What is the most appropriate next step for a child who ingested a button battery from a travel alarm clock, is asymptomatic, and has a normal physical examination?

Immediate Endoscopic Removal is Required

This child requires emergent endoscopy (within 2 hours) for immediate removal of the button battery, regardless of the asymptomatic presentation. Button batteries lodged in the esophagus cause severe alkaline caustic injury through an isothermic hydrolysis reaction that can produce life-threatening complications including perforation, fistula formation, and vascular injury in as little as 2 hours 1, 2, 3.

Critical Time-Dependent Management

Immediate Pre-Endoscopy Interventions (If Within 12 Hours of Ingestion)

• Administer honey (10 mL every 10 minutes, up to 6 doses) and/or sucralfate (10 mL every 10 minutes, up to 3 doses) immediately while arranging for endoscopy 1, 4
• These pH-neutralizing and viscous barrier agents reduce tissue injury progression but must not delay endoscopic removal 1, 4
• The mechanism involves neutralization of the highly alkaline tissue pH created by the battery's electrical current 3, 4

Endoscopic Removal Protocol

• Remove the battery within 2 hours of presentation to minimize tissue damage 1, 2
• After removal, irrigate the esophageal injury site with 50-150 mL of 0.25% acetic acid to neutralize residual alkaline tissue pH 1, 3, 4
• This post-removal irrigation is a critical new intervention that helps mitigate ongoing tissue injury 3, 4

Why Other Options Are Dangerous

Do NOT Administer Cathartics

• Cathartics are contraindicated as they do not accelerate passage and may worsen complications 1
• The battery must be removed endoscopically, not passed through the GI tract 1, 2

Do NOT Simply Observe Stool for Passage

• Esophageal button batteries never receive conservative management 1, 2
• Tissue necrosis begins within 2 hours and can cause perforation, tracheoesophageal fistula, aortoesophageal fistula, and death 1, 2, 3
• Even asymptomatic children with esophageal batteries require immediate removal 1, 2

Do NOT Repeat X-rays in 6 Hours

• Waiting 6 hours would result in severe, potentially irreversible esophageal injury 1, 2
• The injury mechanism is an alkaline caustic burn from electrical current, not mechanical obstruction, so time is critical 3, 4

Location-Specific Considerations

The radiograph location determines urgency but based on the clinical scenario (travel alarm clock battery, likely CR2032 lithium type), if this battery is in the esophagus:

• Esophageal location = emergent removal within 2 hours 1, 2
• Beyond the esophagus in an asymptomatic child with early diagnosis (≤12 hours) = can monitor with repeat X-ray in 7-14 days 1

Common Pitfalls to Avoid

• Never rely on the absence of symptoms to delay intervention - children with esophageal button batteries are often initially asymptomatic but develop catastrophic complications rapidly 1, 2
• Do not confuse button battery management with other foreign bodies - coins and other objects can be observed, but button batteries in the esophagus are surgical emergencies 1, 2
• Lithium batteries (≥20mm diameter, especially CR2032) cause the most severe injuries due to higher voltage and larger surface area contact 1, 3