Evidence-Based Charm:
Button Batteries: Tiny, Shiny and Dangerous
Listen to “Evidence Based Charm: Button Batteries: Tiny, Shiny, and Dangerous” on Spreaker.
January 10, 2025
On today’s episode of Evidence-Based Charm, Courtney sits down with pediatric gastroenterologist, Dr. Ramalingam Arumugam, to discuss a lurking danger in our own homes. With approximately 3500 button battery ingestions per year, it is the fourth leading cause for calls to poison control centers in the United States. With high risk of morbidity and and an escalating risk of severe morbidity and mortality due to the increased use of larger and more powerful button batteries, we’ll explore past the natural history and review what federal regulations are being proposed and/or activated to protect our most vulnerable consumers – children.
Transcript
Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.
Welcome to Talking Pediatrics. I’m your host Dr. Kade Goepferd. On today’s segment, Evidence-Based Charm Guidelines with Courtney, hospitalist Dr. Courtney Herring informs us of the latest evidence-based, expert-driven clinical practice guidelines. Alongside her informative guests, she takes us through all the steps of care from ambulatory to inpatient and back again with a sizable dose of southern charm.
Dr. Courtney Herring: Welcome to today’s episode of Evidence-Based Charm, I’m your host Courtney Herring. With developing technology, the past few decades have seen an increase in demand for compact electronic products and a broadened use of more powerful batteries. The rise in the use of button batteries has been accompanied by the incidence of battery ingestion in children.
As developing curiosity demands young children use their senses to explore their environments and toddlers become increasingly mobile, safety risks become inherently different. With approximately 3,500 button battery ingestions per year seen mostly in under five-year-olds, it is the fourth leading cause for calls to poison control centers in the United States, and we’re not even to the scary part yet. Most ingestions are unwitnessed.
It is believed that the ingestion occurs soon after battery removal from whatever light up or singing toy or whatever household device it may come from. These batteries can cause significant injury when aspirated or swallowed. There has been a seven-fold increase in the incidence of severe morbidity and mortality since the turn of the century, which is due to the increased use of larger and more powerful button batteries.
In 2022, the US federal government passed legislation titled Reese’s Law, placing safety requirements on consumer products containing button sale or coin batteries in a significant stride towards enhancing child safety. To discuss more of the natural history and guidance around button battery ingestion, our guest today, Dr. Ramalingam Arumugam, has an expansive over 30-year career as a pediatric gastroenterologist, currently helping children by way of MNGI Digestive Health, based here in the Twin Cities.
He’s also a co-author of the Children’s Minnesota Button Battery Ingestion Clinical Practice Guidelines. I will dive right in. So Dr. Arumugam from your expertise, is button battery ingestion an emergency?
Dr. Ramalingam Arumugam: Yes, button battery ingestion is one of the most important urgent procedures we do as a pediatric gastroenterologist, ingestion of a button battery can result in immediate, devastating, often deadly consequences. So without waiting for any NPO status or COVID status, the child should be rushed into the children’s hospital, where there is a pediatric gastroenterology services available. And our goal is to remove the button battery from a child’s esophagus in less than two hours, which is often difficult to achieve, but that’s our goal.
Dr. Courtney Herring: So I love that conduit adds a little bit of complexity, because as we are aware, a lot of children do not start in a pediatric healthcare center for assessment. So what would you want first responders or clinicians to know about button battery ingestion and the initial part of triage?
Dr. Ramalingam Arumugam: I would like to know how old is this child, because younger children often end up having narrow esophagus and get lodged in the esophagus, so the age of the child, how many button batteries have been ingested, what is the stage of the… Whether it is a brand new button or is the so-called dead battery and how big the size of the button battery is, bigger the battery is, bigger than 15 millimeter, often results in entrapment in the esophagus and causes serious consequences. And whether any other ingestion of other foreign bodies like a magnet or other things was ingested, whether the child has any preexisting conditions like esophageal surgery or gastroesophageal reflux and other things will help us to plan our management strategy.
Dr. Courtney Herring: So having an idea, especially as the primary assessor of these children, of what type of button battery or even timing, as you already mentioned, some details of course can be crucial. Not only for timing for you as a proceduralist, but also just how to triage this patient, and that really I hope harkens back to what is the family looking for? What are the clinicians looking for for signs of ingestion but much less button battery ingestion, clinically?
Dr. Ramalingam Arumugam: Most of the time the button battery ingestion is unwitnessed. So when a physician or a medical provider comes in contact with this children, the symptoms can be very nonspecific, similar to viral illness or respiratory infection or gastrointestinal infection. The most common signs and symptoms are refusal to eat, throat pain, irritability and respiratory symptoms like cough, wheezing or choking and gagging and drooling can be an important sign.
And more recently some of the button batteries like Energizer battery comes with a coloring agent. So once it in contact with saliva or any moisture that results in bluish tinge, discoloration of the tongue or buckled mucosa, that should alert the emergency provider there is possibility of button pattern.
Dr. Courtney Herring: That’s amazing, and way go Energizer on that development. So really the clinical science of course non-specific, there are some to obviously be aware of. The unwitnessed part is so important in regards for even parents to have just a high awareness of the situation, but up to 20% is reported that they’re asymptomatic.
Dr. Ramalingam Arumugam: That’s correct.
Dr. Courtney Herring: Which of course is not good for a long-term clinical prognosis for some of us. So as we move forward in regards to primary assessment, what if they’re not in a pediatric healthcare center yet? What can those first clinicians do to help this patient?
Dr. Ramalingam Arumugam: The button battery, when it get lodged in the esophagus, results when both surfaces come in contact, it completes the circuit and that results in electricity, and that electricity causes hydrolysis of the fluid in the esophagus. During the process of hydrolysis, hydroxide ions are released that results in very severe alkaline milieu.
Normally, esophagus is neutral in pH. When there is an alkaline milieu, it can result in pH near 13 or 14, which is similar to ingesting a caustic. And so that severe alkaline environment results in liquefaction necrosis and that changes starts happening within 15, 30 minutes. So to mitigate this sequence of events happening, administration of honey, which is available in most houses and it is sweet, will be taken by children, 10 ML every 10 minutes administration for up to six times. It’s shown to minimize the damage happening due to button battery. If they are already in the medical facility, they can give sucralfate or Carafate, 10 ml every 10 minutes, up to three times can be administered. This should be done if the interval between ingestion and the administration is less than hours.
If there is more than 12 hours, there is a very distinct possibility that child would’ve developed already a perforation. We don’t want to give any of these which can result in mediastinitis and other things. Second is honey is also contraindicated in children less than 1-year-old because of the risk of botulism toxin. So if the ingestion is less than 12 hours, if the age is more than one year, and you can administer these preventative measures, which will mitigate the damage, and transporting the child to the nearest children’s hospital where the gastroenterology facility should be the number one priority.
When the child arrives to the emergency room, the child immediate start x-ray to localize where the foreign body is by taking an x-ray, AP and lateral view as well, as in young children including abdomen too to localize where the button battery is. This button battery has some typical radiological findings.
Unlike coin, which will also be a round radial-like shadow, button batteries will have a halo. There is two lines in the margin as well as in the lateral view. There will be a step off, find the positive side of the button battery as a bigger diameter and the negative side of the button battery as a narrower diameter.
So, it is the narrower side which results in most of the damage, so those things should be done immediately. Start consult to the ENT, as well as the gastroenterology service should be initiated and the child should be taken to the OR as soon as possible without waiting for NPO and other stuff. Our goal is to remove it as soon as possible.
Dr. Courtney Herring: And again, from a primary intervention, we are removing what is not included, which it can be with other types of ingestions or things that are forceful anti-emetics and/or even physical dislodgement with bougie, those are not indicated.
Dr. Ramalingam Arumugam: That’s correct.
Dr. Courtney Herring: Especially for our first responders who are trying to of course help us in the field. It’s good to know what our options. Good old honey, everyone. You thought it was just your grandma who said things like that.
Moving on to that definitive treatment, which of course is removal, and I thank you for the call-out for how do you look for this? A double view of lateral and AP chest X-ray is important of course to get the best idea, maybe some identifiers of the type of battery, but also of course location. So when you’re past the endoscopy, what are you looking for when you’re in endoscopy and what kind of complications could we see?
Dr. Ramalingam Arumugam: So when the button battery get lodged, bigger battery, that is more than 15 millimeter in diameter. In a smaller child, it gets lodged in the esophagus, even though the button battery can cause damage to any part of the GI tract, as well as ear, nose, throat, and other orifices. When it gets large in the esophagus, that’s where the deadly combination is.
Bigger battery, smaller child with narrower esophagus, trapped in the esophagus. When the both sides come in contact with each other, complete the circuit and results in this damage. So during the process of removal, you localize which side is the negative, if it is on the anterior surface of the esophagus, that can result in different sets of complications like perforation, tracheoesophageal fistula, fistulization between the esophagus and the major blood vessels like iota, which can cause devastating complication. If the negative side is facing the posterior wall of the esophagus, that can result in [inaudible 00:12:21] and other things. So removal of all the fragments of the button battery as soon as possible.
Even after the removal, the sequence of events continue to happen. See even after many days or even weeks, to mitigate those complications, we should administer topical irrigation of 0.25% acetic acid helps to neutralize the pH, which is from the 13, 14 to normal neutral pH, thereby preventing the liquefaction necrosis, which continues to progress.
Once you’ve taken it out, you make sure there is no perforation. If there is no perforation, then you administer this acetic acid and place a nasogastric tube, and after that procedure you transfer the child to intensive care unit for close monitoring. We will often do a contrast study to make sure there is no esophageal perforation, even though I didn’t see that in the endoscopy. We often do CT angiography to assess whether there is any damage to the nearby blood vessels, what is the site of impaction and what are the major blood vessels around it. Those [inaudible 00:13:41] radiological findings will help us to plan the long-term management and discharge instructions and other things.
Dr. Courtney Herring: I think as we move forward, how do we even think about discharge prep? How do we talk to the medical team? You mentioned follow-up imaging to ensure some of the at least early peaks at potential complications, which isn’t perfect. What is the timeline you’re giving medical teams and/or families about potential complications of button battery ingestion?
Dr. Ramalingam Arumugam: The damage depends on whether it is a brand new battery, which can result in very quick damage much faster. If it is a so-called dead battery, can also cause serious damage. Normally, the standard button batteries have the capacitance of about three volt. When the capacitance drops to 1.5, it stops working in the device. So, even the so-called spent or dead battery has enough residual electricity which can result in damage. So if it is a dead battery, the damage can be slower, and the damages even after the removal can continue to progress. Sometimes it takes even weeks up to two months fine. There are case reports where complications like tracheoesophageal fistula or a perforation or major exsanguination happening after six weeks or eight weeks.
So it is very important that you educate the parents that your child is still not out of the woods, and you should closely monitor not only the parents as well as the day care providers or school teachers should know this child had a button battery. We often send them with a medical alert like bracelet so that if this child suddenly starts vomiting or vomiting blood or looks pale or becomes unconscious, that child should be immediately transported to a children’s hospital where there is a cardiovascular surgery team is available.
So, that’s why in our campus we prefer Minneapolis campus to the St. Paul, because of the availability of cardiothoracic surgeon, and they should watch for any hoarseness of voice and chronic cough and all these things should alert the parents to bring them back to Children’s Hospital. So before discharging, we often assess whether the parents have any language barrier, whether they have transportation issues, whether they are living very far from the children’s hospital. These are all important factors which needs to be taken into consideration before discharge.
Dr. Courtney Herring: Always our goal is to get back to life. The complication rate for serious complications in my understanding is about a little bit less than one in 1,000. And I mean hopefully that stays the same, because we think of button batteries as being about 3,500 known ingestions a year, probably greater with better surveillance. And so with that, you’re hoping that this isn’t something you’re seeing on the per annum for our gastroenterology team, but we have seen significant button battery ingestion complications here at Children’s Minnesota, and I’m sure other facilities have as well. As we’re wrapping up, I briefly alluded to Reese’s Law want to give a shout-out to other country…
We are not the first, I’ll believe that, to look at this as a complication in children and the significance of morbidity and mortality associated for children. Specifically, the UK has a similar law as Reese’s Law that was passed around the same time. But in 2022, we had legislation that through the Consumer Product Safety Commission implemented requirements for button cell and coin battery packaging.
There’s multiple layers around this. It actually was not totally enacted until last month, which is September 2024 for our listeners. So what do you see as your hope for Reese’s Law and just long-term for button battery ingestions?
Dr. Ramalingam Arumugam: So, button batteries are ubiquitous in our environment. So many things like watches and remote control and key fob and greeting cards and blinking shoes and all of them have button batteries. And these batteries when it get… They are very shiny, they are slippery and they look similar to a candy. So, young children’s often end up swallowing this and bigger battery gets end up in a narrower esophagus.
So, Reese’s is actually adorable little girl living in Lubbock, Texas, who ingested and ultimately died of multiple complications, and the parents took the initiative to create this law. According to this, it should be secured in a container and it should be very clearly and any devices which has button battery, the button battery should be very secured while needing an instrument to remove it.
It shouldn’t be loosely coming out of the device, and this button batteries more recently comes with the bitter coating. So thereby, hopefully the child will spit it out. And both Duracell as well as Energizer comes with a bitter coating, and Energizer recently introduced with this coloring agent, which releases bluish discoloration to the buccal mucosa.
In European countries, it comes in a special container in which the new battery will not come out of the container unless you put the old one first, like a key, only then the new one, thereby making sure you’re not disposing the button battery appropriately in a secured container. In United States where such thing is not available, as a parents, we should take precautions. When you are disposing a battery, it should be taped like a just standard tape around the button battery and dispose it in a plastic bag or something to the [inaudible 00:19:59].
Dr. Courtney Herring: So basically cover the surfaces for protection.
Dr. Ramalingam Arumugam: Yes, to prevent, so that it won’t come in contact with your children or with your pets. In both cases, it can cause serious consequences.
Dr. Courtney Herring: I love the call-out to pets, because that’s going to hit home for a lot of people. Again, I can’t thank you enough. We did chemistry, we talked about physics, and ultimately, we’re talking about how to take care of children, which is always the goal here at Talking Pediatrics.
For today are key takeaways, number one, most button battery ingestions are unwitnessed. Number two, if there is any suspicion of button battery ingestion, triage is considered an emergency. Number three, interventions such as honey and/or sucralfate should be trialed while awaiting procedural planning and avoid ineffective interventions as well. Number four, most delayed complications will happen within four weeks post battery removal. Close follow-up is recommended. Number five, Reese’s Law is currently legislation enacted to implement safety requirements for button sale or coin batteries, and it is currently live now. So, look out for your button battery packages.
Dr. Arumugam, thank you again for joining and sharing your expertise with us today. It has really been a pleasure.
Dr. Ramalingam Arumugam: Thank you very much, Courtney.
Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.