Mitigating Risks of Swallowed Button Batteries: New Strategies Before and After Removal

Abstract

Despite ongoing efforts of the national Button Battery Task Force (BBTF), cases of major morbidity and mortality continue to be reported at a higher rate after ingestion of higher voltage and larger button batteries. Initiation of sucralfate or honey shortly after some button battery ingestions is crucial to prevent further injury while awaiting emergent removal. Endoscopic acetic acid irrigation post removal of button battery may halt deeper injury. Gastroenterologists need to be aware of the updates to the National Capital Poison Center algorithm for button battery ingestion.

In 2012, the National Button Battery Task Force (BBTF) was organized within the American Academy of Pediatrics (AAP) and American Broncho-Esophagological Association (ABEA) to develop, coordinate, and implement strategies to reduce the overall incidence and injury severity from button battery (BB) ingestions in children. The BBTF has active involvement by representatives from pediatric otolaryngology, surgery, gastroenterology, radiology, anesthesia, and emergency medicine and from the US Consumer Product Safety Commission and numerous industry representatives. The BBTF currently encourages multidisciplinary discussion and collaboration on research, public education, practice guideline development and dissemination, industry standard development, and hazard elimination ⁽¹⁾.

The ongoing efforts of the BBTF remain critical. Despite industry progress in creating more secure lithium battery compartments and making hazard warnings visible, cases of major morbidity and mortality continue to be reported at an increasing rate. National data suggest rates of all foreign bodies ingested by children under the age of 6 increased by 91.5% from 9.5/10,000 in 1995 to 18/10,000 in 2015, with a disproportionate incidence of battery ingestion. In 1995, only 0.14% of all ingestions in young children were from batteries, in 2015, this number increased to 8.4%. Almost 10% of children who ingested a battery required hospitalization ⁽²⁾. Toddlers are the most vulnerable population, and over 75% of ingestions occur in children under the age of 6 years ⁽³⁾. Regular household objects continue to be the source of most ingestions with more than 70% coming from hearing aids, games/toys, watches, and remote controls. Small electronic devices are now ubiquitous in most households and likely account for this trend. The majority of BB ingested by children under 6 years of age are removed directly from a device ⁽⁴⁾.

The rate of ingestion is further complicated by the increasing risk of severe morbidity and mortality ⁽⁵⁾. Most recent data from the poison control centers show a 5.8-fold increase in severe injury (life threatening or disabling) ⁽⁶⁾ and 12.5-fold increase in mortality between 1994 to 2005 and 2006 to 2017 (Fig. 1). The rise in complication rates mirrors the increase in ingestions of high voltage (3 V), larger lithium BB. In 1990, only 1% of battery ingestions were attributed to lithium batteries; by 2008 this increased to 25%. Similarly, ingestion of the larger, 20 mm batteries rose from 1% to 18% and accounted for 94% of all mortalities ⁽⁶⁾. However, it should be noted that the smaller nonlithium BB are also capable of life-threatening injuries, and smaller diameter BB can get lodged in the esophagus of young children.

FIGURE 1: Moderate and major fatal outcomes of button battery ingestion. Reproduced with permission from National Capital Poison Center button battery ingestions statistics, https://www.poison.org/battery/stats.

MECHANISM OF INJURY

The esophagus has anatomically narrowed regions with increased likelihood of BB impaction, the most common being the area at the thoracic inlet ⁽⁷⁾. If a BB is lodged in the esophagus, it can cause initial tissue damage in 15 minutes ^(8,9). Cadaveric piglet esophageal studies showed that lithium BB caused injury most rapidly, with alkaline and silver oxide batteries requiring 2 to 4 hours longer to cause the same degree of damage. Zinc air batteries are less likely to cause esophageal damage likely secondary to the fact that the relatively aqueous, saliva-rich environment blocks any oxygen from entering the BB, preventing injury ⁽⁹⁾. The injury caused by lodged BB occurs because of an isothermic hydrolysis reaction at the battery's negative pole and generation of hydroxide. The rapid increase of pH to 12 to 13 causes liquefactive necrosis and deep tissue injury. The positive pole of the battery creates a focal acidic tissue environment but because of the nature of coagulative necrosis, the depth of injury is limited. Even “spent” batteries that no longer power a product, can cause damage in this fashion as retained capacitance is enough to cause the electrochemical reaction. Leakage of alkaline electrolyte and pressure necrosis are no longer thought to be significant factors in causing severe tissue damage. Complications from tissue injury and necrosis are well known to occur after removal of the BB, with delayed bleeding events reported up to 27 days postremoval and esophageal perforations up to 48 days postremoval ^(10,11).

MORBIDITY ASSOCIATED WITH BUTTON BATTERY INGESTION

Prompt diagnosis of BB ingestion is paramount to decrease morbidity and mortality. This is challenging given that a majority of the severe outcomes are associated with unwitnessed ingestions, and most patients remain asymptomatic until a complication occurs ^(10,12). Presenting symptoms are nonspecific and include vomiting, dysphagia, chest pain, abdominal pain, tachycardia, fever, hematemesis, melena, cough, sialorrhea, dyspnea, and aphasia ⁽¹⁰⁾. A high index of suspicion is required. Investigation should start with an AP/lateral chest radiograph, with the knowledge that BB have a characteristic “halo” sign to differentiate it from a coin (Fig. 2).

FIGURE 2: Characteristic button battery X-ray appearance with a “halo” on anteroposterior view.

The most common injury from an esophageal button battery is tissue necrosis (Supplemental Digital Content 1, https://links.lww.com/MPG/B779). Severe complications reported include: esophageal stenosis, hemorrhage, tracheoesophageal fistula, vocal cord paralysis, spondylodiscitis, intestinal perforation with peritonitis, cardiovascular and respiratory failure, pneumothorax, pneumoperitoneum, mediastinitis, and anterior spinal artery syndrome with paralysis of both legs ^(10,13). Of children who had a complication, 1 publication reported 44% of patients required open surgery. Fatalities resulted from massive hemorrhage from arterial fistulation (aortic, subclavian, inferior thyroid), aspiration of blood, and bronchopneumonia. In just under half of deaths reported after BB ingestion, the cause was unknown ⁽³⁾. Children with severe sequelae of BB ingestion may require gastrostomy tube placement, parenteral nutrition, intubation, and extracorporeal membrane oxygenation (ECMO) ^(10,13). Since 1977, 59 fatalities have been reported. Nineteen died despite removal of the battery; death occurred between 2 and 80 days after intervention.

CRITICAL UPDATES FOR INTERVENTIONS BEFORE AND AFTER BATTERY REMOVAL

Recent changes to the Poison Control Center guidelines for BB ingestions were driven by important piglet experiments conducted by Jatana et al, that showed neutralization of the alkaline tissue environment after battery ingestion decreased the risk of tissue damage and halted eschar formation. This was initially demonstrated by irrigating a piglet esophagus with an impacted lithium battery every 5 minutes with acidic liquids, such as cola, lemon, and orange juice. All of these were effective at limiting tissue damage to various degrees ⁽⁹⁾. Next, Anfang et al, tested sucralfate (Carafate) and honey in an in vitro cadaveric and in vivo piglet model. Sedated piglets were randomized to receive 10 mL of honey, sucralfate, or saline 10 minutes post button battery placement in the esophagus and every 10 minutes thereafter. The honey and sucralfate neutralized esophageal tissue and reduced esophageal burns. Half of the saline control group developed esophageal perforations 1 week after ingestion compared with no perforations in the piglets treated with honey or sucralfate ⁽¹⁴⁾. In accordance with this data, the National Capital Poison Center (NCPC) BB Triage and Treatment Guidelines have been modified to include honey or sucralfate as first-line therapy after suspected or witnessed ingestions <12 hours (Fig. 3).

FIGURE 3: Management algorithm for ingestion of button batteries in children. Adapted from Kramer et al (18). ¹Consider airway evaluation if there is pre-operative concern for airway injury (TEF), especially when negative pole of battery in facing anteriorly or if any airway related symptoms are present. ²Criteria for gastric (and beyond) batteries for observation only: no history of prior esophageal disease, no magnet co-ingestion, and reliable follow-up. May require endoscopic evaluation on a case-by-case basis taking into consideration the timing of the ingestion if it was witnessed; and considering higher risk of injury in patients ≤5 years of age and battery size ≥20 mm.

The work by Jatana et al also suggested that irrigation of tissue with 50 to 150 mL of 0.25% acetic acid after battery removal may prevent delayed injury ⁽¹⁴⁾. For decades, the medical community was advised against neutralization for fear of causing a thermal injury. In the piglet esophagus model, however, only a minimal increase in esophageal temperature (0–3^oC) was noted and no thermal injury was seen. This neutralizing strategy was recently used post button battery removal in a series of 6 pediatric patients using 0.25% acetic acid-neutralizing irrigation ⁽¹⁵⁾. All cases were reported to have improved mucosal appearance after irrigation. None of the patients experienced perforation or stricture formation. This is thought to be because of immediate pH neutralization towards physiologic range and arrest of liquefactive necrosis ⁽¹⁵⁾.

To remain aligned with work of the BBTF, which includes representation from the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the AAP, it is imperative that all pediatric gastroenterologists be aware of the new recommendations from the NCPC BB Triage and Treatment Guideline to consider the administration of honey or sucralfate as first-line therapy while the patient is en route to the hospital or awaiting BB removal, as well as the postremoval 0.25% acetic acid irrigation tissue neutralization.

ESOPHAGEAL BUTTON BATTERY: PREREMOVAL

In the child over the age of 12 months who presents with a suspected or witnessed ingestion of button battery <12 hours prior and who is able to swallow liquids and for whom commercial honey is immediately available, caregivers are advised to administer 10 mL of honey by mouth every 10 minutes up to a total of 6 doses while en route to the emergency room. The child should otherwise remain NPO. Arrival at a medical facility should not be delayed. Once the child is in a medical care facility, either sucralfate suspension, 1 g/10 mL or honey, 10 mL should be given orally every 10 minutes, up to 3 doses, until radiographic confirmation of esophageal impaction or transfer to OR for BB removal. Sucralfate can also be used instead of honey for infants under 12 months. Use of sucralfate is not FDA-approved for this indication.

The BB should still be removed as soon as possible, irrespective of the child's NPO status, as esophageal damage can begin to occur within 15 minutes after impaction. Administration of honey/sucralfate should not delay battery removal. These guideline changes have been supported and well circulated in the anesthesia literature, and rapid sequence intubation techniques have been recommended ⁽¹⁶⁾. Endoscopic removal is preferred to allow direct visualization for precise removal of the BB and evaluation of tissue injury. In the Netherlands, BBs were removed by pediatric gastroenterologist 50% of the time, by otolaryngology via rigid esophagoscopy 37.5%, and by surgical thoracotomy 12.5% ⁽¹³⁾. Although data on success of removal of esophageal button batteries are limited, overall successful removal of swallowed foreign bodies by flexible and rigid esophagoscopy is reported at higher than 94%. Availability of both flexible and rigid esophagoscopy techniques may be helpful if an initial attempt at removal fails ⁽¹⁷⁾.

ESOPHAGEAL BUTTON BATTERY: POSTREMOVAL IRRIGATION IN OPERATING ROOM

After removal, the mucosa surrounding the battery should be inspected to determine the extent, depth, and location of tissue damage. It is important to identify if the negative pole (narrower/step-off side without the “+” and without the imprint of the name/type of battery) is facing anteriorly or posteriorly as this will inform the direction of maximum injury and the potential structures at risk. Care should be taken to avoid pushing an esophageal BB distally into the stomach as the risk of esophageal perforation may increase. After removal whenever clinical suspicion for perforation is low, the injured areas should be irrigated with 50 to 150 mL of 0.25% sterile acetic acid with excess fluid and debris removed via the endoscope. If airway injury is suspected, consider direct laryngoscopy and brochsocopy under the same anesthetic to evaluate further. Multidisciplinary care of BB ingestion patients is often needed.

Pediatric gastroenterologists should also be cognizant that delayed complications after esophageal BB removal are common and should be anticipated based on location and degree of injury. After removal, if perforation is suspected, consider starting intravenous antibiotics and maintain NPO status. If no concern for perforation on esophagram, children can advance diet to clear liquids and soft diet. Antibiotics can be discontinued if no perforation is identified. Concern for injury near major vascular structures should prompt early computed tomography (CT) angiography or MRI of chest ⁽¹⁸⁾, although no definitive data exist to stratify risk based on the imaging at this time. Involvement of the cardiothoracic surgery team is crucial when potential injury to vascular structures is a concern. Advancement of diet, second look endoscopy, subsequent imaging, and discharge should be determined based on individual cases ⁽¹²⁾. Any airway or gastrointestinal symptoms that occur subsequent to ingestion should be investigated fully. A ‘sentinel bleed’, typically an episode of hematemesis or melena that appear in an otherwise well appearing child, is the classic first presentation of esophageal fistulization to a major vascular structure and may precede a catastrophic bleeding event by hours.

Multidisciplinary involvement is critical in these severe cases as involvement of cardiothoracic surgery and ECMO team is imperative to try achieving a life-saving outcome.

GASTRIC BUTTON BATTERIES

To date, the NCPC has recorded 3 fatalities in children where the battery was initially discovered in the stomach. In these cases, the cause of death was likely because of esophageal injury that occurred from the BB in transit. These children were 13 months of age or younger. Gastric necrosis of uncertain clinical significance has also been reported by BB within the stomach in asymptomatic children ^(19–22).

If a child with a gastric BB is symptomatic in any way, prompt endoscopic evaluation and removal is recommended. In symptomatic patients, both the NASPGHAN Endoscopy committee and NCPC guidelines recommend evaluation of the esophagus for injury, which may have occurred while the battery was lodged in the esophagus before progressing into the stomach.

If the child is asymptomatic and has no history of prior esophageal disease, no magnet co-ingestion, and reliable follow-up, observation may be considered. This decision will require an evaluation on a case-by-case basis taking into consideration the timing of the ingestion and the increased risk of injury in patients ≤5 years of age and battery size ≥20 mm. Abdominal radiograph should be repeated in 2 to 4 days, and the battery should be removed if still intra-gastric.

CONCLUSIONS

Despite the tremendous effort and accomplishments by the BBTF, in coordination with government agencies and industry representatives, the incidence of morbidity and mortality associated with button battery ingestions continues to increase. Our new algorithm reflects mitigation strategies, which have been shown to be effective at reducing injury in animal models. Before battery removal, the administration of serial doses of honey and/or sucralfate can be considered to reduce initial injury. After battery removal, to reduce injury progression, a tissue neutralizing 50 to 150 mL 0.25% acetic acid irrigation can be performed. We believe these new recommendations should be implemented promptly by all pediatric providers, including pediatric gastroenterologists. Further efforts for injury prevention through hazard reduction or elimination are needed to avert devastating complications of BB ingestion. Further expert multidisciplinary collaboration by the BBTF is planned in order to harmonize differences in various existing BB management guidelines.