One Pill Can Kill: The Dangers of Button Batteries

Kids put the darnedest things in their mouths. It’s part of the natural human learning and development process: pica. Pica starts at around age 2 and involves exploring the environment by putting objects into the mouth. Ingestions aren’t part of pica; it’s like window shopping with your mouth—taste but don’t swallow. This is different from intentionally eating things, which kids also do; think of those colorful vape nicotine packages or coated medication tablets that are sweet. But pica is different—there is nothing tasty about a Lego or a battery (though accidents do happen).

Most objects swallowed by children are nontoxic and will not obstruct the esophagus or intestinal tract unless they are long and sharp. Those that do 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 batteries.

Button batteries come in various sizes, similar to a nickel or quarter. They often get stuck in children’s  esophagi, rarely affecting the airway. Rather than producing stridor, as happens with various foreign-body aspirations, button batteries get lodged at the narrowing of the cricopharyngeous muscle, at narrowings caused by the aortic arch or bronchi or at the sphincter that separates the esophagus from the stomach.

Coins, which can readily be differentiated from button batteries on x-ray by identifying the “double density” that makes up button batteries, pass with time and tend not to need endoscopic extraction. Button batteries often do too, but we aren’t willing to wait.

Case Study

A 3-year-old child presents in the emergency department drooling and unable to swallow water. An x-ray confirms the elicited history of a swallowed coin. The child is sent home. Five hours later an ambulance is called for hematemesis. On arrival paramedics find the child without vital signs in a pool of blood. Despite rapid transport to a local pediatric emergency department, the child dies. An autopsy shows a button battery lodged in the esophagus, which eroded into the aorta, leading to a fistula that allowed arterial blood to enter the esophagus. The cause of death was exsanguination. On case review the x-ray was deemed to clearly show the double density of the button battery.

This is not a fictitious case. What prompted me to choose the button battery for this column was the death of a child at a hospital near mine a few months ago from this exact problem. More than 3,500 button battery ingestions are reported to U.S. 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 following 2010 in the United States.

How does a button battery produce so much damage? There are multiple mechanisms that interact 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 create an electrical circuit. The constant current causes hydrolysis, where water is broken down into hydroxide, an alkali, which burns the friable tissue that makes up the esophagus. The physical pressure of the battery in a tight space speeds erosion of the tissue (leaking battery contents are not usually the culprit). Most button batteries large enough to get stuck (over 20 mm) produce 3 volts, which is more than double what it takes to cause hydrolysis.

This erosion can cause the esophagus to leak into the mediastinum, leading to contamination. This causes a severe form of sepsis called mediastinitis that is often fatal. In the worst-case scenario, the battery erodes through the esophagus and the aorta, causing essentially an aortic rupture into the esophagus that cannot be tamponaded. Blood freely flows down into the stomach and up into the mouth, where it can be aspirated. Death can be from asphyxia or exsanguination.

Even if the esophagus doesn’t break open, burning can lead to lifelong morbidity in the forms of strictures, increased cancer risk, and trouble swallowing.

The bottom line is that any child who may have swallowed a button battery needs an emergent x-ray. If a battery is seen, emergent endoscopic removal is mandatory. Damage can begin as quickly as two hours after ingestion. Do not allow the child to eat or drink until assessed in the ER, and do not induce vomiting. If the airway is compromised, laryngoscopy with Magill forceps may be appropriate.

Childproofing the Home

Is your home button-battery proof? Can you educate parents and caregivers about the threat? Here’s a list from poison.org about where you might find button batteries:

• Remote controls (the worst offenders!)
• Garage door openers
• Keyless entry fobs
• Bathroom scales
• Parking transponders
• Toys
• Cameras
• Watches
• PDAs
• Calculators
• Digital thermometers
• Hearing aids
• Singing greeting cards
• Talking books
• Portable stereos
• Handheld video games
• Cell phones
• Home medical equipment/meters
• Flash- and penlights
• Flashing shoes
• Toothbrushes, bedwetting monitors
• Keychains
• Flashing or lighted jewelry or attire
• Any powered household item

Here’s a great resource: the National Battery Ingestion Hotline at 800/498-8666.

Reference

1. Sharpe SJ, Rochette LM, Smith GA. Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. Pediatrics, 2012 Jun; 129(6): 1,111–7.

After a decade working as a helicopter paramedic, Blair Bigham, MD, MSc, EMT-P, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium.