Button Battery Ingestion in a Neonate: Risk, Management, and Implications

Abstract

Patient: Male, 21-day-old

Final Diagnosis: Button battery induced tracheoesophageal fistula and recurrence

Symptoms: Vomiting

Clinical Procedure: Endoscopy

Specialty: Gastroenterology and Hepatology • Pediatrics and Neonatology

Objective:

Unusual clinical course

Background:

Although the ingestion of button batteries (BBs) in neonates is exceedingly rare, it poses severe clinical challenges with potentially catastrophic outcomes. The increase in such cases, particularly among toddlers, is largely due to the widespread availability of portable electronic devices. Ingestion of button or disk batteries is notably more dangerous than other foreign bodies, often leading to acute complications such as burns and esophageal perforation. This report details the diagnosis and management of a 21-day-old neonate who presented with a button battery lodged in the esophagus.

Case Report:

We report the case of a 21-day-old neonate who initially presented with 3 days of persistent vomiting. Diagnostic imaging with a chest radiograph revealed a radiopaque foreign body in the esophagus, identified as a button battery. It was suspected that the battery was inadvertently placed in the neonate’s mouth by a sibling with an intellectual disability. Initial attempts to remove the battery using 4-, 5-, and 6-mm endoscopes were unsuccessful. However, extraction was eventually accomplished with a 2.5-mm rigid esophagoscope. Following the removal, the neonate developed significant complications, including a tracheoesophageal fistula and esophageal stenosis. Extensive follow-up care led to a full recovery, demonstrating resilience despite the severe initial challenges.

Conclusions:

This report emphasizes the critical need for swift identification and removal of ingested button batteries. It details the diagnostic and management strategies employed for a neonate, illustrating the urgency and precision required in such cases.

Introduction

The ingestion of foreign bodies (FBs), particularly button batteries (BBs), constitutes a substantial clinical challenge in pediatric care. While such incidents are relatively common among children, they are exceedingly rare in neonates [1,2]. The increased prevalence of portable electronic devices has led to a rise in cases of BB ingestion, accompanied by an uptick in severe complications and fatalities [3,4]. Although coins remain the most frequently ingested FBs, BBs have become a significant concern due to their potential for causing grave harm [5,6]. Children under age 6 years, especially toddlers, are most susceptible to these accidents [7]. The ingestion of BBs larger than 10 mm is particularly alarming as they are more likely to lodge in the esophagus and induce severe complications [3,8]. The medical consequences of BB ingestion are profound, often resulting in posterior esophageal edema, tissue damage, and potentially fatal conditions such as esophageal perforation, tracheoesophageal fistula, and fistula bleeding [1,8,9]. These effects are primarily attributed to the corrosive nature of BBs, which leads to tissue erosion and necrosis through the release of alkaline electrolytes and OH ions [10,11]. Immediate medical intervention is imperative when an X-ray reveals a BB lodged in the esophagus [12].

In neonates, the ingestion of FBs, particularly BBs, is exceptionally rare but can result in catastrophic outcomes [2,13]. Cases involving neonates often involve family oversight or the activities of older siblings [2]. There have been limited reports of neonatal BB ingestion. For example, Raboei et al described a case involving a 22-day-old neonate who developed serious complications following the ingestion of an alkaline BB [14]. Similarly, Janarthanan et al reported a fatal case where a lodged BB resulted in a tracheoesophageal fistula and esophageal perforation [15]. These and other documented incidents underscore the critical nature of such events in neonates [13,16–18]. Thanks to improvements in X-ray technology, innovative endoscopic methods, and quicker medical reactions, the frequency and mortality rates associated with button battery (BB) ingestion have decreased [19]. However, incidents involving infants still demand close monitoring and urgent medical action. This report presents the diagnosis and treatment of a 21-day-old neonate with an ingested BB lodged in the esophagus.

Case Report

A 21-day-old male neonate of Arab descent, born full-term with a birth weight of 3 kg, was presented to the pediatric emergency department. The presenting concern was moderate, non-projectile vomiting, which had persisted for 3 days and appeared to be temporally associated with feeding. There were no indications of hematemesis or necrotic material in the vomitus, nor were there any biliary constituents observed. Aside from these symptoms, the infant’s health was reportedly normal, with no antecedent respiratory distress, cough, or fever. His prenatal and postnatal histories were unremarkable. The nutritional history included a combination of breastfeeding and formula feeding. The family history indicated that there was an older sibling, aged 3, with intellectual disability, and another older brother age 7 years. The family background was characterized by low socioeconomic status and illiteracy. The past medical and familial history were otherwise nondescript.

Clinical examination revealed a significantly unwell and severely dehydrated infant, who was irritable and cried incessantly. A notable finding was the depression of the anterior fontanelle. The neurological examination was unremarkable, with normal muscle tone and strength. Respiratory assessment, including auscultation, indicated clear lung fields with no adventitious sounds on room air, respiratory rate 48/min. Cardiac examination was normal. Vital signs were as follows: heart rate at 168 bpm, mean arterial pressure at 48 mmHg, and a capillary refill time of 3 seconds. The abdomen was soft and mildly distended, without organomegaly. The rest of the systematic examination was unremarkable.

Differential diagnoses being considered for this neonate’s diagnosis included metabolic disorders, esophageal atresia, tracheoesophageal fistula, infectious gastroenteritis, pyloric stenosis, intestinal obstruction, GERD, metabolic disorders, and, in rare cases, foreign body aspiration. Initial labs included CBC, electrolytes, liver function tests, and a partial sepsis screen. Chest radiographs confirmed the presence of a BB in the esophagus, differentiated from other possible foreign bodies by its characteristic “double rim” sign. In contrast, coins show as a single, uniformly dense radiopaque disc, lacking the layered look of button batteries. The lateral view provides additional evidence of esophageal impaction, showing the battery behind the airway and ahead of the spinal column (Figure 1).

Figure 1.

(A, B) Esophageal button battery impaction in anterior and lateral chest radiographs. Displayed is a single chest radiograph in anterior and lateral views, featuring a radiopaque foreign body with the characteristic circular shape of a button battery (BB) lodged within the esophagus with double rim shadow. In the anterior view, the object is noted to be superimposed on the spine, clearly suggesting its placement within the esophageal passage rather than the trachea. The lateral view further confirms the esophageal impaction, with the battery positioned anterior to the vertebral column and posterior to the airway.

Initial management involved fluid resuscitation, and elevated inflammatory markers prompted the commencement of empirical antibiotic treatment to cover sepsis. After the acquisition of blood and urine specimens, a therapeutic regimen consisting of Cefotaxime at a dosage of 50 mg/kg every 8 hours and Ampicillin at a dosage of 50 mg/kg every 6 hours was instituted. Emergency removal of the BB was performed under general anesthesia, involving a collaborative effort by pediatric surgery and otolaryngology (ENT) teams. After several unsuccessful attempts with 4-, 5-, and 6-mm endoscopes, the BB was successfully removed using a 2.5-mm rigid esophagoscope. Subsequent bronchoscopic examination of the trachea was conducted to evaluate the effects of the BB ingestion, revealing no abnormalities in the tracheal region. However, bronchoscopic examination of the trachea showed a Grade 3a mucosal injury in the esophagus, situated 10 cm from the oral cavity, as classified by the Zargar grading system (Table 1). The extracted BB is depicted in Figure 2. The patient was kept nil per os (NPO), and a nasogastric tube was inserted under visual guidance for lumen patency, with the tip positioned in the stomach. The postoperative course was complicated by the development of a left-sided pneumothorax, necessitating the placement of a left intercostal drain (Figure 3). The patient was subsequently intubated and mechanically ventilated, followed by transfer to the pediatric intensive care unit.

Table 1.

Zargar grading system for classification of esophageal injuries due to button battery impaction. This table outlines the Zargar grading system used to classify the severity of esophageal injuries resulting from button battery impaction. Each grade represents a progression in the severity of mucosal damage, ranging from normal findings to extensive necrosis.

Grading	Descriptions
0	Normal findings on endoscopy
1	Mucosal edema and hyperemia
2a	Friable mucosa, hemorrhages, erosions, blisters, whitish membranes, and superficial ulcerations
2b	Grade 2a findings + deep/circumferential ulcerations
3a	Small scattered multiple ulcerations and areas of necrosis
3b	Extensive necrosis

Adapted from: Ettyreddy AR, Georg MW, Chi DH, Gaines BA, Simons JP. Button battery injuries in the pediatric aerodigestive tract. Ear, Nose & Throat Journal. 2015;94(12):486–93.

Figure 2.

Endoscopic Views of extracted button battery and esophageal mucosal damage. Left: The button battery as visualized during endoscopic removal, showcasing its corroded and disintegrated condition due to prolonged esophageal impaction. Middle: The endoscopic view after removal reveals Grade 3 mucosal damage, characterized by deep ulceration and tissue necrosis. Bottom: The image of removed BB reveals the corrosive effects of prolonged contact with the acidic environment of the esophagus. Notable changes include discoloration, surface erosion, and the breakdown of the battery’s integrity, leading to potential leakage of hazardous materials.

Figure 3.

Anteroposterior (AP) chest X-ray demonstrating postoperative complications with intervention. (A) This AP chest radiograph shows evidence of a left-sided pneumothorax, identified by the absence of lung markings with air leaking (yellow arrow), and lung collapse margin (green arrow). (B) Interventional management is evident by the insertion of a left intercostal tube (red arrow), effectively re-expanding the lung as part of the emergent care provided.

Nutritional support was provided via total parenteral nutrition, with the patient remaining NPO for 10 days. On the twelfth day after BB removal, a Gastrografin contrast study was performed, revealing a tracheoesophageal fistula (TEF) between the upper thoracic esophagus and lower trachea at the T2 vertebral level, with contrast entering the tracheobronchial tree. Additionally, an upper esophageal stenosis measuring 0.5×0.3 cm was noted. The patient remained NPO for a total of 14 days after presentation, pending further evaluation of the TEF. The increased risk of mediastinitis prompted a multidisciplinary team to start a 6-week treatment with broad-spectrum antibiotics and preventive antifungal. Ingested BBs can cause transmural esophageal injuries, which can lead to fungal colonization. This is especially true when combined with broad-spectrum antibiotics, which can disrupt the normal microbial flora. Therefore, it is recommended to use prophylactic anti-fungals. The patient was transferred to the general pediatric ward on January 16, 2022, for continued care.

During the patient’s stay in the pediatric ward, nasogastric tube feeding was administered, and serial esophageal dilatation was performed biweekly using 6-, 7-, and 8-mm balloons. Throughout the course of the illness, the patient was treated with proton pump inhibitors (PPIs). Following a 4-month hospitalization, the patient was discharged with instructions to continue outpatient dilation therapy (Figure 4). The TEF was nearly closed at the 9-month dilation and subsequent 10-month Gastrografin scan. Another hospitalization was required for the initiation of oral trophic feeding. The patient tolerated this well, with no choking or vomiting, and gradual nutritional advancement led to weight gain from 3.5 kg to 4.5 kg. The TEF resolved spontaneously, with minor focal constriction of the upper esophagus noted on radiological follow-up, but without clinical sequelae. The patient was ultimately discharged from the hospital weighing 5.3 kg, in excellent condition. He consistently gained an appropriate amount of weight during regular follow-up visits at the outpatient department, and there were no additional concerns over a 6-month period.

Figure 4.

This composite image presents the endoscopic findings from a patient with esophageal stenosis as a complication following the ingestion of a button battery. The battery ingestion led to a severe, benign-appearing intrinsic stenosis in the middle third of the esophagus, approximately 8 mm in diameter, which precluded the passage of an endoscope. Intervention with a through-the-scope (TTS) dilator and subsequent dilation using a 6-7-8 mm balloon (to a maximum balloon size of 8 mm) was executed, as evidenced by the sequence of images. The endoscopic images (1–8) chronologically document the appearance of the stenosis before and after dilation, providing a visual narrative of the therapeutic procedure and the esophagus’s condition.

Discussion

Recent studies have shown a troubling rise in BB ingestion incidents among children, which pose serious public health concerns due to increasing morbidity and mortality rates. Sahoo et al (2022) reported a significant increase in these incidents [19], mirroring findings by Srikanth et al (2016) and Leinwand et al (2016), who noted a marked increase in severe outcomes from caustic ingestions over the last decade [2,20]. The shift towards larger, more dangerous lithium batteries has exacerbated the risks. Data from a CDC report indicated that from 1997 to 2010, approximately 40 400 children under age 13 years were treated in emergency departments for battery-related injuries, with 58% involving BBs, primarily affecting children under 4 years old [21]. Litovitz et al (2010) documented a 6.7-fold increase in the incidence of serious or fatal outcomes from 1985 to 2009 [22]. These findings underscore the critical need for heightened awareness and proactive measures to address the escalating danger of BB ingestion in young children.

Our case involved a 21-day-old male neonate presenting with moderate, non-projectile vomiting related to feeding, and notably, there were no respiratory symptoms. This contrasts with other cases reviewed, such as by Srikanth et al (2016), where neonates showed symptoms ranging from mild dysphagia to severe respiratory distress [2]. Similarly, Janarthanan et al (2019) described respiratory distress and choking [15], Almagribi (2022) noted choking and feeding difficulties [13], and Sahoo et al (2022) reported respiratory failure at presentation [19]. These varied symptoms underscore the often-ambiguous initial signs of button battery ingestion in neonates, highlighting the need for increased clinical vigilance.

In our case, the diagnosis of a BB ingestion was confirmed by the “double rim” sign on chest radiographs, distinct from the uniform appearance of coins [23]. The lateral view further pinpointed the battery’s location behind the airway. Conversely, cases described by Srikanth et al (2016) presented more diagnostic hurdles; one required a CT scan to identify a double density in the esophagus, while another delayed diagnosis involved a respiratory failure misdirection before an upper-GI study revealed the foreign body [2]. Similarly, Raboei et al (2008) and Janarthanan et al (2019) detected batteries based on parental reports, with distinct radiographic appearances [14,15], while Almagribi (2022) also confirmed a BB through X-ray [13]. These cases demonstrate the variable diagnostic challenges in BB ingestions, ranging from straightforward to complex, necessitating advanced imaging. This variability underscores the need for high suspicion and prompt imaging to manage suspected foreign body ingestions effectively, which is crucial for averting severe complications and ensuring timely intervention.

In our case, the development of a tracheoesophageal fistula (TEF) due to severe esophageal injury aligns with the findings of Brumbaugh et al, who reported ulcerations, perforations, and damage to the adjacent body sections [24]. Varga et al also documented similar severe complications resulting from button battery (BB) ingestion [25]. Notably, conditions such as TEF and esophageal perforation can lead to fatal outcomes if not promptly treated, as demonstrated in case studies by Janarthanan et al and Shaffer et al [15,26]. The literature indicates that nonspecific symptoms following BB ingestion can lead to misdiagnoses, with potential delays of 2 to 2.5 hours before symptoms of burns become apparent, according to Litovitz et al (27). Serious consequences such as paralysis, acute ear infections, vocal cord paresis, aortic perforation, and intestinal perforation were among those described by Liao et al [28]. Given these severe risks, Völker et al emphasized the critical need for rapid endoscopic examination to minimize further tissue damage [29]. In response to these significant health threats, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has initiated a task force to investigate the risks associated with BB ingestion, underlining the urgent need for targeted interventions to prevent these severe outcomes [30].

The extent of tissue damage is significantly influenced by the orientation of the ingested BB; the anode, or positive pole, causes liquefactive necrosis and produces an alkaline environment rich in hydroxide, inflicting more severe damage than the cathode. Deep tissue injury, perforation, and consequences such as fistula formation are exacerbated when the anode faces the esophageal wall. Conversely, a cathode-facing orientation results in lower acidity and milder environmental conditions, leading to less severe damage [31]. Moreover, Yoshikawa et al detailed that the pathophysiology of BB-induced injury involves chemical reactions and tissue damage caused by the electric current from the battery [32]. Kost identified various harmful pathways, including electrolyte loss, alkali generation, and mercury toxicity [33]. Diverse types of injuries can occur with BB ingestion, encompassing electrical, mechanical, thermal, and chemical damage, as discussed by Liao et al and Lahmar et al [28,34]. Instances of esophageal stenosis and alkaline caustic burns, as documented by Fuentes et al and Jatana et al, demonstrate the complexity of these injuries [35,36].

Not only BBs but also a variety of other foreign objects are frequently ingested by infants and neonates. Coins are a prevalent type of ingested foreign body in children, as noted by Khorana et al [37]. According to Shubha et al, small toys or parts such as Lego pieces or beads are also commonly consumed [38]. Bohadana et al (2023) identified jewelry, including rings and earrings, as a potential choking hazard [39]. Lee et al (2016) pointed out that large pieces of food or bones can pose choking dangers [40]. Furthermore, Arana et al observed that common household items such as screws or buttons can also pose a threat [41]. Abbas et al (2013) highlighted cases where the ingestion of multiple magnets led to significant health consequences, underscoring the specific risks posed by magnets [42]. Orsagh-Yentis et al (2019) reported that children often ingest marbles and other similar spherical objects. Given these risks, it is imperative for caregivers to remain vigilant for any signs of distress and to place any items that could be hazardous outside the reach of children [43].

Three days after ingestion, our patient exhibited a Grade 3a mucosal injury in the esophagus, situated 10 cm from the oral cavity, according to the Zargar grading system [44]. Völker et al and Mubarak et al [29,30] consistently emphasizes the necessity of rapid endoscopic intervention to prevent the rapid escalation of tissue damage, which can lead to esophageal perforation within just 2 hours. Supporting this, Richard K. (2023) underscores the critical need for prompt removal of esophageal batteries to prevent severe injuries like perforations and fistulas. Sinclair et al (2023) and Krom et al (2018) advocate for immediate intervention by pediatric surgery and otolaryngology teams, utilizing specialized tools such as a 2.5-mm rigid esophagoscope to mitigate risks [45,46]. Lisi et al (2021) highlighted the importance of a coordinated multidisciplinary approach during these emergencies [47]. If battery removal is delayed beyond 12 hours, administering honey or sucralfate can mitigate harm [48,49]. Mubarak et al (2021) recommend a CT scan to assess for non-obvious vascular damage and further endorse routine CT scans and endoscopy to evaluate potential esophageal or vascular injuries [30]. Aligned with guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, the protocol dictates removing esophageal batteries within 2 hours to minimize severe outcomes [23]. Our case and other reports [29,41,48] highlight the grave risks BB ingestion poses to infants and underscores the urgent need for increased vigilance and rapid medical response. Our management reflects the literature’s consensus on the need for swift, proficient intervention to optimize patient outcomes in pediatric BB ingestion cases.

A concerted effort by many parties is necessary to prevent children from swallowing BBs. The American Academy of Pediatrics and the American Broncho-Esophological Association established the National Button Battery Task Force in 2012 to work with businesses to improve safety by using child-resistant packaging and warning labeling (Kröll et al, 2018) [50]. Paul (2015) and Litovitz et al (2010) both stress the need to protect battery compartments and ensure children do not have access to them [22,51]. Guidelines and initial treatment regimens are provided by Poisons Information Centers, which play a crucial role in managing such cases, particularly in remote locations [51]. Lahmar et al (2018) proposed legislative action requiring use of blister packaging and sealed battery compartments [34]. Securing all battery-operated devices and raising public awareness are crucial for children with special needs (Kröll et al, 2018) [50]. It is also crucial to educate caregivers on emergency responses and to check their toys often [52].

Conclusions

This report discusses the diagnosis and treatment of a 21-day-old neonate who ingested a button battery lodged in the esophagus. It emphasizes the urgent need for prompt action to prevent serious complications and calls for increased awareness among healthcare professionals and caregivers about the dangers of button battery ingestion.