- A lithium coin cell may have been ingested (if you don’t know what kind of button battery was swallowed, assume it is a lithium coin cell unless it is a hearing aid battery);
- The child is 12 months of age or older (because honey is not safe in children younger than one year);
- The battery was swallowed within the prior 12 hours (because the risk that esophageal perforation is already present increases after 12 hours);
- The child is able to swallow; and
- Honey is immediately available.
- Give 10 mL (2 teaspoons) of honey by mouth every 10 minutes for up to 6 doses. Do not worry about the exact dose or timing.
- Use commercial honey if available, rather than specialized or artisanal honey (to avoid inadvertent use of large amounts of honey produced from potentially toxic flowers).
- Honey is NOT a substitute for immediate removal of a battery lodged in the esophagus. Honey slows the development of battery injury but won’t stop it from occurring. Do not delay going to an ER.
Honey is administered to coat the battery and prevent local generation of hydroxide, thereby delaying alkaline burns to adjacent tissue. Efficacy is based on a 2018 study (Anfang et al) assessing the in vitro protective effects of various liquids in the cadaveric porcine esophagus and in vivo protective effects of honey and sucralfate (Carafate ® ) compared to saline irrigations of batteries placed in the esophagus of live piglets. Both honey and sucralfate (Carafate ® ) effectively prevented the expected battery-induced pH increase and decreased the depth of the resulting esophageal injury.
- The patient is entirely asymptomatic and has been asymptomatic since the battery was ingested.
- Only one battery was ingested
- A magnet was not also ingested.
- The battery has been reliably identified based on imprint code or measurement of an identical cell, and the diameter is < 12 mm. Definitive determination of the battery diameter prior to passage is unlikely in at least 40% of ingestions. Assume hearing aid batteries are less than 12 mm.
- There is no history of prior esophageal surgery, esophageal stricture/narrowing, motility disorders, or other esophageal disease.
- The patient (or caregiver) is reliable, mentally competent, and agrees to report symptoms that develop prior to battery passage, or over the subsequent month if passage is not documented, and understands the importance of promptly seeking evaluation for symptoms possibly related to the ingested battery.
- After a battery is removed from the esophagus, inspect the area endoscopically for evidence of perforation. If none is evident, irrigate the injured areas with 50 mL to 150 mL of 0.25% sterile acetic acid (obtained from the hospital pharmacy). Irrigate in increments and suction away excess fluid and debris through the endoscope. For decades toxicologists have advised against neutralization for fear of causing a thermal injury. However, a recent study (Jatana, 2016) using piglet esophagus preparations after button battery removal, showed only a minimal increase in temperature (0-3 o C), effective tissue surface pH neutralization, and decrease in the visible injury using this neutralization strategy. The tissue surface pH neutralization may reduce the development of progressive, delayed-onset esophageal injury after battery removal.
- Determine the length of observation, duration of esophageal rest, and need for serial imaging or endoscopy/bronchoscopy based on the severity and location of the injury, anticipating specific complications based on the injury location, battery position and orientation. Consider the proximity of the lodged battery and injured area to major arteries. Monitor patients at risk of fistulization into blood vessels carefully, as inpatients, with serial imaging (contrast CT or MRI of chest and/or neck) and stool guaiacs. Intervene early if perforation is imminent. Monitor for respiratory symptoms, especially with swallowing, to diagnose tracheoesophageal fistulas early.
- Expect delayed onset of esophageal perforations and fistulas involving the trachea or major vessels. Perforations were diagnosed by 48 days post removal in 98.1% of cases, and delays up to 27 days post removal were observed for esophageal-vascular fistulas. Recurrent laryngeal nerve injury may be evident on presentation or may not develop or be diagnosed for weeks after battery removal. Esophageal strictures and spondylodiscitis may not manifest for weeks to months post ingestion.
- Patients with esophageal injury should be admitted and observed due to the high risk of local edema developing with worsening symptoms, especially airway compromise when the battery is lodged high in the esophagus. In stable, well-appearing children, a clear liquid diet can be started after an esophagram shows no evidence of perforation. The esophagram is obtained at least 1-2 days after battery removal, earlier (1 day) for cases with mucosal injury only, and later for cases with deeper injury. Diet may be advanced to soft as tolerated, but all children who have had an esophageal battery removed should be limited to soft foods for a full 28 days to avoid mechanical damage to a healing esophagus. In children with more severe injuries, subsequent care and diagnostic intervention is guided by clinical manifestations.
- Patients with batteries removed from the upper esophagus should be monitored carefully for voice changes, respiratory distress, or stridor. If any of these are present or suggested, the cords should be visualized under direct laryngoscopic view in the awake patient to confirm bilateral vocal cord mobility. Unilateral or bilateral vocal cord paralysis is a common complication of battery ingestion due to damage to the recurrent laryngeal nerve(s). Paralysis may be delayed and not detected for days or weeks.
- Always consider the possibility of battery proximity to the aorta or other major vessels. If this is anatomically likely due to the position of the battery, use a contrast CT or MRI diagnostically to confirm there is at least 3 mm of tissue between the area of esophageal injury and adjacent vessels. Watch for sentinel bleeds, which may be subtle. Engage cardiothoracic surgery early if there is any possibility of an impending esophageal-vascular fistula.
- A magnet was also ingested,
- The patient develops signs or symptoms that are likely related to the battery ingestion, or
- A large button battery (≥ 15 mm diameter), ingested by a child younger than 6 years, remains in the stomach for 4 days or longer. If battery diameter is unknown, estimate if from the x-ray, factoring out magnification (which tends to overestimate battery diameter).
- If a large button battery (≥ 20 mm) is in the stomach or beyond of a child younger than 5 years, and based on history, might have lodged in the esophagus for > 2 hours before passing to the stomach, consider diagnostic endoscopy to exclude the remote possibility of esophageal injury. (In a handful of cases, patients with significant and symptomatic esophageal injury have been found with batteries that have already passed beyond the esophagus.) If symptoms suggestive of esophageal or gastric injury are (or were) present, urgent endoscopy is recommended to exclude esophageal injury.
- Ipecac administration (ineffective).
- Blind battery removal with a balloon catheter or a magnet affixed to a nasogastric tube (can’t determine extent of injury).
- Blood or urine concentrations of mercury or other battery ingredients (unnecessary).
- Chelation (unnecessary).
- Laxatives (ineffective) or polyethylene glycol electrolyte solution (unproven effectiveness and unknown if solution enhances electrolysis).
© 2010-2024 National Capital Poison Center
Revised: 9/2016; 6/2018
