Emerging Battery-Ingestion Hazard: Clinical Implications

NPDS: Frequency and Outcome Trends

NPDS data show 6.3 to 15.1 reported button battery ingestions per million population annually but fail to demonstrate a consistent upward or downward frequency trend (Fig 1). In 2007 to 2009, 3461 to 3758 button battery ingestion cases were reported to US poison centers annually. Of 56535 button battery ingestions reported to the NPDS (1985–2009), 68.1% occurred in children who were younger than 6 years and 20.3% in children who were aged 6 through 19 years (Tables 5 and 6, which are published as supplemental information at http://pediatrics.aappublications.org/cgi/content/full/peds.2009-3037/DC1).

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FIGURE 1

NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.

Although clinically significant (moderate, major, or fatal) outcomes occurred in only 1.3% of button cell ingestions during the 25-year period, the percentage of cases with clinically significant outcomes increased 4.4-fold from the first 3 years (0.596%) to the last 3 years (2.65%; linear regression, R² = 0.67, P < .0001; Fig 1). Focusing only on the most serious outcomes (Fig 5, which is published as supplemental information at http://pediatrics.aappublications.org/cgi/content/full/peds.2009-3037/DC1), there was a 6.7-fold increase in the rate of major or fatal outcomes by the final 3-year period (0.443%, 2007–2009) compared with the initial 3-year period (0.066%, 1985–1987). In comparison, there was a twofold increase in the percentage of major or fatal outcomes for all human poison exposures (all substances) reported to US poison centers.

NBIH: Series Description and Battery Characteristics

During the 18.25-year period, 8648 battery ingestion cases were reported to the NBIH, including 8161 button cell and 487 cylindrical cell (eg, AA, AAA) ingestions. Ingestion was confirmed in 81.9% of cases, by radiograph (76.7%), battery presence in stool or emesis, or endoscopic retrieval. Children who were younger than 6 years were involved in 62.5% of button cell ingestions.

Four battery sizes accounted for 95% of ingested button cells with known diameter: 11.6 mm (55.1%); 7.8 to 7.9 mm (30.6%); 20 mm (6.4%); and 5.8 mm (3.0%). Large-diameter cells (≥20 mm), implicated in only 6.7% of ingested button cells during the entire period, increased from 1% of cases in 1990–1993 to 18% in 2008 (diameter known for 60.6%; Fig 2).

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FIGURE 2

Temporal changes in diameter of ingested button cells (NBIH).

When button battery chemistry was known (57.7%), 41.7% were manganese dioxide/alkaline, 31.8% were zinc-air, and 13.1% were silver oxide. Whereas lithium cells composed only 9.0% of ingested button batteries during the entire period, 24% were lithium cells in 2008, up from 1.3% in 1990–1993. Figure 3 shows the rise in lithium cells beginning in the late 1990s and a precipitous drop in ingestions of mercuric oxide cells in the early 1990s.

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FIGURE 3

Temporal changes in chemical systems of ingested button cells (NBIH).

Imprint code was known for 56.7% of ingested button cells but often obtained after battery passage. Imported button cells occasionally had no imprint code. Discharge state, known in 68.6% of cases, included 20.9% new, 65.8% partially spent (enough residual energy to power products), and 13.3% spent (“dead”).

NBIH: Gut Transit Times and Use of Emetics, Endoscopy, and Surgery

See “Supplemental Information”.

NBIH: Outcome Predictors

Of 33 major outcome or fatal cases with known diameter, 31 (93.9%) involved button batteries that were ≥20 mm (Table 1). No clinically significant (moderate, major, or fatal) outcomes were observed with 15- to 18-mm cells, suggesting better outcomes compared with 20- to 25-mm cells (P < .0001, Fisher's exact test). Lithium cells were more likely associated with clinically significant outcomes than were other chemistries (Table 2).

Age was an important predictor of severity. All fatalities and 85% of major effects occurred in children who were younger than 4 years (Table 3). A major effect or death occurred in 12.6% of children who were younger than 6 years and ingested 20- to 25-mm batteries.

Logistic regression was used to identify button cell ingestion outcome predictors (Table 7, which is published as supplemental information at http://pediatrics.aappublications.org/cgi/content/full/peds.2009-3037/DC1). Battery diameter of 20 to 25 mm was the most important predictor of a clinically significant outcome (odds ratio [OR]: 24.6; P < .001), followed by age younger than 4 years (OR: 3.2; P < .0001) and ingestion of >1 battery (OR: 2.1; P = .02). Chemical system was not included in the model because it is highly correlated with diameter. When both diameter and chemistry were known (n = 4199), 99.3% of 20- to 25-mm ingested button cells were lithium, 82.5% of lithium cells were 20 to 25 mm, 84.3% of zinc-air cells were <8 mm, 87.8% of manganese dioxide cells were 9 to 14 mm (usually 11.6 mm), and all silver oxide cells were <15 mm. It was not possible to determine the contribution of the lithium chemistry to ingestion severity for large-diameter cells, because only 2 ingestions were known to involve 20- to 25-mm nonlithium batteries. The outcome of ingestions of small lithium cells (<20 mm) was no worse than the outcome of ingestions of other small button cells (P = .196, Fisher's exact test).

Of 221 ingestions of whole hearing aids (containing batteries), 78.7% were by individuals who were aged ≥60 years. When outcome was known (195 cases), 89.2% had no effect, 4.1% had a minor effect, and 1 patient with concomitant medical problems had a moderate effect. There were no major effects or deaths.

Cylindrical cell ingestions showed proportionately more minor and moderate effects (Table 2). Outcome was unknown more than twice as often because of the nature of cylindrical cell ingestions (at least 43% were intentional, suicidal, or associated with a neuropsychiatric disorder; another 6% were by incarcerated individuals). In addition, 37.8% of cylindrical cell ingestions involved multiple cells compared with 8.7% of button cell ingestions (P < .001, χ²).

New cells were 3.2 times more likely to be associated with clinically significant outcomes compared with spent cells when only 20- to 25-mm cells were assessed (P = .04, logistic regression); however, discharge state was not a predictor of outcome when all button cell sizes were considered. Co-ingestion of a battery and a magnet was reported in 2 NBIH cases. Both required ≥1 surgical procedure to resect necrotic bowel as a result of entrapment of the intestinal wall between the battery and the magnet. The association of battery corrosion and outcome is discussed in “Supplemental Information”.

NBIH and Medical Literature: Clinical Issues and the Urgency of Removal

Thirteen fatalities were identified (1977–2009), 9 (69%) in the most recent 6 years (2004–2009). All fatalities occurred in 11-month-old to 3-year-old children. Only 1 ingestion was witnessed. The diagnosis was missed by health care providers in 7 of the 13 deaths because of nonspecific presenting symptoms of vomiting, fever, lethargy, poor appetite, irritability, cough, wheezing, and/or dehydration. Batteries were in the esophagus for 10 hours to 2 weeks before removal or death. Exsanguination as a result of esophageal fistulas into major arteries occurred in 9 patients, including 7 aortoesophageal fistulas.^7,11,12,46 Delayed, unanticipated, and uncontrollable massive bleeding occurred up to 18 days after battery removal.

From 2000 to 2009, 92.1% of batteries that were identified in major and fatal ingestions were 20-mm lithium cells. Of major and fatal ingestions with known imprint code (n = 34, 2000–2009), most were CR 2032 (70.6%) or CR 2025 (20.6%). In 7 major or fatal outcome cases, batteries were <20 mm (11.6–16 mm), and age, when known (5 of 7), ranged from 22 days to 10 months.

Of 73 major outcome cases, 91.8% occurred in children who were younger than 4 years (range: 22 days to 9 years; <1 year: 28.8%; 1 year: 43.8%; 2 years: 11.0%; 3 years: 8.2%). Forty-one (56.2%) major outcome cases were unwitnessed (30.1% witnessed, 13.7% unknown). Nineteen (46.3%) of the unwitnessed ingestions were initially misdiagnosed compared with 1 witnessed ingestion (4.5%, battery mistaken for coin). Although most misdiagnoses involved failure to recognize the ingestion because of nonspecific symptoms, misdiagnoses also occurred when ingested batteries were misidentified as electrocardiogram electrodes, external objects,^20,36 or coins on radiograph or were above the uppermost radiograph border.

The battery was lodged in the esophagus for just 2 to 2.5 hours in 3 major outcome cases, causing severe burns, esophageal stenosis that required repeated dilation, a tracheostomy for persistent stridor, or bilateral vocal cord paralysis. Estimated time to removal was within 4 hours in 7 cases, within 8 hours in 17 cases (cumulative total), within 12 hours in 27 cases, within 24 hours in 36 cases, within 2 days in 42 cases, within 3 days in 48 cases, within 1 week in 60 cases, within 2 weeks in 67 cases, within ≥6 weeks in 72 cases, and completely unknown in 1 case. Delayed removal followed failure to seek medical care promptly, misdiagnosis, failure to recognize the need for urgent removal, transfer for pediatric endoscopy, or insistence on fasting before administering anesthesia.

Complications in major outcome cases included tracheoesophageal fistulas (35 cases [47.9%]), other esophageal perforations (17 cases [23.3%]), esophageal strictures or stenosis usually requiring repeated dilations (28 cases [38.4%]), vocal cord paralysis from recurrent laryngeal nerve damage (7 cases [9.6%]), mediastinitis, cardiac or respiratory arrests, pneumothorax, pneumoperitoneum, tracheal stenosis or tracheomalacia, aspiration pneumonia, empyema, lung abscess, and spondylodiscitis. Tracheoesophageal fistulas became symptomatic up to 9 days after battery removal (with even longer delays to diagnosis), strictures were delayed by weeks to months, and the single case of spondylodiscitis presented nearly 6 weeks after battery removal. Many patients required a tracheostomy, feeding tube, repeated esophageal dilation, and/or surgical esophageal or tracheal repair. See additional detail in “Supplemental Information”.