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Button battery ingestion.

Foreign body ingestion is a potentially serious problem that peaks in children between the ages of six months and three years, however, it is not uncommon in older children or teenagers with mental disabilities and/or behavioral problems.

Small, non-hazardous foreign bodies (such as wooden or plastic toys) will pass beyond the esophagus and negotiate themselves through the rest of the gastrointestinal tract. Coins, sharp objects, multiple magnets, and button batteries are hazardous, potentially dangerous foreign bodies if lodged in the esophagus. Because of their size, shape and physical characteristics, if not managed in an efficient fashion, these items can cause serious morbidity (perforation) and mortality (i.e., erosion into major blood vessels or airway).

Energizer-brand lithium button batteries offer significant advantages over other type of batteries. Their most significant advantages are extended shelf life, good low-temperature operation, high operating voltage and excellent leakage resistance. The 20 mm-diameter lithium button batteries, however, have brought new challenges to pediatric health care providers.

The button battery ingestion incidence reported to U.S. poison centers from 1985 to 2009 fluctuated between 6.3 and 15.1 cases per million people, with no clear incidence trend. A 6.7-fold increase in the percentage of ingestions with major or fatal outcomes, however, was observed during this period.

The increase in severity has been attributed to the increased use of the 20 mm lithium button battery as an increasingly popular battery type. From 2000-2009, 92% of fatal ingestions or major outcomes from button batteries were in fact from 20 mm lithium cells.

Button battery ingestions are most common at the extremes of age, with peak frequencies in one-to-three-year-olds (62.5% are younger than six years) and in the elderly (usually mistaken as pills).

Twnety millimeter button batteries are more dangerous than their smaller counterparts because:

* They are larger and more likely to become stuck in the child's esophagus. The esophageal diameter is about 5 mm in an infant, 8-9 mm in older children, and about 10-15 mm in adults.

* They can cause esophageal damage within four hours after ingestion.

The corrosive effect on the esophagus of a lodged button battery is caused by the generation of an external electrolytic current that hydrolyzes tissue fluids and produces hydroxide at the battery's negative pole (the anode). The abrasion or erosion to the esophageal mucosa will lead to stricture formation or perforation.

The 20 mm lithium batteries are three-volt cells with a higher capacitance and generate more current, which results in more rapid production of large quantity of hydroxide. Injury can continue after battery removal for days to weeks due to residual alkali or weakened tissues. Iatrogenic (doctor caused) morbidity or mortality can also follow removal procedures by professionals.

About 40% of foreign body ingestions by children are not witnessed. Esophageal foreign body ingestions are usually symptomatic causing drooling, gagging and refusal of oral intake. Attempts at drinking or swallowing solids result in regurgitation or choking. Older children my say they have the feeling of a foreign body lodged in the esophagus.

Perforation of the esophagus produces signs of mediastinitis (inflammation of the space between the lungs), such as fever, malaise and pain, and subcutaneous emphysema in the neck, the characteristic crackling feel to the touch due to presence of air under the skin.

The majority of button battery ingestions occur immediately following removal from a product. About 40% of cases involve batteries that are loose, either sitting out or discarded.

The most common sources of button batteries that are ingested are hearing aids and watches. Other button battery sources include remote controls, games and toys, calculators, cameras, lighted key chains, fishing bobs, flashing jewelry, musical greeting cards or books, and digital thermometers. Manufacturers should design products with secure battery compartments that can withstand a child's prying hands or a fall.

For a correct and prompt diagnosis of button battery ingestion it is vital that parents and caregivers are aware of missing batteries from household gadgets. Most of the non-witnessed button battery ingestions are initially misdiagnosed due to nonspecific symptoms or because they are mistaken for a coin.

The button battery's radiopaque spherical appearance on plain radiography of the chest can in fact mislead the clinician and the finding can be interpreted as a coin leading to misdiagnosis and delayed presentation and treatment.

Spare coins are items easily available around the house and unfortunately have dimensions similar to 20 mm button batteries:
United States coins

Penny:       19 mm
Nickel:   21.21 mm
Quarter:   24.2 mm

United Kingdom coins

1 penny:           20.32 mm
1 pound sterling:   22.5 mm
10 pence:           24.5 mm

There are well-recognized discriminating radiographic features between a 20 mm button battery and a coin: a "double density" or rim (bilaminar design of the battery) on the antero-posterior view along with a stepped-off lateral silhouette (anode-cathode junction). In the absence of a history of observed ingestion, it should be assumed that coin-like foreign body is a button battery until proven otherwise.

Once the diagnosis of button battery lodged in the esophagus is made, emergent removal by rigid or flexible esophagoscopy under general anesthesia is required. The child should be observed following esophagoscopy for signs of possible perforation and is initially restricted to clear liquid diet for the first few hours.

Complications in late-presenting or diagnosed cases include esophageal perforations, esophageal strictures requiring repeated dilations, tracheo-esohageal fistulation (an abnormal connection between the esophagus and trachea), bleeding due to erosion into blood vessels, vocal cord paralysis and death.

By Giampiero Soccorso, MD

Dr. Soccorso earned his medical degree in Italy and then trained in general surgery in England. He became a member of the Royal College of Surgeons of Edinburgh. Currently he is a senior resident in General Paedatric Surgery in the United Kingdom.
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Author:Soccorso, Giampiero
Publication:Pediatrics for Parents
Geographic Code:1USA
Date:May 1, 2012
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