Evolving Clinical Care in Esophageal Button Batteries: Impact of Expert-Opinion Guideline Adoption and Continued Gaps in Care : Journal of Pediatric Gastroenterology and Nutrition

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Original Articles: Gastroenterology

Evolving Clinical Care in Esophageal Button Batteries: Impact of Expert-Opinion Guideline Adoption and Continued Gaps in Care

Sinclair, Elizabeth M.; Santore, Matthew T.; Agarwal, Maneesha; Kitzman, Jamie§; Sauer, Cary G.; Riedesel, Erica L.||

Author Information
Journal of Pediatric Gastroenterology and Nutrition 74(2):p 236-243, February 2022. | DOI: 10.1097/MPG.0000000000003346


An infographic is available for this article at:https://links.lww.com/MPG/C573.

What Is Known/What Is New

What Is Known

  • Esophageal button battery impaction may be severe with potential for life threatening complications.
  • Button battery ingestions have dramatically increased over the past 10 years in the United States.
  • Care for these patients is complex and involves multiple subspecialties.

What Is New

  • Largest study focusing on patient care before and following adoption of expert-opinion guidelines.
  • Adoption of guidelines resulted in increased cross-sectional imaging, increased nil per os time, increased intensive care unit stay, increased hospital length of stay without a change in patient outcomes.
  • Identification of gaps in current guidelines.

Multiple studies have documented a dramatic rise in button battery ingestion (BBI) over the past 20 years in the United States with increasing morbidity and mortality, especially in cases of esophageal impaction (1–3). The rise of these injuries has led to the development of expert-opinion guidelines from the National Capital Poison Center (NCPC) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) to help manage these patients at risk for dreaded complications including esophageal perforation, tracheoesophageal (TEF), and aorto-esophageal fistula (AEF) (4–8).

These expert-opinion guidelines emphasize prompt diagnosis, rapid intervention, and use of cross-sectional imaging in the post-battery removal period to identify clinical complications. Adoption of these guidelines could significantly affect the hospital course of this population. There is limited data regarding the impact of guideline adoption on a patient's clinical course, outcomes, and medical resource utilization. Additionally, these guidelines continue to have gaps regarding recommendations for feeding practices and clinical follow-up in these patients, even in the most recent iterations and expanded multi-disciplinary guidelines are needed (9,10).

In this study, we sought to characterize the patient population and clinical course of esophageal BBI at our institution before and following adoption of guidelines with specific attention to button battery (BB) removal time, battery removal practices, and imaging. We also sought to provide descriptive data regarding areas that do not have clear guidelines in the literature including multi-disciplinary inpatient care, feeding practices, and outpatient follow-up.


Patient Selection

This retrospective study characterized patients 6 months to 18 years treated for BBI from January 1, 2007–August 1, 2020 at a large volume, urban academic pediatric hospital system. Institutional guidelines for clinical management of patients with BBI were created in 2018, based on NASPGHAN guidelines and 2016 NCPC guidelines. Data was separated into two groups: pre-guideline, 2007–2017, and post-guideline, 2018–2020. This study received approval from the local institutional review board. Inclusion criteria were BBI within the esophagus, available documentation of endoscopic removal, and clinical management at our institution. Patients were excluded if removal occurred at another center, endoscopic removal was not performed, or patient had esophageal injury with a gastric or intestinal battery.

Data Collection

Collected data included general patient characteristics, removal of esophageal button battery, immediate post-battery removal clinical course, and details of inpatient care course captured though the electronic medical record (EMR) including operative and procedural notes.

Time to battery removal was reported in reference to NASPGHAN recommended goal of under 2 hours (7). Prolonged impactions were defined as >12 hours in accordance with NCPC guidelines, due to increased risk of severe damage and esophageal perforation (8). Impactions with an unknown time of ingestion were categorized as prolonged. Length of hospital stay was calculated from initial admission to initial discharge at one of our three pediatric hospitals and considered continuous even if patients were transferred between facilities.

Data from outpatient follow-up course was also collected with a specific focus on development of long-term anatomic complications including development of esophageal stricture, tracheoesophageal fistula (TEF), or aorto-esophageal fistula (AEF).

Statistical Analysis

After calculating descriptive statistics to examine the demographic, treatment characteristics, and outcomes of patients, we used chi-square and Wilcoxon rank-sum tests to compare the characteristics of the pre-guideline (2008–2017) and post-guideline (2018–2020) cohorts. For any categorical data with a zero cell or a cell with a value <10, we used a Fisher exact test to compare cohorts. We conducted complete case analyses because <1% of data were missing for each variable of interest. Analyses were conducted using Stata, version 14.


A total of 283 cases of BBI were cared for at our institution during the study time period. Of these, 67 patients were esophageal BBI. Four patients were excluded via criteria listed, resulting in a final cohort of 63 patients, 31 from 2007–2017 and 32 from 2018–2020. Patient characteristics including age, sex, race, and ethnicity are detailed in Table 1. Battery size and esophageal location as identified on initial X-ray are shown in Table 1. There were no significant differences in patient characteristics between groups before and after guideline adoption.

TABLE 1 - Patient characteristics
2008–2017 (N = 31) 2018–2020 (N = 32)
Median (min, max) Median (min, max)
Age (mo) 27 (9, 83) 31.5 (7,87)
N (%) N (%)
 Female 13 (41.9) 13 (40.6)
 Male 18 (58.1) 19 (59.4)
 Black 13 (41.9) 19 (59.4)
 White 15 (48.4) 12 (37.5)
 Other 2 (6.5) 0 (0)
 Declined 1 (3.2) 1 (3.1)
 Non-Hispanic 27 (87.1) 30 (93.8)
 Hispanic 4 (12.9) 2 (6.2)
Initial X-ray characteristics
Median (min, max) Median (min, max)
Battery size (cm) 2.1 (1, 2.3) 2.1 (0.8, 2.4)
N (%) N (%)
>2 cm
 Yes 30 (96.8) 30 (93.8)
Esophageal location
 Proximal 18 (58.1) 19 (59.4)
 Mid 4 (12.9) 7 (21.9)
 Distal 9 (29.0) 6 (18.8)
Duration of button battery exposure
Estimated duration N (%) N (%)
<2 h 0 (0) 1 (3.1)
3–6 h 7 (22.6) 10 (31.3)
7–12 h 7 (22.6) 8 (25.0)
>12 h 1 (3.2) 2 (6.3)
>24 h 6 (19.4) 2 (6.3)
Unknown 10 (32.3) 9 (28.1)
Characteristics of patients with esophageal BBI including X-ray data and estimated duration of BBI. Age and battery size reported as medians and quartiles. Battery size was measured on AP X-ray. Proximal esophagus on X-ray was defined as between C6 and T4 vertebral bodies, mid esophagus between T4 and T9, and distal esophagus below T9 and above gastroesophageal junction. Estimated duration of button battery exposure starting from estimated ingestion to endoscopic removal.BBI = button battery impaction.
One patient with a congenital stricture due to tracheoesophageal fistula (TEF) had 0.8 cm esophageal impaction.

Duration of Button Battery Exposure

Total estimated duration of BB exposure is detailed in Table 1. This estimate begins at time of suspected ingestion as documented in the initial clinical note and ends at time of removal in the operating room. Time spent at referring facility, transport time, and time spent before operating room (OR) were summed to generate total estimated duration. Prior to 2018, 54.8% of patients had a prolonged BBI defined as >12 hours. From 2018 to 2020, 40.6% of patients had a prolonged esophageal BBI. Once patients arrived at our facility, time from Emergency Department (ED) arrival to OR had a median time of 114 minutes before 2018 (range 45–346), and a median time of 106 (range 21–252) minutes from 2018 to 2020.

Button Battery Removal

All patients underwent endoscopic battery removal under general anesthesia and details of battery removal are reported in Table 2. At our institution, endoscopic removal is performed by pediatric gastroenterologists, general surgeons, and otolaryngologists. Flexible esophagogastroduodenoscopy (EGD) was overall performed by gastroenterologists while rigid esophagoscopy was performed by otolaryngologists or general surgeons. Esophageal rinse was determined by individual provider. A statistically significantly higher number underwent acetic acid rinse post-adoption (P = 0.045).

TABLE 2 - Inpatient care and outcomes
Button battery removal
2008–2018 (N = 31) (N%) 2018–2020 (N = 32) (N%) P value
Flexible EGD only 16 (51.6) 16 (50.0)
Rigid EGD only 7 (22.6) 9 (28.1)
Both 8 (25.8) 7 (21.9)
Underwent any rinse 5 (16.1) 12 (37.5)
Acetic acid 0 6 (18.8) 0.045
Saline 4 (12.9) 5 (15.6)
Sterile water 1 (3.2) 1 (3.1)
 Yes 9 (29.0) 28 (87.5) <0.001
Serial MRI/CT
 Yes 1 (3.2) 25 (78.1) <0.001
 Yes 30 (96.8) 29 (90.6)
Serial esophagram
 Yes 19 (61.3) 15 (46.9)
Timing of initial esophagram
 <48 h 22 (71.0) 5 (15.6) <0.001
 3–5 days 5 (16.1) 7 (21.9)
 >6 days 3 (9.7) 17 (53.1)
 N/A 1 (3.2) 3 (9.4)
Feeding practices
2008–2017 (N = 30) 2018–2020 (N = 31)
Any NPO N (%)
 Yes 27 (90.0) 29 (93.5)
Median days NPO (min, max) 6.5 (1, 75) 9 (1, 93)
Any tube feeding N (%)
 Yes 14 (46.7) 21 (67.7)
Tube feeding >14 days N (%)
 Yes 6 (20.0) 5 (16.1)
Median tube feeding days (min, max) 12 (2, 55) 8 (2, 93)
Any PN days N (%)
 Yes 6 (20.0) 12 (38.7)
Median PN days (min, max) 10 (6, 17) 7 (3, 14)
2008–2017 (N = 31) 2018–2020 (N = 32) P value
Hospitalization N (%)
 Yes 31 (100) 32 (100)
Median length of stay (LOS) (days) (min, max) 4 (0, 22) 11 (0, 20)
ICU stay N (%)
 Yes 11 (35.5) 24 (75.0) 0.002
Median ICU LOS (days) (min, max) 6 (1,17) 6 (1,13)
Median initial anesthesia exposures (min, max) 1 (1,4) 2 (1, 5) 0.002
Median anesthesia exposures due to BBI (min, max) 1 (1,8) 3 (1,8)
Intubated >24 h N (%)
 Yes 9 (29.0) 14 (43.8)
Median intubation Duration (days) (min, max) 1 (1,8) 2 (1,8)
Central venous line (CVL) N (%)
 Yes 7 (22.6) 15 (46.9)
Clinical outcomes
N (%) N (%)
Outpatient follow-up
 Yes 19 (61.3) 23 (71.9)
Hospital readmission
 Yes 2 (6.5) 3 (9.4)
Long-term anatomic complication
 Yes 7 (22.6) 5 (15.6)
  Esophageal stricture 4 (12.9) 3 (9.4)
  Tracheo-esophageal fistula (TEF) 3 (9.7) 0
  Aorto-esophageal fistula (AEF) 0 1 (3.1)
  Other 0 1 (3.1)
Data detailing battery removal. cross section imaging, esophagram, feeding practices following esophageal button battery removal, hospitalization data including length of stay, ICU stay, intubation, central line placement, anesthesia events, follow-up, and anatomic complications before and following adoption of guidelines. “Any NPO” was defined as NPO following battery removal.BBI = button battery impaction; CT = computed tomography; EGD = esophagogastroduodenoscopy; ICU = intensive care unit; MRI = magnetic resonance imaging; NPO = nil per os; PN = parenteral nutrition.
One patient in each group was NPO and G-tube fed at baseline and excluded from this analysis.
Patient had an incidental discovery of an esophageal duplication cyst on MRI and underwent subsequent surgical repair.


All patients underwent initial X-ray to determine size and location of BBI. Data regarding cross-sectional imaging and esophagram are detailed in Table 2. Prior to 2018, more patients had esophagram within 48 hours of battery removal (P < 0.001). After 2018, significantly more patients underwent any cross-sectional imaging (P < 0.001). Serial cross-sectional imaging also increased significantly (P < 0.001) with a total of 26 patients imaged with serial magnetic resonance imaging (MRI) (a total of 71 MRIs). Nearly all patients who received serial cross-sectional imaging (95%) required sedation.

Feeding Practices

Feeding practices following battery removal including nothing by mouth (NPO) status, duration, tube feeding, and parental nutrition are detailed in Table 2. Timing of initial feeding and advancement was highly variable in our cohort but after 2018, median NPO time was longer (6.5 vs 9 days) and more patients experienced tube feeding (46.7% vs 67.7%) and parenteral feeding (20% vs 38.7%).

Hospitalization and Clinical Outcomes

Hospital course including median length of stay (LOS), median ICU duration, anesthesia events, follow-up, readmission, and long-term anatomic complications are detailed in Table 2. After 2018, patients had an increased LOS, more patients had an ICU stay (P = 0.002), and significantly more anesthesia events (P = 0.002).


BBI in children poses a significant danger, especially in the setting of esophageal impaction. Esophageal injury following BBI is due to a combination of caustic injury, ischemic pressure necrosis, and tissue hydrolysis triggered by electrical charge at the negative battery pole resulting in alkaline tissue damage which occurs as quickly as 15 minutes following impaction (11,12). Although rare, severe complications from BBI are increasing and fatalities are a reality (13).

Rising numbers of pediatric BBI have resulted in publication of expert-opinion guidelines to assist medical practitioners who care for these patients. The National Capital Poison Center (NCPC) initially published guidelines for BBI management in 2010, identifying many knowledge gaps (1). NASPGHAN first published clinical management guidelines regarding BBI in 2015. These guidelines have been subsequently revised to reflect new understanding of esophageal injury and mitigation strategies (7,8). Figure 1 compares key aspects of each guideline as well as current updated guidelines, which continue to emphasize prompt recognition and removal of BBI as well as advocate for mitigation with honey, sucralfate, and irrigation at time of battery removal.

Comparison of expert-opinion guidelines. Key aspects of managing patients with esophageal BBI are compared across available guidelines and show evolution over time as new evidence became available. BBI = button battery impaction.

Our institution adopted guidelines in 2018 modeled on NCPC and NASPGHAN due to rising number of BBI and especially esophageal impaction in our region. This retrospective observational study details patients with esophageal BBI at our institution before and after guideline adoption.

We found that general patient characteristics in our cohort align with national data regarding age, sex, and battery size where male patients 1–3 years old with batteries at least 2 cm most likely to have esophageal impaction (1,14,15). The large number of batteries identified in the proximal esophagus in our cohort also mirrors that reported in larger studies (16).

Current recommendations emphasize timely recognition and removal of button battery due to risk of serious injury in as little as 2 hours (7). All patients in our cohort were evaluated with appropriate frontal and lateral X-ray from the nose to the rectum both before and after guideline adoption. In addition, median time to removal as measured from arrival at our institution and arrival in the OR met the 2-hour benchmark set by NASPGHAN and NCPC guidelines at all time points in our study.

Hospital course following esophageal battery removal was significantly changed following implementation of guidelines in 2018. Increased ICU stay and increased number of patients with intubation >24 hours was seen. Overall hospital LOS was also significantly affected, with a median LOS of 11 days post-adoption compared to 4 days pre-adoption. Much of this can be attributed to adoption of NASPGHAN guidelines for cross-sectional imaging with computed tomography (CT) or MRI imaging in patients with significant esophageal injury following battery removal (7,10). After 2018, significantly more patients underwent cross-sectional imaging. Although not every patient in our cohort underwent serial imaging following guideline adoption, we document a statistically significant increase; 78% of BBI were imaged with serial MRI (26 patients equaling a total of 71 MRIs). This change in practice pattern is not without downstream effect. Cross-sectional imaging, especially with MRI, in this patient population often requires general anesthesia. In our cohort, beginning in 2018, 95% of patients required anesthesia or conscious sedation for serial MRI imaging. This explains the increase in anesthesia exposures following guideline adoption seen in our study. This increase raises concerns as repeated use of general anesthetics and sedation in children younger than three may affect brain development (17).

Adoption of imaging practices also explains increased ICU stay and intubation. In our cohort, instead of immediate extubation following battery removal, patients remained intubated until initial cross-sectional imaging, which necessitated an ICU stay. Most patients were extubated following imaging and then transferred to general surgical or inpatient ward.

Adoption of guidelines had minimal impact on button battery removal practices in our cohort. At our institution, the choice to perform rigid or flexible endoscopy for esophageal BB removal depends on the experience and practice of the treating physician. Both techniques were utilized in our patient cohort with flexible EGD largely used by gastroenterology while rigid esophagoscopy was performed by general pediatric surgery or otolaryngology. Irrigation of the esophageal mucosa with acetic acid at time of battery removal did significantly increase, however was not universal with some patients receiving irrigation with normal saline or sterile water per provider preference, although the latter rinses do not neutralize pH (18).

As part of our study, we also reviewed clinical outcomes of patients with esophageal BBI at our institution before and after guideline adoption. Anatomic complications occurred in 19% of our cohort, with no differences between the groups. The most common complication seen was esophageal stricture. Severe anatomic complications were seen in both groups, reflecting the overall significant risk following battery ingestion. In our cohort, anatomic complications from BBI were seldom identified at the time of removal, instead occurring 4–25 days after removal. This likely reflects the growing understanding that these complications develop during the healing process following battery removal. Hospital readmission was not affected by guideline adoption in our study, however outpatient follow-up did increase.

Our descriptive data clinical course of esophageal BBI at our institution also identifies continued gaps in knowledge as well as gaps in current guidelines for clinical management of esophageal BBI, summarized in Figure 2.

Continued gaps in management of esophageal button battery ingestion. Summary list of areas that need more evidence-based guidelines and multidisciplinary collaboration.

Honey or sucralfate administration is recommended in NCPC guidelines, a recent publication by Lerner et al, and 2020 ESPGHAN guidelines for patients with known esophageal BBI to mitigate esophageal mucosal damage (8–10). In our cohort, honey was only given in one case and zero patients received sucralfate. This is most likely due to a fundamental lack of knowledge by caregivers. Interestingly, Poison Control was contacted only twice by parents or outside medical practitioners before presentation at our institution. Additionally, NCPC guidelines stress honey administration should only be performed if battery was ingested within prior 12 hours. In our cohort, nearly one-third of patients would not have been eligible for this intervention as ingestion was unsuspected or duration was unknown. In addition, while honey or sucralfate administration has been shown effective in animal studies human studies are still lacking (18–20).

Although guidelines universally recommend emergent endoscopic removal of esophageal button batteries, evidence regarding optimal removal technique is lacking. NASPGHAN guidelines recommend flexible EGD first but discuss that rigid endoscopy may be necessary in some cases (7), and recent studies have demonstrated safety and efficacy of both techniques (21,22). Of note, approximately 20% of patients in our cohort required use of both rigid and flexible endoscopy for battery removal, either addition of rigid scope in difficult removals or addition of flexible scope for improved injury visualization and controlled irrigation. This suggests that further investigation into esophagoscopy techniques with comparative data may be helpful to guide practice in the future. Timing and role of repeat EGD in these patients has been suggested by some authors but has not been clearly evaluated (23). Another gap in both guidelines and current knowledge is accurate quantification of severity of mucosal injury at time of battery removal. Guidelines and literature frequently reference “severe injury,” however there is no universally accepted quantification scheme. In addition, no literature exists to correlate severity of mucosal injury at time of battery removal with clinical outcome in these patients.

The adoption of cross-sectional imaging guidelines clearly affects clinical care and hospital course in patients with esophageal BBI. Our data demonstrates that serial imaging significantly increases the possibility of a prolonged hospital stay and need for repeated anesthetics in this patient population. Unfortunately, while case reports and recent single center reviews have discussed relevant imaging findings on both CT, CT angiography (CT/CTA) and MRI the direct role cross sectional imaging plays in clinical decision making is still unclear (15,24–26). In our cohort, one patient developed an AE fistula 25 days after battery removal despite serial MRIs documenting improvement in imaging findings and a normal esophagram (27). This highlights the need for further investigation into diagnostic imaging techniques and specificity of imaging findings to predict severe outcomes.

Additionally, guidelines published in the anesthesia literature recommend rapid sequence intubation and more liberal NPO guidelines to facilitate decreased time to battery removal (28). Such recommendations could be incorporated in to NCPC or NASPGHAN guidelines or become part of a multi-disciplinary guideline.

Airway assessment in this cohort was highly variable, often occurring in response to imaging or clinical symptoms. While airway assessment is not a focus of currently published expert-opinion guidelines, it is an important evaluation that requires further study especially regarding timing and needs to be incorporated into multi-disciplinary guidelines (23,29).

Very little published data regarding nutrition and feeding practices is available in this patient population. NCPC recommends soft foods for 28 days in patients following esophageal battery removal “to avoid mechanical damage to the healing esophagus (8).” All current guidelines recommend nil per os (NPO) if severe injury is seen. Recent guidelines recommend advancing diet once esophagram has excluded perforation (9,10). Feeding practices in our cohort were highly variable. Nearly all patients in our cohort had disruption of normal feeding. NPO time was prolonged following adoption of guidelines and there were more overall periods of NPO time due to repeat imaging requiring anesthesia/sedation. Additionally, post-adoption more patients received enteral tube feedings and parenteral nutrition with central line placement. There is data in both intestinal rehabilitation literature and inflammatory bowel disease literature that continued enteral feeding during periods of illness promotes mucosal healing in the intestine and “gut rest” is detrimental (30,31). An oral liquid diet or prolonged tube feeding might minimize risk of damage from solid foods and early enteral feeding might promote esophageal mucosal healing. Further investigation and recommendations are needed regarding appropriate nutrition in this population of young children where prolonged NPO time could impact a period of crucial growth and development.

Finally, the impact of increased resource utilization that results from increased interventions and longer hospital stays because of clinical management guidelines requires further study. Our data clearly demonstrates that adoption of guidelines led to increased inpatient LOS and imaging, however it is unclear from our study or other published data that any intervention or imaging accurately predicts or prevents the development of severe anatomic complications or results in earlier detection. In addition, with increased interventions and longer hospital stays, there is an increased financial cost of these hospitalizations to the system overall as well as increased emotion and financial burden on patients and families (32,33). Further study regarding resource utilization, financial and emotional costs of BBI is needed.


The results of this study should be interpreted within the context of its limitations. Research was limited to a single urban pediatric hospital system. While nearly all ingestions in our state are referred to our center for definitive care, this study reports only those patients with battery removal and hospital care at our institution. This study reports a large cohort of esophageal BBI, however the total number remains statistically small, and the number of complications is even smaller, so data may not be generalizable.

This report collected data retrospectively over the course of 12.5 years. During this period, expert-opinion guidelines from NCPC and NASPGHAN including use of mitigation strategies, imaging, and antibiotic administration were actively changing. Additionally, while institutional guidelines created in 2018 for clinical management following esophageal BBI were strongly encouraged they were not strictly enforced. Although this creates some variability in our data sets, the overall statistics remain significant. Airway assessment and antibiotic use were beyond the scope of this study. Finally, this study is limited in that the data is descriptive.

Work is on-going at our institution to further standardize care and to facilitate future data collection and analysis in this patient population.


This article provides one of the first and largest reviews comparing patient care after institutional adoption of guidelines in the care of patients with esophageal BBI. We demonstrated that adopting guidelines resulted in increased serial imaging and prolonged monitoring for complications which resulted in an expected increase in hospital length of stay. Serial cross sectional imaging may also have led to increased intubations and anesthesia events, ICU stays, and longer and more frequent NPO periods; however, this study also highlights continued gaps in management of esophageal BBI. Expanded, collaborative guidelines which incorporate recommendations and concerns from other disciplines including radiology, anesthesiology, and surgery are needed. In addition, it is important to develop nutrition guidelines in these toddlers who are at risk for malnutrition and in an important stage of growth and development. Our study highlights the need for collaborative guidelines which must include hospital care, nutrition, and outpatient follow-up. Further collaborative multi-institutional studies are needed in order to study the impact of clinical interventions on both short and long-term outcomes.


We would like to thank Dr Elizabeth Saunders for assistance in preparing this manuscript.


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button battery; esophagus; foreign body

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