What is the recommended emergency management for a child who has ingested a button battery, including imaging, timing of endoscopic removal, and adjunctive treatments such as honey, sucralfate, antibiotics, and steroids?

Emergency Management of Button Battery Ingestion in Children

Immediate Imaging and Localization

Obtain chest and abdominal plain radiographs immediately—without any delay—to confirm the presence and exact location of the button battery in any child with suspected ingestion. 1

• Use biplanar views to distinguish esophageal from tracheal positioning and to differentiate button batteries from coins (batteries show a characteristic "halo" or double-ring sign on lateral view). 1, 2
• For children with pica or excessive mouthing behaviors, obtain abdominal radiography to identify additional foreign bodies that may alter management. 1
• Do not perform oral contrast studies (barium or gastrografin) as they coat the battery, impair endoscopic visualization, and provide no clinical benefit. 1

Time-Critical Endoscopic Removal for Esophageal Impaction

Perform emergent flexible endoscopy as soon as possible—ideally within 2 hours and never later than 6 hours after ingestion—for any battery lodged in the esophagus. 1, 3, 4

• Tissue damage from pressure necrosis, electrical burns, and alkaline chemical injury begins within 2 hours and progresses rapidly to catastrophic complications including tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). 1, 5, 3
• Do not induce vomiting or administer activated charcoal, as these interventions have no benefit and may worsen injury. 1
• Activate emergency services immediately upon identification of esophageal impaction—this is a true medical emergency. 1

Temporizing Measures While Awaiting Endoscopy (Esophageal Battery Only)

In children older than 1 year, if endoscopy will be delayed and ingestion occurred ≤12 hours ago, administer honey (10 mL every 10 minutes, up to 6 doses) to mitigate mucosal injury. 1, 4

• Sucralfate may be considered under the same conditions as an alternative to honey. 1, 4
• These temporizing measures must never postpone definitive endoscopic removal—they are adjuncts only while mobilizing resources for immediate removal. 1

Post-Removal Evaluation and Injury Grading

During endoscopic removal, grade the depth of esophageal injury using established classification systems and document any burns, ulceration, or necrosis. 1, 6

Advanced Imaging for Severe or Delayed Presentations

Obtain contrast-enhanced CT of the neck and chest when there is clinical suspicion for transmural necrosis, mediastinitis, or vascular injury. 1, 6, 4

• Indications for CT include: delayed diagnosis (>12 hours from ingestion to first X-ray confirmation or removal), fever, sepsis, subcutaneous emphysema, severe chest pain, or respiratory distress. 6, 4
• Absence of post-contrast wall enhancement on CT indicates full-thickness transmural necrosis and mandates emergency surgery. 1, 6
• Even if the battery has passed beyond the esophagus in delayed presentations, consider endoscopy to screen for esophageal damage and CT to rule out vascular injury, even in asymptomatic children. 4

Surgical Indications and Approach

Emergency surgery is indicated for confirmed or suspected perforation, transmural necrosis on CT (absent wall enhancement), tracheo-esophageal fistula, or aorto-esophageal fistula. 1, 5

• The preferred operative technique is esophagotomy with minimal resection of necrotic tissue and primary repair over a feeding tube. 1
• More extensive procedures (external drainage, esophageal exclusion, or resection) are reserved for cases where primary repair is not feasible due to extensive contamination or non-viable tissue edges. 7, 1
• Do not use hemoclipping for battery-induced esophageal injuries—the damage is typically deep and transmural, requiring definitive surgical repair rather than endoscopic closure. 1

Management of Batteries Beyond the Esophagus

For batteries that have passed into the stomach or beyond in asymptomatic patients with early diagnosis (≤12 hours), monitor with repeat X-ray in 7 to 14 days if not already evacuated in stool. 4

• This represents a significant departure from older guidelines that recommended removal after 2-4 days, reflecting updated evidence that gastric batteries rarely cause harm in most cases. 4
• However, be aware that severe gastric wall injury can occur, particularly in young infants under 6 months, and consider earlier removal in this age group. 8

Critical Pitfalls to Avoid

Never postpone endoscopic removal of an esophageal button battery—tissue damage begins within 2 hours and catastrophic complications can develop rapidly. 1, 2, 3

• Avoid oral contrast studies before removal as they obscure the battery and hinder endoscopic visualization. 1
• Do not rely on absence of symptoms to guide urgency—clinical symptoms do not correlate reliably with the extent of gastrointestinal damage. 7
• In delayed presentations (>12 hours), strongly consider CT before removal to assess for vascular injury, as manipulation during endoscopy could precipitate fatal hemorrhage from an aorto-esophageal fistula. 4

Adjunctive Treatments and Antibiotics

While the guidelines emphasize honey and sucralfate as temporizing measures, they do not provide specific recommendations for routine antibiotic or steroid use. 1, 4

• Consider antibiotics and steroids on a case-by-case basis for severe injuries, perforation, or mediastinitis, following general principles for managing esophageal perforations and corrosive injuries. 7
• Obtain biopsies during follow-up endoscopy if depth of injury or infection is uncertain. 6