Children put the stupidest things in their mouths. It is part of the natural human learning and development process: pica. Pica starts around the age of 2 and involves exploring the environment by putting objects in the mouth. Ingestion is not part of pica; it’s like window shopping with your mouth – taste but don’t swallow. This is different from eating things on purpose, no matter what children do; think of those colorful vape nicotine packs or coated medication tablets that are sweet. But pica is different – there’s nothing nice about a Lego or a battery (although accidents do happen).
Most objects swallowed by children are non-toxic and will not block the esophagus or intestines unless they are long and sharp. The ones that get stuck, like coins, often pass after a few hours. But one object has received a lot of attention over the years, and for good reason: button cell batteries.
Button batteries come in a variety of sizes, similar to a nickel or quarter. They often get stuck in the esophagus of children and rarely affect the airways. Instead of producing stridor, as happens with various foreign body aspirations, button batteries become trapped at the narrowing of the cricopharyngeous muscle, at strictures caused by the aortic arch or bronchi, or at the sphincter that separates the esophagus from the stomach.
Coins, which can be easily distinguished from button batteries on X-rays by identifying the “dual density” that make up button batteries, pass over time and usually do not require endoscopic extraction. Button batteries often do that too, but we don’t want to wait.
A 3-year-old child presents himself drooling in the emergency department and is unable to swallow water. An X-ray confirms the leaked history of a swallowed coin. The child is sent home. Five hours later, an ambulance is called for hematemesis. On arrival, ambulance personnel find the child without vital signs in a pool of blood. Despite rapid transport to a local children’s ward, the child dies. An autopsy shows a button battery in the esophagus, which has eroded in the aorta, leading to a fistula that allows arterial blood to enter the esophagus. The cause of death was blood loss. When judging the case, it was assumed that the X-ray clearly showed the double density of the button battery.
This is not a fictional case. What led me to choose the button battery for this column was the death of a child in a hospital near me a few months ago from this exact problem. More than 3,500 button battery swallows are reported to US poison control centers annually; there were 14 deaths between 1995-2010 according to the CDC, 1 and an additional 11 deaths of children aged 7 months to 3 years were recorded in a six-year period after 2010 in the United States.
How does a button battery cause so much damage? There are multiple mechanisms that work together to cause the deadly complication of esophageal erosion. Most button batteries are lithium ion batteries. Saliva causes the positive and negative ends of the battery to form an electrical circuit. The constant current causes hydrolysis, in which water breaks down into hydroxide, an alkali, which burns the friable tissue of the esophagus. The physical pressure of the battery in a small space accelerates tissue erosion (leaking battery contents are usually not the culprit). Most button cell batteries large enough to stick (over 20mm) will produce 3 volts, which is more than double what it takes to cause hydrolysis.
This erosion allows the esophagus to leak into the mediastinum, leading to contamination. This causes a severe form of sepsis called mediastinitis, which is often fatal. In the worst case, the battery erodes through the esophagus and aorta, essentially creating an aortic rupture in the esophagus that cannot be tamponed. Blood flows freely down into the stomach and up into the mouth, where it can be sucked up. Death can result from asphyxiation or loss of blood.
Even if the esophagus doesn’t break open, burning can lead to lifelong morbidity in the form of strictures, increased risk of cancer, and difficulty swallowing.
The bottom line is that any child who may have swallowed a button battery will need an emergent X-ray. If a battery is seen, emergent endoscopic removal is mandatory. Damage can start as early as two hours after ingestion. Do not allow the child to eat or drink until assessed in the emergency room, or induce vomiting. If the airway is compromised, laryngoscopy with Magill forceps may be appropriate.
Child safety in the house
Is your home button battery resistant? Can you inform parents and carers about the threat? Here’s a list from poison.org on where to find coin-cell batteries:
Remote controls (the worst offenders!) Garage door openers Keyless entry fobs Personal scales Parking transponders Toys Cameras Watches PDAs Calculators Digital thermometers Hearing aids Singing greeting cards Talking books Portable stereos Handheld video games Mobile phones Home medical equipment / meters Flash and pen lights Flashing shoes Toothbrushes, bedwetting keychains Flashing or illuminated jewelry or clothing All electrical household items
Here’s a great resource: the National Battery Ingestion Hotline at 800 / 498-8666.
1. Sharpe SJ, Rochette LM, Smith GA. Visits to the emergency department of children with batteries in the United States, 1990-2009. Pediatrics, June 2012; 129 (6): 1,111-7.
After a decade of working as a helicopter paramedic, Blair Bigham, MD, MSc, EMT-P, completed medical school in Ontario, Canada, where he is now a primary care physician in the emergency department. He is the author of more than 30 scientific papers, led major national projects to advance preclinical research, and participated in multiple collaborations, including the Resuscitation Outcomes Consortium.