Question 2: In children with ingested button batteries in the stomach, which patients are at the highest risk for complications?

In September 2016, the National Capital Poison Center revised its treatment guideline and algorithm for button battery ingestion. While in the past it was not uncommon to endoscopically remove button batteries located in the stomach, the National Battery Ingestion Hotline (NBIH) triage and treatment guideline suggests an observation/reevaluation approach for button batteries in the stomach in children who are asymptomatic, particularly if the patient is older than 12 years. While endoscopic removal of esophageal button batteries is standard—even in asymptomatic patients—treatment of the asymptomatic button battery in the stomach may be a little more tricky, and the data are rather limited.

A three-year retrospective study by Lee et al described 12 button battery ingestions with one in the esophagus, five in the stomach, and six distal to the duodenum.¹ The authors report that “none showed any symptoms after the ingestion” and mention that batteries greater than 1.5 cm in diameter or 3V batteries—compared to 1.5V batteries—appear to be a higher risk for moderate to severe complications. While the authors do mention an increase in case studies demonstrating complications in younger children, they state that their study did not find a correlation between age and risk of complications.^2,3

Another four-year retrospective study by Rios et al described 25 button battery ingestions retrieved from both the esophagus (n = 10) and stomach (n = 12).⁴ Three endoscopic retrievals were unsuccessful secondary to migration of the battery distal to the duodenum. Eight out of 10 (80 percent) of the esophageal-lodged batteries had symptoms, while 11 out of 15 (73 percent) of the stomach or distal battery locations were asymptomatic. While there were 12 gastric-located button batteries—which were predominantly asymptomatic—six out of 12 (50 percent) had mucosal damage, with a trend of younger age (median 1 year, 10 months) when compared to those children without mucosal lesions (median 3 years, 1 month; P = 0.23). There was no significance in time of ingestion (P = 0.75) in cases of gastric button batteries with and without mucosal injury. This may suggest that practitioners have a higher level of concern for asymptomatic younger children even when the battery is localized to the stomach.

Summary

The National Capital Poison Center has an algorithm to help guide treatment of button battery ingestions. While asymptomatic ingestions may be observed and reevaluated, younger patients, higher voltage (ie, 3V), and diameters greater than 1.5 cm appear to contribute to an increased risk of complication, even when localized to the stomach.