Catastrophic haemorrhage from button battery ingestion in children: a growing problem

Ingested foreign bodies are generally considered relatively benign. Over an 18-month period in 2013–2014, four toddlers died in the UK following ‘button battery’ (BB) ingestion. These small shiny objects, attractive to young children, have increased in use around the home. Families and professionals alike seem unaware of the potential risks. In 2014, UK national media publicised the danger following one toddler's death. A Coroner's regulation 28 mandate triggered action by the Royal College of Emergency Medicine and other organisations. An NHS England Patient Safety Alert followed in December. Recommendations included lockable battery compartments on all devices containing BBs, not just toys. Over the last 30 years, North American physicians have mapped complications following BB ingestion 1. In the USA, someone presents to the Emergency Department (ED) every three hours with a BB related problem 2. The data show that although the majority of ingested BBs pass through the bowel without causing a problem, there is an increasing incidence of severe, debilitating injury or fatal BB ingestions over recent years. BBs cause significant harm if they become lodged in the upper airway or oesophagus 3. This is more likely with larger lithium batteries (above 20 mm diameter). Higher voltage (3 volt) BB potentially may cause serious burns within 1–2 hours. BBs of this type are widely used in electronic toys and gadgets. The peak incidence of BB ingestion is in one to two-year-olds 4, but all young children are at risk, as are patients with dysmotility, stenosis or strictures of the gastrointestinal tract. Up to 40% of BB ingestions in children are not witnessed 5 and there may be no history in preverbal or reticent children. Initial presentation is often nonspecific with vomiting, poor appetite, cough or lethargy, which may delay diagnosis. Serious burns occur due to generation of an electric current that hydrolyses tissue fluids and produces hydroxide at the BB's negative pole causing rapid liquefaction necrosis. A BB must become lodged or impacted to allow enough hydroxide to accumulate at one site for damage to occur. Pressure necrosis may combine with hydroxide to erode through tissue. The oesophagus is most at risk as it has weak peristalsis and there are three areas of narrowing (1st cricopharyngeal sphincter; 2nd where oesophagus is crossed by the aortic arch; 3rd lower oesophageal sphincter). A BB lodged in the oesophagus can erode into the aorta, trachea, lung or mediastinum. Burns continue to erode despite BB removal; an aorto-oesophageal fistula occurred 27 days after removal 6. Leakage of the lithium BB contents does not cause harm; however, in alkaline batteries, hydroxide can leak out in addition to being produced in the tissue resulting in tissue damage 3, 7. BBs therefore do not need to be chewed or damaged to cause injury. ‘Spent’ BBs unable to power a gadget still contain a residual voltage that can harm but new BBs are the most dangerous. Graphic video reconstructions have been created to illustrate the speed of damage 8(Fig. 1). Chiari's triad describes the classical presentation of aorto oesophageal fistula (AOF) as mid thoracic pain, sentinel arterial haemorrhage and exsanguination after a symptom-free interval 9. Many unsuspected cases present with bright red haematemesis. In the United States, 70% of children who died presented with haematemesis or malaena in the days or hours preceding their fatal haemorrhage 10. Smaller sentinel bleeds must be taken seriously, as they can be followed by catastrophic exsanguination. Major upper gastrointestinal bleeding is rare in children, with the commonest underlying cause being chronic liver disease. In any previously well child presenting with significant upper gastrointestinal bleed, ED staff should suspect BB ingestion as part of the differential diagnosis. Even without a positive history, X-rays of the neck, chest and abdomen should be performed to look for a foreign body. In some fatal cases of aortoesophageal fistula (including one UK case), the battery was not found at postmortem, having been either vomited out at home or passed through the bowel (presumably after lodging in oesophagus) before hospital attendance. Even with a negative X-Ray, if there is no clear explanation for the haematemesis, an urgent referral and transfer to a tertiary paediatric centre should occur especially in young children. Rapid X-ray identification of radio-opaque foreign bodies is crucial in preventing delay in treatment and reducing the risk of complications. BBs may be differentiated from coins on AP radiograph by a ‘double rim’. A lateral view shows a ‘step off’ to the narrower, negative pole of the battery not seen in a uniform coin, but may be difficult for new thinner BBs. Unwitnessed ingestion of coin-like foreign bodies should be assumed to be BBs until proven otherwise 4. Urgent endoscopic removal of BB before symptoms occur (even if the child has eaten) is crucial to reduce the risk of complications – ‘time is tissue’. If a BB is identified in a child with haematemesis, the team must act quickly to resuscitate and transfer these children to tertiary centres capable of repairing the site of major haemorrhage. Gain intravenous or intraosseous access, and activate the major haemorrhage protocol. Urgently refer to tertiary paediatric (general and thoracic) surgeons via regional paediatric intensive care (PIC) transport teams using conference call to expedite urgent transport and facilitate senior surgical involvement. A recent paper showed that activation of the major trauma team significantly reduces time to theatre 11. Transfer to the nearest ECMO centre (including ECLS centres in UK) is optimal. The US National Capital Poison Center has developed a guideline for management of BB ingestion: www.poison.org/battery/guideline.asp. An adapted version for UK use is available on the Royal College of Emergency Medicine website. Prompt diagnosis and removal of a button battery lodged in the oesophagus or upper airway is a true, time critical surgical emergency which may prevent death or severe complications. Consider BB ingestion in all previously well young children presenting with haematemesis, with or without history of ingestion. The sentinel bleed may be followed by a ‘symptom-free period’ before rapid, unsalvageable exsanguination.