With the current spate of reported ingestions of dangerous modern foreign bodies, such as button batteries and high-powered (rare earth) magnets, we are reminded that these unfortunate events often have serious consequences, resulting in injury, disability, and deaths in children. Sadly, these events are increasing despite efforts to encourage practitioners to advocate for safe storage of batteries and devices.
Case Reports: Two Children, Two Different Outcomes
Our team was recently called by an emergency department (ED) attending to evaluate a 19-month-old boy suspected of having ingested a button battery. The parents had not observed the ingestion but noted that the child was playing with a device and that the battery was "nowhere to be seen." The child had one episode of vomiting and gagging on the way to the ED.
On exam, the child was in no distress; however, a chest film documented a button battery (2 cm x 2 cm) in the mid esophagus. The child underwent emergency esophagoscopy under general anesthesia, and the battery was removed without difficulty. An area of erosion and burn was noted at the site where the battery was lodged.
There were no postoperative complications. He received antibiotics and was observed overnight. At discharge, our team provided anticipatory guidance to his family regarding potential later complications of esophageal button battery impaction. At a follow-up clinic visit 3 weeks later, he remained asymptomatic. This is a very fortunate outcome, as there can be significant complications resulting from button battery ingestions.
The potential long-term issues are illustrated by another child cared for at our hospital. In this child, a button battery swallowed approximately 2 days earlier led to esophageal perforation into the trachea. After months of airway support and nasogastric feeding in the pediatric intensive care unit, he underwent multiple unsuccessful surgeries to reconstruct his esophagus. He ultimately required colonic interposition surgery and will need airway reconstructive surgery.
Recent Studies Highlight Serious Complications
Button or coin batteries — those small, disc-shaped cells used to power the myriad electronic devices found in the home (eg, toys, digital watches, hearing aids, remote controls) — are ubiquitous.
Although larger lithium cells are more likely to lodge in the esophagus, the small nonlithium batteries also cause severe esophageal injuries. Tissue impaction of a button battery may lead to electrical or mechanical injury and/or caustic damage to the underlying mucosa due to the formation of hydroxide ions, which causes a rise in vicinal pH, thereby inducing liquefaction and necrosis of tissue.
The list of potential complications of button battery ingestion include esophageal erosion culminating in perforation or stenosis, tracheoesophageal fistula, vocal cord paralysis, and tracheal stenosis, which may result in fistulae formation into neighboring structures, including major vessels. Exsanguination from the latter is the most common mode of death reported in fatalities after impaction.
In a recent review, Akinkugbe and colleagues described the range and impact of vascular complications after button battery impaction, using 361 cases involving severe complications or death identified in the National Capital Poison Center registry and a PubMed search. Of these cases, 19% were fatal, and 14% involved vascular injuries. Three quarters (75%) of vascular complications were aorto-esophageal fistulae, and 82% of vascular injuries were not survivable. Fatal vascular cases had a significantly longer median impaction time (96 hours vs 144 hours), emphasizing that prolonged button battery impaction is a key risk factor for vascular complications and death.
The two most common airway sequelae observed in another recent systematic review were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Additionally, 23 children had bilateral vocal cord paralysis.
Chandler and colleagues recently underscored the ongoing scope of the problem. They described the epidemiology of battery-related ED visits in the United States among children younger than 18 years from 2010 to 2019, summarizing data from the National Electronic Injury Surveillance System operated by the US Consumer Product Safety Commission (CPSC). This analysis uncovered more than 70,000 battery-related ED visits during the study period (approximately 9.5 per 100,000 children annually). The estimated incidence is at least a twofold increase over data collected prior to 2010. The mean patient age was 3.2 years, and 84% were younger than 5 years. Button batteries accounted for approximately 85% of the ED encounters.
The authors noted that recent efforts at prevention have not significantly reduced injury rates, and they made a plea for stronger regulatory efforts that focus on hazard reduction or elimination through safer button battery design.
Management Strategies
Vigilance is key. Ingestion may not be observed, and often there are no obvious symptoms. However, possible ingestion should be a consideration if the child refuses to eat or drink or has sudden onset of vomiting, gagging, drooling, wheezing, difficulty swallowing or breathing, or coughing. If a child has ingested or is suspected to have ingested a battery, they should be urgently evaluated, since the tissue injury can occur in a short period.
An updated position paper from the European Society for Paediatric Gastroenterology Hepatology and Nutrition reviewed the diagnosis, management, and prevention of button battery ingestion in children, which includes a useful algorithm. The key is rapid localization of the battery; if there is esophageal impaction noted on chest radiographs (anteroposterior and lateral views), immediate removal is imperative. In instances of delayed diagnosis, even if the battery has passed the esophagus, endoscopy to screen for esophageal damage and a CT scan to rule out vascular injury are recommended even in asymptomatic children.
The National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline provides another useful algorithm that is available on its website.
What Can Be Done?
With the rising incidence of these cases and the severity of the consequences, there is a clear need for action. This can take the form of four key steps.
1.Educate parents regarding the dangers associated with these items and encourage safe storage and disposal. Safety messaging alone, however, may not be enough to persuade children, teens, and caregivers to avoid the hazard.
2. Prevention is everyone's business. Some manufacturers have introduced features to prevent ingestions, including child-resistant packaging and strong warning labels. For example, Landsdowne Labs created ChildLok button battery technology using advanced material science, which is designed to deactivate batteries following accidental ingestion, specifically reducing the risk of liquefactive tissue necrosis.
3. Regulation is another means. In August, President Biden signed Public Law No: 117-171 (Reese's Law) designed to "protect children and other consumers against hazards associated with the accidental ingestion of button cell or coin batteries by requiring the CPSC to promulgate a consumer product safety standard to require child-resistant closures on consumer products that use such batteries, and for other purposes." The law honors an 18-month-old child who died following ingestion of a button battery from a device and the persistent, diligent efforts of her mother to raise awareness and ensure safety.
4. A record of cases in a databaseis needed. The Global Injury Research Collaborative (GIRC) was initiated in August 2019 to "collect pertinent, non-identified data, to be compliant with current HIPAA standards, in order to allow worldwide data collection across all health systems." This offers a mechanism for medical professionals to report patients with aspiration or ingestion events using the free GIRC App.
Regulatory Efforts: One Step Forward, One Step Back
After the CPSC identified high-powered magnets as the number one "hidden home hazard" in 2008, they were effectively removed from the US market in 2012. Advocacy efforts led by the American Academy of Pediatrics and the North American Society of Pediatric Gastroenterology Hepatology and Nutrition ultimately resulted in a 2014 federal rule to limit the size and/or strength of marketed magnets. Magnet ingestions decreased significantly.
Unfortunately, this was a temporary measure. In 2016, the United States Court of Appeals for the 10th Circuit vacated the CPSC safety standard for high-powered magnets. This has been followed by recent reports of an increase in button battery and magnet ingestions, especially during COVID-19 as children spent more time indoors.
Middelberg and colleagues described the epidemiology and outcomes in children ingesting high-powered magnets after their reintroduction to the market. This multicenter study confirmed a high incidence of magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019. Approximately 10% experienced a life-threatening morbidity, 46% required an endoscopy and/or surgery, and 56% required hospitalization. There was no reported mortality.
Shaul and colleagues summarized the reports of children younger than 18 years who presented to the ED and/or were admitted to the Children's Hospital of Philadelphia for ingestion of single or multiple magnets. They compared three eras: pre-ban (2008–2012), intra-ban (2013–2016), and post-ban (2017–2020).
As expected, multiple magnet ingestions led to significant morbidity, including hospitalizations, endoscopic procedures, surgical procedures, and severe outcomes. They found a 160% increase in children with magnet ingestions in the post-ban period. Such findings emphasize the need to enact public policy measures for the regulation of high-powered magnets.
In an effort to reduce the risk of children and teens experiencing serious, even life-threatening injuries from swallowing small, dangerous, high-powered magnets, the CPSC recently voted to approve a new federal safety standard for magnets. The CPSC proposed standards for magnets regarding the size and flux index, a measurement of the total magnetic field. Ingested high-powered magnets can attract each other and result in intestinal perforation. The new mandatory federal standard requires loose or separable magnets in certain magnet products to be either too large to swallow or weak enough to reduce the risk of internal injuries.
In conclusion, these new regulations and the revised set of safety standards provide some level of hope for curtailing this increasing problem. However, they must also be accompanied by continued individual and organizational advocacy and directed research if we are to protect our children.
William F. Balistreri, MD, is the Dorothy M. M. Kersten Professor of Pediatrics; director emeritus, Pediatric Liver Care Center; medical director emeritus, Liver Transplantation; and professor, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center. He has served as director of the Division of Gastroenterology, Hepatology and Nutrition at Cincinnati Children's for 25 years and frequently covers gastroenterology, liver, and nutrition-related topics for Medscape. Balistreri is currently editor-in-chief of the Journal of Pediatrics and has previously served as editor-in-chief of several journals and textbooks. He is the first pediatrician to act as president of the American Association for the Study of Liver Diseases. In his spare time, he coaches youth lacrosse.
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Cite this: Dangerous Attraction: Magnet, Button Battery Ingestion Poses Serious GI Risks for Kids - Medscape - Oct 18, 2022.
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