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