Button battery taping and disposal: Risk reduction strategies for the household setting.

OBJECTIVES: Pediatric esophageal button battery (BB) injury occurs rapidly and continues to be a significant source of morbidity and mortality. Unfortunately, a BB that no longer supplies power to a device can still have enough residual voltage to cause injury within the body. Development of additional prevention strategies for consumers may reduce esophageal injury risk. METHODS: In this study, 24 commercially available button batteries (BBs) were horizontally and vertically wrapped (2 layers, full circumferential coverage, 90° apart) with 6 different types of common household tapes (Scotch®/clear, Scotch®/Magic, masking tape, packing tape/clear, packing tape/brown, black electrical tape) and left at room temperature for 30 days. In addition, 6 of the CR2032 batteries covered with each type of tape were placed in a cadaveric piglet esophageal model for a 4-h period and then compared to controls without tape for tissue pH changes and visible tissue injury. RESULTS: None of the tape-wrapped batteries showed voltage changes nor presented any hazard stemming from BB ingestion. All 6 tape covered batteries placed in the cadaveric piglet esophageal tissue model demonstrated no visible tissue injury and no change in tissue pH in contrast to the controls. Review of BB packaging language from various brands of commercially available CR2032 batteries showed that none had specific disposal recommendations. CONCLUSION: Both BB and electronics manufacturers should consider instructing the use of common household tape options to cover these BB immediately after removal from a device for either recycling or disposal. Such precautions may help to reduce related ingestion injuries in children.

Current management of button battery injuries.

Button batteries (BB) are found in common household items and can lead to significant morbidity and mortality in the pediatric population when ingested. BBs are made of various chemistries and have a unique size and shape that yield significant injury when lodged in the pediatric esophagus. BBs create a local tissue pH environment of 10 to 13 and can induce liquefactive necrosis at the negative pole. This initial injury can progress with further tissue breakdown even after removal. Unfortunately, patients may present with vague symptoms similar to viral illnesses and there is not always a known history of ingestion. Plain film X-ray can be diagnostic. Exposure can lead to caustic injury within 2 hours. Thus, timely endoscopic removal is the mainstay of treatment. Novel mitigation and neutralization strategies have been implemented into treatment guidelines. These include the preremoval ingestion of honey or sucralfate and intraoperative irrigation with acetic acid. Depending on the severity of injury following removal, careful consideration should be given for potential delayed complications including fistulization into major vessels which often leads to death. The National Button Battery Taskforce and several industry members have implemented prevention strategies such as educational safety outreach campaigns, child-resistant packaging changes, and warning labels. Governmental regulation and industry changes are key to limit not only the amount of BB ingestions, but also the devastating consequences that can result. Anonymous reporting of BB injuries through the Global Injury Research Collaborative has been made convenient and centralized through the advent of a user-friendly smartphone iOS/App Store and Android/GooglePlay application called the "GIRC App"; all specialists who manage foreign body cases should contribute their cases to help prevent future injuries. BB ingestion must be recognized and treated promptly using a multidisciplinary approach to optimize outcomes for these patients. Ultimately, a safer BB technology is critically needed to reduce or eliminate the severe and life-threatening injuries in children. LEVEL OF EVIDENCE: 5.

pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury.

OBJECTIVES/HYPOTHESIS: Ingestion of button batteries (BB) can rapidly lead to caustic esophageal injury in infants and children, resulting in significant morbidity and mortality. To identify novel mitigation strategies, we tested common weakly acidic household beverages, viscous liquids, and Carafate® for their ability to act as protective esophageal irrigations until endoscopic removal of the BB. STUDY DESIGN: Cadaveric and live animal model. METHODS: Apple juice, orange juice, Gatorade®, POWERADE®, pure honey, pure maple syrup, and Carafate® were screened using a 3 V lithium (3 V-CR2032) BB on cadaveric porcine esophagus. The most promising in vitro options were tested against a saline control in live American Yorkshire piglets with anode-facing placement of the BB on the posterior wall of the proximal esophagus for 60 minutes. BB voltage and tissue pH were measured before battery placement and after removal. The 10 mL irrigations occurred every 10 minutes from t = 5 minutes. Gross and histologic assessment was performed on the esophagus of piglets euthanized 7 ± 0.5 days following BB exposure. RESULTS: Honey and Carafate® demonstrated to a significant degree the most protective effects in vitro and in vivo. Both neutralized the tissue pH increase and created more localized and superficial injuries; observed in vivo was a decrease in both full-thickness injury (i.e., shallower depths of necrotic and granulation tissue) and outward extension of injury in the deep muscle beyond surface ulcer margins (P < .05). CONCLUSIONS: In the crucial period between BB ingestion and endoscopic removal, early and frequent ingestion of honey in the household setting and Carafate® in the clinical setting has the potential to reduce injury severity and improve patient outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 129:49-57, 2019.

Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal.

OBJECTIVES/HYPOTHESIS: Button battery (BB) injuries continue to be a significant source of morbidity and mortality, and there is a need to confirm the mechanism of injury for development of additional mitigation strategies. STUDY DESIGN: Cadaveric piglet esophageal model. METHODS: Lithium, silver oxide, alkaline, and zinc-air BBs were placed in thawed sections of cadaveric piglet esophagus, bathed in normal saline. Severity of gross visual burn, pH, and temperature were recorded every 30 minutes for 6 hours. In other esophageal tissue specimens, the lithium BB was removed after 24, 36, and 48 hours and the site was irrigated with either 0.25% or 3% acetic acid. Separately, ReaLemon® juice, orange juice, Coke®, Dasani® water, Pepsi®, and saline were infused over a vertically suspended esophagus with a CR2032 lithium battery every 5 minutes for 2 hours while tissue temperature and pH were measured. RESULTS: A gradual rise in tissue pH and minimal change in temperature was noted for all BBs. ReaLemon® and orange juice applied every 5 minutes were most effective at neutralization of tissue pH with minimal change in tissue temperature. After BB removal (24, 36, 48 hours), irrigation of esophageal tissue specimens with 50-150 mL 0.25% acetic acid neutralized the highly alkaline tissue pH. CONCLUSIONS: BB appear to cause an isothermic hydrolysis reaction resulting in an alkaline caustic injury. Potential new mitigation strategies include application of neutralizing weakly acidic solutions that may reduce esophageal injury progression. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1276-1282, 2017.