Button battery ingestions account for approximately 14 per 100,000 emergency department visits, according to a recent paper published in Current Gastroenterology Reports. Though rare, gastrointestinal bleeding associated with button battery ingestion can be fatal in up to 81% of cases. This complication is more common in children less than 5 years old, if the battery was 20 mm in size or greater, if the ingestion was unwitnessed or if the battery was lodged in the esophagus for a prolonged period.
Ali Andre Mencin, M.D., a pediatric gastroenterologist and chief of the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at NewYork-Presbyterian & Columbia, was the senior author on the paper that proposes a gastrointestinal bleeding management algorithm for button battery ingestion.
Below, Dr. Mencin shares the importance of evidence-based guidelines for managing vascular complications of button battery ingestion, and how physicians can prevent and mitigate button battery-related injuries.
How Button Battery Ingestions Can Lead to Serious Complications
Several factors can influence the severity of injury caused by button batteries, including the size of the child, the size of the battery, and the amount of time it takes for the child to receive emergency care. Serious complications from ingestion can include esophageal perforation, tracheal fistula formation, and life-threatening hemorrhage from an arterio-esophageal fistula among others.
If there is suspicion for vascular injury or any history of bleeding in the context of a battery ingestion, the child should be managed at a center with cardiothoracic surgery.
These complications are typically seen in cases where the child is less than five years of age, and the button is greater than 20 millimeters in diameter. If the battery lodges in the stomach rather than the esophagus, complications tend to be less severe.
Though significant injury can occur in as little as 15 minutes after the battery makes contact with the esophagus, most of the time severe damage happens when the battery ingestion goes unrecognized for several days. Ideally, a child with a button battery lodged in their esophagus should have the battery removed within two hours of ingestion.
Our hope is that this paper will inform new guidelines and encourage more research on button battery ingestion to support specific management decisions.
— Dr. Ali Mencin
Counseling families about the dangers of button batteries is one way to try to prevent ingestions. These discussions could be done during routine preventive care counselling for young children about swallowing foreign bodies and keeping children safe from harmful substances such as cleaning products. Manufacturers have made significant progress by placing warning labels on the packaging of items that contain button batteries. Some batteries are also coated with substance that colors the tongue blue or has bitter taste. It is important to educate families about storing button batteries out of the reach of children and bringing a child to the emergency department immediately if there is a suspected button battery ingestion.
Managing Vascular Complications of Button Battery Ingestion
Given that there is scant evidence-based literature to guide clinicians on managing button battery-related vascular injury, our hope is that this paper will inform new guidelines and encourage more research on button battery ingestion to support specific management decisions.
The management algorithm that we propose in our paper is a synthesis of algorithms published by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), with a focus on how to manage vascular complications. We also propose an endoscopic scoring system and imaging guideline to help determine a patient’s risk of developing a vascular injury. We hope that the algorithm and the scoring systems will help clinicians assess whether the patient’s injury is mild or severe to inform treatment decisions and address potentially fatal complications.
Button Battery Ingestion Protocol at NewYork-Presbyterian and Columbia
Every institution should have a protocol in place for managing button battery ingestions. The most important part of management is urgently seeking medical attention for immediate battery removal. If there is a delay in coming to the emergency department – for example, a patient who lives in a rural area far from the nearest hospital – a child older than 1 year of age can take honey which can coat and protect their esophagus while in transit to the emergency department.
Typically, a standard protocol includes an X-ray as soon as possible to determine where the battery is lodged. The next step is to get the patient into operating room or endoscopy suite as quickly as possible for removal. While some institutions designate one type of provider to perform all battery removal procedures, our protocol in the operating room at NewYork-Presbyterian and Columbia is to leverage the expertise of gastroenterologists, general surgeons, and otolaryngologists as needed.
Vascular injury can progress following button battery ingestion. It’s essential that centers that do not have cardiothoracic surgery capabilities have a protocol in place to immediately transfer patients with a confirmed or suspected vascular injury to a center like NewYork-Presbyterian and Columbia where they can receive surgical or endovascular treatment.
