The dangers of button batteriesPublished by MAC on 2021-06-12
Source: Today.com, EMS World
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, and 11 deaths of children aged 7 months to 3 years were recorded in a six-year period following 2010 in the United States.
A button battery is a small single cell battery shaped as a squat cylinder typically 5 to 25 mm in diameter and 1 to 6 mm high — resembling a button. Stainless steel usually forms the bottom body and positive terminal of the cell. An insulated top cap is the negative terminal. Common anode materials are zinc or lithium. Common cathode materials are manganese dioxide, silver oxide, carbon monofluoride or cupric oxide.
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.
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.
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
Singing greeting cards
Handheld video games
Home medical equipment/meters
Flash- and penlights
Toothbrushes, bedwetting monitors
Flashing or lighted jewelry or attire
Any powered household item
Here’s a great resource: the National Battery Ingestion Hotline at 800/498-8666.
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.
A toddler swallowed a button battery and died. Her mom is taking action.
At the end of October, a spunky 17-month-old named Reese started wheezing. Her mother, Trista Hamsmith, took the congested, stuffy toddler to the pediatrician, who said it was likely croup.
Soon afterward, the concerned mom noticed that a button battery was missing from a remote control. Gripped with dread, the Hamsmith family raced to the local emergency room with Reese. That’s when they learned devastating news: Reese had swallowed the tiny battery, and it had caused a hole in her esophagus.
“Once the battery is ingested, it starts to erode and it starts to burn,” Hamsmith, 39, of Lubbock, Texas, told TODAY Parents. “Button battery ingestion is so much more common that people realize.”
Reese never recovered. She died on Dec. 17, 2020.
“This story needs to be told,” Reese’s mother said. “It didn’t have to happen.”
Even as a toddler, Reese was a star.
“It’s almost like she demanded applause,” her mom said. “I’m not even kidding — she captivated the room.”
That’s one reason why Hamsmith became so worried when, at the end of October, Reese became lethargic, congested and wheezy. Her pediatrician diagnosed her with croup over the weekend and gave her medication, telling her parents to bring her back on Monday if she worsened. As soon as Hamsmith noticed the button battery was missing, she said the family “hauled booty” to get to the emergency room.
“They did an X-ray and confirmed that it was in there and they did emergency surgery to remove the battery,” she said.
Dr. Emily Durkin, who did not treat Reese, said that swallowing button batteries can cause serious injuries for some children, especially if the batteries become lodged in the esophagus. The esophagus has two areas that are narrow, at the upper and lower end, and button batteries often get trapped there.
“If you get a narrow, flat, pancake-like button battery that gets stuck at one of these natural narrowings, then the front wall of the esophagus collapses against the button battery and the back wall,” said Durkin, medical director of children’s surgery at Helen DeVos Children’s Hospital in Grand Rapids, Michigan. “(This) completes that circuit, and electric current actually flows through the esophageal tissues. And when that happens, it starts to kill the tissues at the burn.”
That can “very rapidly” create a hole in the esophagus, which can lead to loads of complications, Durkin said.
“It can be just a devastating injury for a child,” Durkin explained. “It can require operations and having to be fed with a tube.”
Reese underwent emergency surgery in late October and was released home after a short hospital stay. A few days later, the Hamsmith family returned to the emergency room when Reese’s condition began to decline again. The surgeon wanted to do a CT scan.
“We found out that a fistula had been created, which is like a passageway,” Hamsmith said. “There was a hole burned through her trachea and through her esophagus. When that tunnel formed, it was allowing air to go where it didn’t need to be. Food and drinks also went where they didn’t need to go.”
Doctors gave Reese a gastronomy tube to help her receive nutrition by bypassing that hole. She returned to her hospital room sedated on a ventilator.
“That morning was the last morning that we saw her as herself,” Hamsmith said.
The family hoped that in time, Reese would heal without more intervention. But by early December, doctors decided she needed surgery to repair the fistula.
“The surgery went great and then from there it was just more waiting, more resting, more healing,” Hamsmith said. “A few weeks later they tried to take her off the ventilator and she did great.”
One day Hamsmith stepped away from her daughter’s hospital bedside for a few minutes. As she returned, she noticed the hallways were empty — a sign that someone was in distress. She reeled in shock when she entered her daughter’s room and realized the person in distress was Reese.
“I heard them say, ‘Starting compressions,’ and she was gone for about eight to ten minutes,” she said. “We were able to get her back. Ultimately they said she wasn’t strong enough yet.”
Later, the doctors again tried weaning her off the ventilator with little success. They decided to give Reese a tracheostomy to help her breathe.
“It was terrifying for me,” Hamsmith recalled. “But I was also excited that we were just one step closer to getting her back and having her awake again.”
The tracheostomy surgery went well, but three days later, Reese began struggling again. Doctors changed her tracheostomy tube and tried other interventions, but Reese’s vital signs plummeted.
“I started praying. She coded again. They did CPR, all of the things, for about 30 to 40 minutes,” Hamsmith said. “I had never prayed so hard in my life or begged God like that. …
“We just didn’t get her back.”
Hamsmith said she wants Reese’s story to be shared so that other parents understand the dangers of button batteries. Ultimately, she hopes manufacturers will start making safer batteries and that Congress will address it.
“We just need safer batteries,” she said.
“The button batteries that are the most dangerous are typically the ones that are about the size of a nickel or a quarter,” the doctor explained. “Those are the ones that I think shouldn't be made.”
The battery industry has introduced new safety measures in recent years. Duracell, for instance, added a bitter-tasting coating to its lithium coin batteries to help deter accidental ingestions.
Hamsmith said she also hopes manufacturers begin making safer device covers — such as putting screws on compartments with small batteries inside them — so children can’t get into them.
“Kids are dying,” she said. “We’ve got to do everything we can to get this information to parents and put pressure on the industry to make changes to protect the kids.”