Time Is Money in Case of a Button Battery Ingestion

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TL;DR

Button battery ingestion in children is a preventable and increasingly common emergency that can cause severe esophageal damage within hours. This case series of three children (ages 16 months to 2 years) illustrates complications including esophageal diverticulum, mediastinitis, and tracheoesophageal fistula, with delays in diagnosis worsening outcomes. New guidelines recommend honey or sucralfate before endoscopy and acetic acid irrigation during removal to reduce injury, but prevention through safer battery compartment design remains critical.

Full summary

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**Background:** The frequency of emergency department visits for unintentional foreign body ingestion in children has doubled over the past 13 years. Button battery (BB) ingestion is particularly dangerous due to the risk of esophageal impaction and subsequent complications, which have increased 7-fold over the past 2 decades. Morbidity and mortality arise primarily from esophageal impaction, with risk factors including alkaline esophageal environment, increased battery size and power, younger age, longer duration of impaction, and remaining battery voltage. This case report discusses three complicated BB ingestions seen over 6 months, along with updated diagnostic and management guidelines.

**Methods:** Three pediatric cases of button battery ingestion presenting to a single institution over a 6-month period are described. Clinical presentation, diagnostic workup, treatment, and outcomes are reported. The authors also review current guidelines and present a diagnostic and therapeutic algorithm for suspected BB ingestion.

**Key Results:** - Case 1: A 20-month-old girl presented with 6 months of dysphagia, chronic rhonchi, poor weight gain, and stagnating saliva. Gastroscopy revealed a BB below the upper esophageal sphincter. After removal, a food-containing diverticulum and distal stenosis were found. She required tube feeding, antibiotics, and a proton pump inhibitor (PPI). Repeated endoscopic dilatations and an attempt at endoscopic diverticulum treatment were insufficient, and surgery is planned. - Case 2: A 2-year-old boy presented with fever and dysphagia for solids, initially treated for otitis media. He deteriorated with pallor and grunting; C-reactive protein was 180 mg/L. Chest radiograph showed a BB with double halo sign on anterior-posterior view and step-off sign on lateral view. CT showed no perforation but evidence of mediastinitis. Endoscopic removal revealed esophageal mucosal necrosis. An esophagogram 2 days later showed a minor perforation. After 1 week of tube feeding, oral intake resumed. Endoscopy at 6 weeks showed a non-stenotic esophageal scar. - Case 3: A 16-month-old girl ingested a foreign body initially described as a coin on radiograph. Endoscopic removal 8 hours after ingestion revealed a BB with mucosal injury. She developed fever and infection the next day; CT showed pneumonic infiltrate without pneumomediastinum. One week after removal, she presented with drooling and food refusal. Endoscopy revealed a tracheoesophageal fistula. Surgical repair was performed with sternocleidomastoid muscle flap and esophageal suture. She required 8 days of ventilation, 3 weeks of antibiotics for mediastinitis, and developed vocal cord paresis (possible recurrent laryngeal nerve injury). An esophagogram after 3 weeks showed a relapsed tracheoesophageal fistula that closed spontaneously. She resumed fluid intake after 1 month and was discharged after 5 weeks. She required repeated endoscopic dilatations with one session of steroid injection.

KEY GUIDELINE RECOMMENDATIONS DISCUSSED

Symptoms are present in only 30% of patients, so cannot guide investigation decisions. For recent ingestion (<12 hours) in children over 12 months, honey (10 mL every 10 minutes, max 6 doses) or sucralfate (10 mL every 10 minutes, max 3 doses) can be given before endoscopy. Mucosal damage can occur within 2 hours, so immediate endoscopic removal is indicated for all esophageal BBs even if the patient has eaten. During endoscopy, acetic acid irrigation (50–150 mL of 0.25% acetic acid) may reduce late complications in the absence of perforation. Batteries beyond the esophagus typically pass spontaneously within 7–14 days. All patients with mucosal damage should be admitted for monitoring, with a normal esophagogram after 1–2 days allowing liquid diet progression. Of all BB ingestions, 70% could be avoided with screw-secured compartments, individual blisters, bitter-tasting batteries, and covering one side of the battery.

**Clinical Implications:** BB ingestion in children is a true emergency requiring urgent endoscopic removal. Delayed diagnosis dramatically increases complication risk, as demonstrated by these cases (6-month delay in Case 1, initial misidentification as a coin in Case 3). New pre-removal strategies (honey/sucralfate) and intra-procedural interventions (acetic acid irrigation) may reduce injury severity, though evidence is based on small series. Prevention through improved battery compartment design and public awareness is paramount, as 70% of ingestions are potentially avoidable.