improved markedly after the treatment, and a follow-up radiograph was normal (Fig. 1C) on the next day. No complications occurred after he was discharged home.
An 11-month-old girl was referred for treatment of tracheoesophageal fistula after battery ingestion manifested by dysphagia, fever, and cough. Computed tomographic esophagography showed a perforation in the midesophagus (Fig. 2A). After admission, she was treated with broad-spectrum antibiotics and placement of a feeding tube and received 7 radiologic and 4 tracheobronchoscopy examinations. The fistula closed spontaneously after 4 months (Fig. 2B).
A 6-year-old boy was seen at our outpatient department with perforation of nasal septum (Fig. 3). Until a button battery was removed from his nasal cavity, it had been lodged in the nose for 3 days. The boy had relapsing epistaxis up to now.
Battery-related injuries led to varied medical outcomes in these cases. One of the 2 cases involving airway lodgment of button battery developed nasal septal perforation after removal of the foreign body. Because the condition of his nasal septum did not allow for an immediate repair, the boy had relapsing epistaxis during the next few months. Of the 4 children with button battery ingestion, 3 developed tracheoesophageal fistula; among them, 1 had systemic infection.
Literature search yielded no articles published in English by authors from the mainland China. Twenty-eight articles on button battery ingestion in children were obtained by search of Chinese-language literature, comprising 25 case reports, 2 health education articles, and 1 imaging study. In total, 172 cases of button battery intake as foreign body in children were identified since the first report in 2000. The route of button battery intake included oral ingestion in 12 cases, nasal inhalation in 159 cases, and accidental aural entrapment in 1 case. Of the 159 cases involving nasal inhalation and lodgment of button battery, 23 and 10 children developed nasal septal perforation and nasal adhesion, respectively. Tracheoesophageal fistula was identified in 4 of the 12 ingestion cases.
In addition, 9 articles were published between 2001 and 2009, 8 articles in 2009, and 11 articles between 2010 and 2012.
In the present series, tracheoesophageal fistula was identified in 3 children with button battery ingestion, all of whom underwent radiologic examinations, fiber-optic bronchoscopies, surgical procedures, and hospitalization before the fistula close spontaneously. These patients also received broad-spectrum antibiotics and placement of a feeding tube. One patient who experienced airway button battery lodgment developed nasal septal perforation and had relapsing epistaxis. Conceivably, BRI had lead to catastrophic and devastating outcomes to the children and their families. Globally, damages from button batteries have been reported from Spain, Australia, Korea, the United States, and many other countries during the recent decades.3,5–9 Specific complications arising from button battery ingestion, including lower motor neuron facial nerve palsy, malignant otitis externa, bilateral vocal cord paresis, aortic perforation with exsanguination, and Meckel diverticulum perforation, have also been reported.10–16 Between 1977 and 2009, BRI caused 13 cases of fatal outcomes and 73 cases of major outcomes in a large population.3 All these data clearly shed light on the hazards of button batteries as an emerging killer among young children worldwide.
Removal of the battery, once its presence is identified, is usually not difficult. However, timely clinical diagnosis is rarely achievable in children because of late presentation and misdiagnosis, especially when the history obtained from the parents was contradictory. In the present cohort, a 2-year-old boy was referred to the Department of Otolaryngology within 2 hours after he ingested a button battery. Esophagography showed a round density in his upper esophagus. Nearly 8 hours had passed before the ingested button battery was subsequently removed under endoscopy, given the routine 6-hour preoperative fasting needed for general anesthesia. Amanatidou et al9 reported 31 cases of button battery ingestion recorded by the Greek Poison Information Center from November 2007 to February 2008, with the intervals between the accidental ingestion and the first medical contact ranging from 5 minutes to 10 days (mean, 14.9 hours). In some cases, the removal was delayed by even more than 1 month. The mean time to removal was 18.33 hours in our patients. Litovitz et al3 estimated the time to battery removal in 73 cases as follows: less than 4 hours in 7 cases, less than 8 hours in 17 cases, less than 12 hours in 27 cases, less than 24 hours in 36 cases, less than 2 days in 42 cases, less than 3 days in 48 cases, less than 1 week in 60 cases, less than 2 weeks in 67 cases, less than 6 weeks in 72 cases, and completely unknown in 1 case. Only a very low percentage of patients (17/73; 23.3%) had their ingested batteries removed (<8 hours) without “delay.” Unfortunately, button batteries lodging in the esophagus can cause severe tissue damage even just within 2 hours.17 Such a disappointing frustration seems beyond what modern medicine alone can overcome. We do believe that button battery ingestion is not only a medical problem for emergency physicians, pediatricians, and otolaryngologists, but also a social issue that should raise wider concerns.
In light of the difficulties for prompt removal of lodged button battery, effective preventive strategies seem to be of paramount importance to reduce related injuries in children. During the observation period of our study, there was a 6.7-fold increase in the rate of major or fatal outcomes by the last 3 years (2007–2009, 0.443%) compared with the first 3-year period (1985–1987, 0.066%). This suggested the unsatisfactory status of prevention and a dire need for enhancing awareness and knowledge of BRI in parents and care providers. In 2011, the American Consumer Product Safety Commission warned against the frequent accidents, including injuries or death, related to the increasing use of button battery. To our surprise, only 2 articles in the literature addressed health educations on button battery as a foreign body among Chinese children during the past 10 years. From all the articles retrieved in this study, there seemed to be little concern raised about the hazards of button batteries to children, mirroring BRI as a neglected entity in this country.
Similarly, only 172 children with button battery intake as foreign body were reported in China between 2000 and 2013, compared with the 8648 battery ingestions (button and cylindrical) reported by the National Battery Ingestion Hotline from July 1, 1990, to September 30, 2008. A total of 13 cases with fatal outcomes and 73 cases with major outcomes (life-threatening or disabling) involving esophageal or airway button battery lodgment were retrievable in the literature or in the National Battery Ingestion Hotline database, but no case with fatal or major outcome was reported in the Chinese-language literature. Other than indicating that the incidence of button BRI was virtually low in China with the largest children population in the world, these paradoxical findings revealed a lack in designated surveillance institution and reporting system for button BRI.
In summary, button battery intake as foreign body is an emerging killer among children worldwide. Button BRI among Chinese children have been so far underreported. Given the potentially devastating outcomes from BRI and the limited role of prompt surgical interventions, preventive efforts to raise awareness, enhance surveillance, and enforce reporting of such injuries should become the most effective strategy for management.
The authors are grateful to Dr Guangqiao Zeng for his critical reading of the article.
1. Blatnik DS, Toohill RJ, Lehman RH. Fatal complication from an alkaline battery foreign body in the esophagus. Ann Otol Rhinol Laryngol
. 1977; 86 (5): 611–615.
2. Lin VY, Daniel SJ, Papsin BC. Button batteries in the ear, nose and upper aerodigestive tract. Int J Pediatr Otorhinolaryngol
. 2004; 68 (4): 473–479.
3. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics
. 2010; 125 (6): 1178–1183.
4. Centers for Disease Control and Prevention (CDC). Injuries from batteries among children aged <13 years—United States, 1995–2010. MMWR Morb Mortal Wkly Rep
. 2012; 61 (34): 661–666.
5. Lee KC, Lee NH, Ban JH, et al. Surgical treatment using an allograft dermal matrix for nasal septal perforation. Yonsei Med J
. 2008; 49 (2): 244–248.
6. Zanetta A, Cuestas G, Rodríguez H, et al. Septal perforation in children due to button battery lodged in the nose: case series. Arch Argent Pediatr
. 2012; 110 (5): 430–434.
7. Liao AY, McDonald D. Oesophageal complication from button battery ingestion in an infant. J Paediatr Child Health
. 2013; 49 (4): 330–332.
8. Soccorso G, Grossman O, Martinelli M, et al. 20 mm lithium button battery causing an oesophageal perforation in a toddler: lessons in diagnosis and treatment. Arch Dis Child
. 2012; 97 (8): 746–747.
9. Amanatidou V, Sofidiotou V, Fountas K, et al. Button battery ingestion: the Greek experience and review of the literature. Pediatr Emerg Care
. 2011; 27 (3): 186–188.
10. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction. J Pediatr Surg
. 1999; 34 (10): 1527–1531.
11. Vaishnav A, Spitz L. Alkaline battery-induced tracheo-oesophageal fistula. Br J Surg
. 1989; 76 (10): 1045.
12. Willis GA, Ho WC. Perforation of Meckel’s diverticulum by an alkaline hearing aid battery. Can Med Assoc J
. 1982; 126 (5): 497–498.
13. Gordon AC, Gough MH. Oesophageal perforation after button battery ingestion. Ann R Coll Surg Engl
. 1993; 75 (5): 362–364.
14. Cheng LC, Chiu CS. Foreign body-induced aorto-oesophageal fistula: a review of five cases and their management. Hong Kong Med J
. 2006; 12 (3): 219–221.
15. Sigalet D, Lees G. Tracheoesophageal injury secondary to disc battery ingestion. J Pediatr Surg
. 1988; 23 (11): 996–998.
16. Gomes CC, Sakano E, Lucchezi MC, et al. Button battery as a foreign body in the nasal cavities. Special aspects. Rhinology
. 1994; 32 (2): 98–100.
17. Tanaka J, Yamashita M, Yamashita M, et al. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol
. 1998; 40 (4): 193–196.