In recent days, they brought in a child who had swallowed a battery, one of those flat, slim watch batteries that we are familiar with. On this occasion, I updated my own knowledge a bit, and I wanted to share it with you.
In the pediatric surgeon’s journal, I discussed cases of button battery ingestion. Happy reading,
There is an article compiling 8648 cases of battery ingestion. 94% of these cases involve button batteries. Why? Because they are smaller. Most commonly, children under the age of six swallow them, especially between 1-2 years old. Do you know when they tend to swallow them the most? The moment you take them out of the device. You know, that moment when we momentarily take the battery out of the device and put it aside, like to replace it with a new one – that’s when they put it in their mouths.
Which devices are most commonly involved? Hearing aids, toys, watches, calculators, and flashlights.
Here are a few practical facts about batteries:
Batteries have two sides: Positive and negative.
The positive side generally contains substances like Lithium Manganese if it’s 3V and Manganese or Mercury if it’s 1.5V.
The negative side often contains Zinc or Lithium. The actual electrical current occurs from this surface, and this is the part that can cause real harm to the tissue.
Usually, between the positive and negative surfaces, there is Sodium Hydroxide, which is strong enough to burn tissues.
Companies generally prefer Lithium (Li), which is lighter and has a longer lifespan.
As the diameter of the battery exceeds 12mm, the likelihood of getting stuck in the esophagus increases.
What happens when a battery is swallowed?
The most significant problem occurs when it gets stuck in the esophagus. Everything depends on how long the battery remains stuck in the esophagus, its charge, and its size. The damage it can cause to the esophagus starts within 2 hours and intensifies after 8-12 hours.
The battery damages the tissue by generating electricity, causing pressure, creating necrosis, and leaking its contents onto the mucosa. It’s crucial to note that even in depleted batteries, there is still enough capacity to produce electricity that can harm the tissue.
For children who have swallowed a battery, we need to gather some information first: the type of battery, its size, charge level, how long ago it was swallowed, how many were swallowed, any known esophageal surgery or disease, and whether a magnet was swallowed along with it. For example, a child might have swallowed both a magnet and a battery, and these two metals can stick together, trapping a piece of the intestinal wall in between, which can get crushed and cause complications like perforation or fistula formation.
After obtaining this information, we look at the child’s symptoms. In most cases, there are no problems. If there is difficulty swallowing, drooling, or black specks in the saliva, we suspect that the battery might be stuck in the esophagus. If there are symptoms like bloody vomiting, difficulty breathing, fever, paleness, low blood pressure, rapid heartbeat, or crackling sensations under the skin in the neck or chest wall, the situation has become more complicated.
We quickly take an X-ray. It’s important to remember that the X-ray should show the entire digestive system, from the mouth to the anus. There is a fact that in about 10% of cases, more than one object has been swallowed.
What should be done first?
If we are sure the child has swallowed a battery, and if the child is asymptomatic, meaning they have no symptoms, is over one year old, and has no known allergies, we give them one dose, about 5ml, of pure honey. This can be repeated until an X-ray is taken. Actually, what I’m saying contradicts the rule that the stomach should be empty in situations where surgery may be required, I know, but the benefit of honey in reducing the burn by neutralizing the esophagus outweighs the risk of aspiration damage that may occur at the beginning of the operation. However, if we don’t know when the battery was swallowed, and there is a late diagnosis, nothing should be given orally without the necessary evaluations.
For children with no complaints, over 12 years old, who have swallowed a battery smaller than 12mm in diameter, and the battery location is seen below the esophagus on the X-ray, we recommend follow-up. If no emergency develops, an X-ray is taken if the battery is still not visible in the stool within 10-14 days.
If the battery is stuck in the esophagus: We strongly recommend urgent endoscopy to remove it. At this stage, pediatric gastroenterologists usually come into play. If there is excessive salivation or difficulty breathing, an ear, nose, and throat specialist may also be needed. If there is serious bleeding, pediatric surgeons and cardiovascular surgeons may also get involved.
After removing the battery during endoscopy, if the esophageal mucosa looks good, the patient can go home immediately. But if there are burn symptoms, caution may be needed. After removing the battery, the burning process can continue, and even 18 days later, the battery can burn the esophageal wall, puncture the main vessels behind it, and cause serious bleeding. We know this from published case reports of potential fatal bleeding. Alternatively, the battery can puncture the esophagus and damage the adjacent airway, creating a passage between the esophagus and the trachea. We call this a fistula, and serious problems can arise when saliva and food enter the lungs. If we see burns on endoscopy, usually about 4 weeks later, we take films to check if there is any narrowing of the esophagus. If there is stenosis after a burn, problems with swallowing may begin to appear 1-2 months later.
If the battery is visible in the stomach: The stomach is less affected by the battery than the esophagus. We know this. Still, our preference is for endoscopy and removal. Because there are studies showing that, even if there are no complaints in the child, burns in the stomach mucosa are observed when the battery is removed. So why wait? Moreover, if the child is under 5 years old and the battery is larger than 2cm, it probably won’t pass from the stomach to the intestines.
If the battery has passed from the stomach to the intestines: It will usually pass through the anus without any problems. If there are no signs of urgent abdominal pain, bloody stools, or fever, follow-up for up to two weeks is recommended. If it still hasn’t come out in the stool during this time, an X-ray should be taken to check if it is in a fixed position or not. During this period, there is no need for repeated enemas to increase bowel movements; they should not be done.
Be careful, and it’s best to ensure your child is not around during battery changes or when you take a new battery out of its box. Also, refrain from using your mouth as a third hand to free up your hands; battery ingestion can lead to very serious problems.
We’ve reached the end of another journal. Stay well,
October, 2023
Prof. Dr. Egemen Eroğlu
