What is the immediate management for a pediatric patient under 6 years old with suspected button battery ingestion?

Immediate Management of Button Battery Ingestion in Children Under 6 Years

For any child under 6 years with suspected button battery ingestion, immediately obtain imaging to locate the battery and activate emergency medical services for emergent endoscopic removal within 2 hours (at latest within 6 hours) if the battery is lodged in the esophagus, as tissue damage can occur rapidly and lead to catastrophic complications including aorto-esophageal fistula and death. 1, 2

Immediate Actions Upon Presentation

Step 1: Rapid Imaging Localization

• Obtain biplanar radiographs (AP and lateral views) immediately to confirm battery presence and exact anatomical location 1, 3
• CT scan is the key examination if perforation or other battery-related complications are suspected, with 90-100% sensitivity compared to only 32% for plain X-rays 4
• Do not delay imaging—children may present with vague, nonspecific symptoms including fussiness, decreased appetite, drooling, difficulty swallowing, hematemesis, or may be completely asymptomatic 2, 5

Step 2: Risk Stratification Based on Location

Esophageal Impaction (HIGHEST RISK):

• Activate emergency services immediately and arrange emergent flexible endoscopy within 2 hours, at latest within 6 hours 1, 2
• Pressure necrosis, electrical burns, and chemical injury can cause severe tissue damage in as little as 2 hours 1, 2
• This applies regardless of whether the child is symptomatic or asymptomatic 1, 5

Beyond the Esophagus:

• The risk profile changes dramatically for batteries that have passed into the stomach or beyond, allowing for more conservative management 1

Pre-Removal Management

What TO DO:

• For children >1 year old: Administer honey if ingestion occurred <12 hours ago and removal will be delayed 1
• Alternatively, administer sucralfate under the same conditions 1
• Keep the patient nil by mouth except for the above interventions 1, 4

What NOT TO DO:

• Do not administer water or milk to dilute the ingestion 1
• Do not induce vomiting 1
• Do not administer activated charcoal 1
• Do not perform contrast swallow studies—they increase aspiration risk and impair endoscopic visualization 3, 4

Endoscopic Removal Technique

• Flexible endoscopy is the first-line approach for removal 3, 4
• Rigid endoscopy should be considered as second-line if flexible endoscopy fails, particularly for batteries in the upper esophagus 3, 4
• Use retrieval techniques with baskets, snares, or grasping forceps 4

Post-Removal Monitoring

Immediate Complications to Monitor:

• Tracheo-esophageal fistula (TEF): Can develop even after successful removal due to tissue necrosis 6, 7, 5
• Aorto-esophageal fistula (AEF): The most catastrophic complication, leading to massive bleeding and death 6, 5
• Esophageal perforation and mediastinitis: Characterized by severe sore throat, deep cervical pain, chest pain, dysphagia, fever, and crepitus 4, 5
• Esophageal stenosis: May develop as a delayed complication requiring follow-up 7, 5
• Vocal cord paralysis: Reported complication requiring monitoring 5

Warning Signs Requiring Immediate Intervention:

• Stridor or obstructed breathing pattern 3, 4
• Fever 4, 5
• Deep cervical or chest pain 3, 4
• Hematemesis 2
• Agitation or respiratory distress 3

Critical Pitfalls to Avoid

The most dangerous pitfall is delayed recognition and removal. Even small batteries (<20 mm) can cause serious complications, and asymptomatic children are still at high risk 5. The median time from ingestion to presentation in serious complications is only 5 hours, but tissue damage begins within 2 hours 2, 5.

Do not wait for symptoms to develop before acting—18.8% of children with serious complications were initially asymptomatic 5. The widespread availability of button batteries in consumer electronics has led to a dramatic increase in ingestions, and emergency providers must maintain a high index of suspicion 2.

Prolonged esophageal retention leads to pressure necrosis, perforation, mediastinitis, and potentially fatal vascular fistulas 3, 6, 5. One reported case involved a 21-day-old neonate who developed both tracheo-esophageal fistula and esophageal stenosis after battery ingestion 7.