Management of button battery ingestion

In this Issue of Clinical Toxicology, Vaucel and colleagues [1] have retrospectively created and validated a tool based on clinical indicators, called the button battery impaction score, to risk stratify the probability of a button battery being lodged in the oesophagus. The aim of this tool is to facilitate the triage process, directing individuals to an appropriate medical facility.

The ingestion of button batteries represents a substantial risk to children, as indicated by the escalating frequency of severe or fatal incidents in recent decades [2–4]. This increasing trend can be attributed to the expanding utilization of button batteries in electronic devices [5]. Children less than 4 years of age are particularly susceptible to injuries because of their smaller and narrower oesophagus, coupled with their tendency to frequently place objects in their mouths. Animal studies have shown that necrosis can occur as quickly as 15 min after ingestion [2], and severe injury can occur within 2 h [3]. Hence, a suspected ingestion of a button battery is a time-critical issue that requires urgent medical imaging to determine the location of the battery [3] to allow urgent endoscopic removal within 2 h if lodged within the oesophagus [2, 6].

However, whilst suspected button battery ingestions are common, a parent or caregiver actually witnessing the ingestion is uncommon [4]. A prospective observational study of button battery exposure calls to the New South Wales Poison Information Centre reported that of 188 cases of possible button battery ingestion, only eight were witnessed [4], with four of these witnessed ingestions having a button battery lodged in the oesophagus. Cairns and colleagues [4] reported that the most common calls made were when batteries were noted to be missing (40%), children were spotted with the product (19%), and batteries were found near a child (13%) [4]. However, as a button battery lodged in the oesophagus can cause severe complications, all children were directed to hospital for urgent imaging [7].

The button battery impaction score [1] offers a clinical tool to potentially risk stratify children to an appropriate medical facility. Vaucel and colleagues [1] retrospectively reviewed 1,430 cases of suspected button battery ingestions in children less than 12 years old who were referred to eight French poisons information centres between 2015 and 2021. Of these, only 86 were found to have a button battery impacted in the oesophagus. The button battery impaction score that was developed and validated in this dataset consists of seven factors, including button battery size ≥ 15 mm and six features (cough, drooling, dysphagia/food refusal, fever, pain, vomiting). A score ≥ 1 had an 86% sensitivity for a button battery lodged in the oesophagus and a negative predictive value of 0.98, allowing the identification of lower-risk patients. This scoring system is simple and easy to apply in a pre-hospital setting. It can be used by poisons information centres to perform a risk assessment to allow triage to an appropriate centre with endoscopic capability in high-risk patients and provide first-aid treatments without causing any delay in definitive medical imaging.

Major limitations of this score are that it cannot be fully applied to children less than 2 years of age, as pain on swallowing, an important factor, is difficult to elucidate in this group, and the size of the battery must be known. Button battery ingestion is common in children between 1 - 2 years of age [4], with 19 (14%) of the 86 who had oesophageal impaction being less than 2 years of age.

Regardless of clinical symptoms and signs, suspected button battery ingestion in children requires urgent imaging (radiographs of the upper airway and chest). Another strategy employed by some poison centres to decrease the time to imaging is to notify the medical facility (i.e., emergency department) that a child has been referred to their service for urgent imaging. The medical facility is advised to perform a radiograph upon the patient’s arrival [4]. This is particularly useful in busy hospitals with prolonged waiting times, and this strategy could be implemented in all high-risk patients. Further validation of the button battery impaction score is required in other datasets and, ideally prospectively, to determine the benefits of this tool.

Vaucel and colleagues [1] noted battery size was an important risk factor for oesophageal impaction. The 20 mm diameter 3 V lithium button batteries pose the greatest risk (due to their size and voltage) and were responsible for 92% of severe and fatal button battery incidents [3, 8]. Among these incidents, the CR2032 button battery is implicated in 70% of cases [6]. It is important to note, that even smaller batteries can still cause significant caustic injury [9]. Additionally, it is noteworthy that button batteries with little to no remaining voltage can cause tissue damage (albeit less than a completely charged battery) due to capacitance retention [10].

Given the potential for significant harm, another area of research in suspected button battery ingestion is to identify effective, accessible, and safe first-aid strategies to minimise tissue injury while awaiting definitive removal. A variety of household products have been tested as potential first-aid treatments [6, 11–13]. Currently, the most evidence, although limited to animal studies only, is for honey as a first-aid strategy. A button battery causes injury when lodged in the oesophagus as a closed circuit is formed between the anode and cathode of the battery, and an electrical current is generated [8, 14]. This causes water in the oesophageal mucosa to rapidly hydrolyse and produce hydroxide ions, creating an alkaline environment that facilitates caustic injury [10, 15]. The most extensive damage can be observed at the anode, where the hydroxide ions originate, resulting in pH levels as high as 13 [15]. The use of honey and sucralfate as first-aid measures is based on the theory that they act as physical barriers to protect against tissue damage. Being weak acids with viscous properties, they are thought to prevent electrolysis, reduce hydroxide formation, and lower the alkalinity of the environment, thereby limiting the extent of caustic injury [6]. In particular, honey is thought to be effective due to its low water content, which is intentionally designed to prevent fermentation and maintain honey quality [16]. As a result, it is highly viscous and can, therefore, act as a protective barrier for a longer period [6, 16, 17]. The advantage of honey or other household substances, such as the recently proposed jam, is that if available, they can be initiated easily by a parent or caregiver before the arrival of the child at a medical facility and continued in hospital until endoscopic retrieval for those with proven oesophageal impaction [6, 12, 13, 18].

The National Capital Poison Center [19] and the North American and European Societies for Paediatric Gastroenterology, Hepatology and Nutrition [14] have incorporated honey into their guidelines. The guidelines recommend either honey if within 12 h or sucralfate ingestion for patients awaiting endoscopic removal as these substances may potentially reduce injury severity. Honey as a first-aid strategy is also recommended to parents if button battery ingestion is strongly suspected in their child [14]. The advised dose is 10 mL every 10 min for a maximum of six doses of honey and three doses of sucralfate, respectively [14]. However, this should never delay the localization and removal of the button battery, which remains the definitive treatment. Honey is, however, not recommended for patients who have dysphagia, suspected perforations, mediastinitis, sepsis, honey allergies or who are less than 1 year old due to the risk of infant botulism [6, 14].

The evidence supporting this recommendation is limited to a few cadaveric oesophageal models and two animal studies [6, 11–13]. Most of the studies have been performed on cadaveric oesophageal segments (in vitro), and even in the two live animal models (in vivo), these substances were not swallowed by the animals but instead administered via syringes under anaesthesia [6, 18]. Hence, it is unknown if the amount of honey (or other tested substances) will coat the battery if swallowed and whether the protective effects of these household substances translate into a reduced area of injury in children. However, given the low risk of the intervention, the serious injury that can occur, and the possible benefits of honey, it has been adopted as a first-aid strategy in many guidelines.

It is important, however, to note that many serious outcomes from button battery ingestion occur after unwitnessed ingestions. In these cases, there is often a delay in recognition and diagnosis, as the child cannot readily give a history of ingestion [3]. So, although strategies such as the button battery impaction score, rapid access to imaging or first-aid strategies are important, public health measures to prevent ingestion are vital.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Angela L Chiew is funded by a National Health and Medical Research Council (NHMRC) Investigator Grant (Emerging Leadership 1): ID 2016380.