What Are the Treatment Guidelines for Button Battery Ingestion?

What Are the Treatment Guidelines for Button Battery Ingestion?

Patient Presentation
A 2-year-old female came to the emergency room after her mother found her playing with a toy and only 1 of the two button-like batteries could be found about 1 hour previously. The mother stated that the child and her 6 year old brother had been playing quietly and she was doing household tasks. The brother could not provide more information. There were no other battery toys in the area where the children were playing and the mother denied magnets in the home. The review of systems was negative for coughing, choking, abnormal voice or swallowing, pain, lethargy, irritability, emesis, diarrhea or fever. The pertinent physical exam showed a well-appearing female in no distress with normal growth patterns. HEENT, lung and abdominal examination were negative. The radiologic evaluation showed a round foreign body in the stomach.

The diagnosis of a button battery ingestion was made. The mother had stated that the batteries were bigger than a pencil eraser but not as big as a penny. A family friend went to the home and brought the toy. The sister battery measured 11 mm. The patient was discharged home with instructions to check the child’s stools for the battery and to go to their regular physician for an x-ray if the battery could not be found in the stools in 10 days. The emergency room physician emphasized to follow up if the child complained of any even minor symptoms as the battery may still need to be removed.

Case Image
Figure 101 – AP radiograph of the abdomen (from another patient) demonstrates a round radiopaque object in the antrum of the stomach that appears to be a button battery.

Discussion
The number of battery related visits and injuries are increasing. Data from 1990-2009 found 65,788 emergency room visits for battery-related exposures in < 18 year olds or an average of 3289/year. Data from 1995-2010 for children < 13 years estimated that 40,400 children were seen for battery related injuries. This same data found that ~75% were in children < 4 years of age and 10% required hospitalization. Overall 14 fatalities were reported and 12 recorded the battery-type; all were button batteries.

Button batteries, particularly those made of lithium and > 20 mm in diameter, are the most concerning. Lithium batteries do not cause injury because of leakage but have an irritating electrode and often have higher energy that generates more current. Many lithium batteries are 3-V batteries as opposed to 1.5 V in other types. Lithium causes electrolysis of tissue and localized hydroxide generation at the negative pole (smaller side of the button battery and without the imprint). Batteries in the esophagus can cause injury in as little as 2 hours.

Analysis of fatalities has shown many non-specific presenting symptoms including fever, emesis, lethargy, poor appetite, irritability, cough, wheezing and/or dehydration. This makes it very difficult to determine what evaluation and/or treatment is necessary particularly in unwitnessed events. Additionally, even if batteries are removed, some patients had unanticipated, uncontrolled bleeding up to 18 days later.

Some size comparisons include: pencil eraser = 6-7 mm, dime = 18 mm, penny = 19 mm, nickel = 21 mm, quarter = 24 mm. Hearing aid batteries are considered < 12 mm.

Learning Point
An algorithm for evaluation and treatment of button batteries was proposed in 2010 and has been used frequently to guide management decisions. Key elements of the algorithm include child’s age, battery size, battery location, symptoms, time and co-ingestion (such as magnets). A pictoral and text-based algorithm can be found from the National Capital Poison Center at http://www.poison.org/battery/guideline.asp. Management questions can also be directed to the National Battery Ingestion Hotline at 202-625-3333 or the website at National Capital Poison Center.

Questions for Further Discussion
1. What problems can magnet ingestion cause?
2. What advice should be given to families to avoid battery-related injuries?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foreign Bodies

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010 Jun;125(6):1168-77.

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 Aug 31;61(34):661-6.

Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990-2009. Pediatrics; 2012;129:1111-1117.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    December 24, 2012

  • What Are Common Presentations of Primary Immunodeficiencies?

    Patient Presentation
    A 4-year-old male with known X-linked agammaglobulinaemia (XLA) came to clinic with persistent diarrhea for the past 2 days. The stools were initially looser but now had a watery consistency and were increasing in frequency. There was no blood or mucous in the stools but they were noxious smelling. His last antibiotic treatment was one month ago for otitis media. The younger sibling attended daycare and rotavirus was occurring in the toddler rooms, but the sibling was asymptomatic. He was able to drink and was urinating 3-4 times/day.

    The past medical history showed the diagnosis of XLA at 9-10 months of age after several episodes of otitis media, diarrheal infections and a complicated pneumonia. He also had poor weight gain. The pertinent physical exam showed a tired appearing male with normal vital signs. He was thin appearing with weight at the 10% and height at the 15%. HEENT showed multiple scars of his tympanic membranes. Mucous membranes were wet. His lungs were clear. His abdominal examination showed increased bowel sounds without organomegaly. Genitourinary examination was normal. The diagnosis of probable viral diarrhea in an immunocompromised child was made. After discussion with his immunologist, the patient was sent home with instructions for increasing fluids, home monitoring and close telephone contact. The laboratory evaluation of a stool culture was eventually positive for rotavirus, and he slowly improved over the next week.

    Discussion
    Of the various primary immunodeficiencies (PIDs), primary antibody deficiencies are the most common. B-cell deficiencies that occur early in the maturational process (i.e. Bruton’s or X-linked agammaglobulinaemia) tend to be more severe than those that occur later (selective IgA and IgG subclass deficiencies.)

    X-linked agammaglobulinaemia (XLA) was first described by Bruton in 1952 and is caused by the gene BTK, a protein tyrosine kinase that blocks B-cell maturation resulting in severely decreased B-cells and all classes of antibodies. Female carriers are asymptomatic generally and males have clinical manifestations with problems occurring after 3-4 months of age (because of circulating maternal antibodies) but before 1 year. Recurrent respiratory tract infections are frequent presentations (60-80%) especially otitis media, sinusitis, and pneumonia. Diarrhea also occurs (25%). Common pathogens include S. pneumonia, H. influenzae, Staphlococcus sp., Pseudomonas sp., and Giardia sp.. Long term, patients may have malignancies and chronic pulmonary damage.

    Children with immunodeficiencies often have other logical reasons for the problems they are having. Thus, their immunodeficiency is not diagnosed or is diagnosed later.
    There is no absolute indicator as to when a child should be evaluated for a potential immune problem but the following can be considered:

    • Systemic bacterial infections, 2 or more, e.g. sepsis, meningitis, deep abscess
    • Bacterial infections, 3 or more, e.g. draining otitis media
    • Upper respiratory infections, > 6-8 in one year
    • Recurrent infection of same organism, e.g. meningococcemia
    • Need for surgical treatment, e.g. drainage of abscess, lobectomy for chronic pneumonia
    • Failure to thrive, weight loss or growth retardation
    • Unusual infections, i.e. Pseudomonas carinii in a presumably normal child

    For a listing of common immunological tests to consider see When Should I Order an Immune Workup?

    Learning Point
    Common suspected primary immunodeficiencies with common mimics include:

    • Recurrent infections of the airway and head and neck
      • Antibody deficiency – normal recurrent infections
      • Complement deficiency – cystic fibrosis, primary ciliary dyskinesia, congenital anomaly
      • HIV – adenoid hypertrophy
      • Phagocyte deficiency – hyperreactivity including asthma, allergy
      • Wiskott Aldrich syndrome – inhaled foreign body
    • Recurrent infection with same pathogen
      • Encapsulated bacteria (= antibody deficiency) – recurrent exposure
      • Meningococci (= complement deficiency) – primary infection inadequately treated
      • Candida (= T-lymphocyte deficiency) – anatomical defects
      • Mycobacteria (= macrophage) – T-cell interaction problem
    • Recurrent pyogenic infections
      • Congenital granulocyte defects – neutropenia (drug-related or autoimmune), hematological malignancy, skin problems (i.e. burn, eczema), Staphlococcus aureus carriage of virulent strain
    • Unusual infections
      • HIV – chronic disease, malignancy, malnutrition, immunosuppressive therapy
      • Inate immunity defects
      • T-cell deficiencies including severe combined immunodeficiency and HIV – secondary immunodeficiency
      • Wiskott Aldrich
    • Failure to thrive
      • T-cell deficiencies including severe combined immunodeficiency and HIV – multiple causes

    Questions for Further Discussion
    1. Describe the laboratory findings for common variable immunodeficiency?
    2. List common T-cell defects?
    3. What vaccines are contraindicated in children with various immunodeficiencies?
    4. How effective are the vaccines that can be given?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Diarrhea and Immune System and Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Yong PF, Chee R, Grimbacher B. Hypogammaglobulinaemia. Immunol Allergy Clin North Am. 2008 Nov;28(4):691-713, vii.

    de Vries E, Driessen G. Educational paper: Primary immunodeficiencies in children: a diagnostic challenge. Eur J Pediatr. 2011 Feb;170(2):169-77.

    Driessen G, van der Burg M. Educational paper: primary antibody deficiencies. Eur J Pediatr. 2011 Jun;170(6):693-702.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    December 17, 2012

  • What Causes Thrombocytosis?

    Patient Presentation

    A 17-month-old male came to clinic with a rash on his left leg. The patient had been well except for recent upper respiratory infection symptoms for the past 2 weeks. The past medical history was negative. The review of systems showed no fever, emesis, weight changes, sweating, or fatigue.

    The pertinent physical exam showed a well-appearing toddler with normal vital signs and growth parameters between 50-90%. HEENT had shoddy anterior cervical lymph nodes and moderate rhinorrhea. Abdomen was negative. His skin examination revealed an area of petechiae on the inner left lower leg. He had some mild bruising on bilateral shins in different states of healing. He had no other lesions. Lymph nodes were negative on the rest of the body except for shoddy inguinal nodes bilaterally. The laboratory evaluation revealed a complete blood count with a hemoglobin of 11.2 mg/dl, white blood cell count of 20.8 x 1000/mm2 and platelets of 180,000 . The laboratory technologist called to say that the platelet count was not reported normally because the platelets were in clusters and the estimated count was more than 1 million. Additionally, many of the white blood cells appeared to be uniform blue cells. The smear was being sent for pathologist’s review because of the abnormalities including the possibility of a malignancy. Liver function tests and viral panels were also sent.

    During the patient’s clinical course, the physician contacted a hematologist with an appointment the next day. During that visit, the hematologist confirmed the petechiae which had not spread over the night. Another complete blood count had a white blood cell count of 18.3 x 1000/mm2 and 740,000 platelets. The blood smear review showed many white blood cells that were reactive but did not appear malignant and some of the platelets were in clusters but many more were not. The liver function tests had very mild transaminase elevation, and the viral panel was positive for cytomegalovirus. This was felt to be the presumed diagnosis and the patient was followed. Over the next two weeks, the laboratory tests normalized and the patient was doing well.

    Discussion
    Cytomegalovirus (CMV) belongs to the herpes virus family. It can be acquired though contact with infected body fluids and cause primary infection. It can also become latent and then reactivated. It is also possible to become infected with another CMV strain.

    Primary maternal CMV infection has a 30-40% risk of transplacental transmission to the fetus, and if infected a 20-25% risk of some type of developmental problems in the child. Most congenitally infected infants have no symptoms at birth but 5-15% will have sequelae such as hearing loss, vision problems or mental retardation. If affected at birth, common symptoms include growth retardation, microcephaly, hepatosplenomegaly, jaundice, anemia, thrombocytopenia, petechiae and chorioretinitis. Death occurs in 20-30% of affected infants. Additionally, in transplant patients or patients with immunodeficiency, CMV can be a major cause of morbidity and mortality.

    Immunocompetent children and adults usually have no symptoms and no long-term problems. Flu-like symptoms can occur including fever, malaise, myalgia, cervical lymphadenopathy and sometimes pneumonia or hepatitis.

    Extreme hyperthombocytosis is generally defined as > 1 million platelets. It does occur but usually only in a small percentage of cases (0.5%).

    Learning Point

    The differential diagnosis of thrombocytosis includes:

    • Reactive
      • Anemia, iron deficiency
      • Arthritis, rheumatoid
      • Bacterial infection
      • Inflammatory bowel disease
      • Post-splenectomy or functional asplenia
      • Rebound after drugs/alcohol
      • Surgery
      • Trauma
    • Myelodysplastic disorder
      • Acute myelogeous leukemia
      • Chronic myelogenous leukemia
      • Essential thrombocythemia
    • Von Willebrand type II
    • Artificial
      • Cryoglobulinemia
      • Cytoplasmic fragments
      • Pseudohyperkalemia

    Extreme or hyperthrombocytosis

    • Infection – 31%
    • Postsplenectomy or hyposplenism – 19%
    • Malignancy – 14%
    • Trauma – 14%
    • Inflammation (noninfectious) – 9%
    • Blood loss – 6%
    • Rebound thrombocytosis – 3%
    • Uncertain – 4%

    Questions for Further Discussion
    1. What causes leukocytosis?
    2. What causes thrombocytopenia? See “What is the Approach to a Child with Thrombocytopenia?”

    Related Cases

      Symptom/Presentation: Rash

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Cytomegalovirus Infections and Platelet Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Wiedmeier SE, Henry E, Burnett J, Anderson T, Christensen RD. Thrombocytosis in neonates and young infants: a report of 25 patients with platelet counts of > or = 1000000 microl(-1). J Perinatol. 2010 Mar;30(3):222-6.

    Chiarello P, Magnolia M, Rubino M, Liguori SA, Miniero R. Thrombocytosis in children. Minerva Pediatr. 2011 Dec;63(6):507-13.

    Tefferi A. Approach to the Paitent with Thrombocytosis. Up to Date.
    Available from the Internet at http://www.uptodate.com.proxy.lib.uiowa.edu/contents/approach-to-the-patient-with-thrombocytosis?source=search_result&search=thrombocytosis&selectedTitle=1%7E150 (rev. 9/6/2012, cited 10/16/2012).

    Yinon Y, Farine D, Yudin MH et. al. Cytomegalovirus in Pregnancy. SOGC Clinical Practice Guideline. JOGC 2010;348-353.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital