Researchers in the US found there has been a significant increase over the last 25 years in the percentage of severe injury and deaths in children who swallow batteries, at the same time as button batteries have become increasingly common for use in household products.
Two papers by Dr. Toby Litovitz of the National Capital Poison Center in Washington DC and colleagues published recently in the journal Pediatrics describe how they analyzed button battery ingestion cases, how they might be prevented, and what the clinical implications are.
When button batteries, such as the increasingly common 20 mm diameter lithium cell used to power many household products, get stuck in the throat they can cause severe tissue damage within just 2 hours of ingestion. Further damage can also ensue, such as paralysis of the vocal cords, narrowing or stricture of the esophagus or food pipe, a hole connecting the windpipe to the food pipe (tracheoesophageal fistula), or severe internal bleeding as a result of a hole into a major blood vessel.
In the first paper, the researchers describe how they analyzed a total of 8,648 battery ingestion cases that were reported to the National Battery Ingestion Hotline in the US.
They found that:
- 62 per cent of cases of battery swallowing in children under 6 were of batteries that came directly from a product.
- This compared with 30 per cent that were loose and 8 per cent that were in their packaging.
- For the most hazardous battery, the 20 mm lithium cell, in 37 per cent of cases of swallowing in young children, the batteries were intended for remote controls.
- In cases where adults swallowed batteries, 81 per cent of them were of batteries that were loose, eg been left lying around or discarded.
- This compared with 4 per cent that came out of a product, 3 per cent from battery packaging, and 12 per cent swallowed inside a hearing aid.
- 36 per cent of the ingestions involved batteries that were intended for hearing aids.
- 16 per cent of ingestions involved batteries that were mistaken for pills, mostly by older adults.
Litovitz and colleagues concluded that we should teach parents and people who care for children about how to prevent battery ingestion.
Also, in light of the finding that nearly two thirds of battery ingestions are of batteries taken out of products, they recommended that manufacturers house the batteries in household products in a secure compartment, perhaps even requiring a tool to open it.
In the second paper, Litovitz and colleagues added more data sources to include all known cases involving esophageal or airway button battery lodgment in the US. These sources included over 55,000 cases from the National Poison Data System (from 1985 to 2009), and the medical literature as well as the National Battery Ingestion Hotline.
They found that:
- All data sources showed a worsening of outcomes over the last 25 years.
- The worse was from the National Poison Data System, which showed there was a “6.7-fold increase in the percentage of battery ingestions with major or fatal outcomes from 1985 to 2009”.
- Ingestions of 20 to 25 mm diameter cells went up form 1 per cent of ingested button batteries in 1990 to 18 per cent in 2008.
- This rise mirrored the rise in lithium-cell ingestions (1.3 per cent to 24 per cent).
- Outcomes were significantly worse in cases where large diameter (greater that 20 mm) lithium cells were ingested, and where the cases involved children under 4 years of age.
- However, the most severe outcomes involved the 20 mm lithium cells.
- Severe burns with serious consequences occurred in just 2.0 to 2.5 hours.
- 92 per cent of the fatal, and 56 per cent of the major outcomes were not witnessed.
- 54 per cent of the fatal, and 27 per cent of the major outcomes were misdiagnosed.
Most of the misdiagnoses were because of “nonspecific presentations”, wrote the authors, emphasizing that injuries continued to get worse after the batteries were removed. These included:
“… unanticipated and delayed esophageal perforations, tracheoesophageal fistulas, fistulization into major vessels, and massive hemorrhage”.
The researchers recommended that guidelines be revised to emphasize the importance of speedy removal from the esophagus, and to encourage increased vigilance, for instance to look out for delayed complications and to spot patients who may need to be X-rayed urgently.
According to the National Capital Poison Center, every year more than 3,500 Americans of all ages swallow button batteries. These batteries are used to power a diverse range of household and personal products, including watches, hearing aids, singing greeting cards, jewellery, toys, games, remote control devices, and others.
In most cases, the button battery passes through the body and comes out in the stool, but sometimes it gets stuck, and these are the cases that cause problems. For instance, a battery stuck in the esophagus or food pipe causes tissue damage because of the alkaline hydroxide that results from the electrical current set up around the battery. This burns the tissue.
If anyone swallows a battery, the Center says they, or someone with them needs to:
- Straight away call the 24-hour National Battery Ingestion Hotline at 202-625-3333 (you can call collect if necessary), your physician or the emergency room doctor can consult an expert on this number any time day or night, 24/7.
- Find out the battery identification number (eg from the packaging or a matching battery).
- Arrange an X-ray to see if the battery has gone through to the stomach.
- If it does not show signs of moving and is lodged in the esophagus, it should be removed straight away.
- Don’t induce vomiting, and don’t eat or drink until the X-ray shows the battery has moved past the esophagus.
- Look for signs of fever, vomiting, abdominal pain, or blood in the stools and report these symptoms immediately.
- Check the stools until the battery has passed.
Button batteries can also cause permanent injury if put up the nose or in the ears. The Center notes on its website that such injuries tend to occur mainly in young children and the elderly. The symptoms include pain and/or discharge from the nose or ear.
Nose or ear drops should not be used before seeing the doctor, because they could make the injury worse.
“Preventing Battery Ingestions: An Analysis of 8648 Cases.”
Toby Litovitz, Nicole Whitaker, and Lynn Clark.
Pediatrics, May 2010.
“Emerging Battery-Ingestion Hazard: Clinical Implications.”
Toby Litovitz, Nicole Whitaker, Lynn Clark, Nicole C. White, and Melinda Marsolek.
Pediatrics, May 2010.
Source: National Capital Poison Center (US).
Written by: Catharine Paddock, PhD