What is the correct treatment for a toddler who has swallowed a coin battery?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Button batteries beyond the esophagus Timing for removal of button batteries beyond the esophagus (and particularly in the stomach) is controversial Specific treatment strategies may vary among experts Management in consultation with a pediatric gastroenterologist is prudent for gastric button batteries even though removal is controversial for asymptomatic patients If the child is younger than 5 years and the button battery diameter is 20 mm or larger, then recent NASPGHAN guidelines suggest urgent (within 24 hours) endoscopic removal Allows for evaluation for esophageal injury If the child is 5 years or older and/or the button battery diameter is less than 20 mm, then may manage with outpatient observation unless symptomatic Repeat radiograph in 48 hours for button batteries 20 mm or larger if not endoscopically removed Repeat radiograph in 10 to 14 days for button batteries less than 20 mm if fail to pass in stool Endoscopic removal is recommended if GI symptoms are present or develop, or button batteries have not passed the stomach by the time of repeat radiograph (after 48 hours for button batteries larger than 20 mm and after 10-14 days for button batteries less than 20 mm) Button batteries beyond the pylorus in asymptomatic patients may be expectantly managed at home (without gastroenterologist consultation) unless symptoms develop Most button batteries that clear the stomach pass through the GI tract in children within about a week Recommend home caregiver monitoring of stool for spontaneous passage of the battery If spontaneous passage is not confirmed after 10 to 14 days, obtain repeat abdominal radiograph to evaluate for retained batteries Ileocecal valve and appendix are common locations foreign bodies may lodge themselves beyond the pylorus

Treatment Cause damage to the esophagus and surrounding structures via alkaline-type injury and liquefactive necrosis Damage may occur even in a weak or nearly dead battery If retained in the esophagus, perforation into surrounding vascular structures including aorta may occur and can lead to death Damage is time dependent and can occur in as little as 15 minutes to 2 hours Higher-risk characteristics include ingestions in children younger than 5 years and higher battery voltage 20-mm lithium button batteries pose the greatest risk and are responsible for most complications Esophageal button batteries Require immediate identification and removal as soon as possible irrespective of NPO status Standard of care is definitive removal by 2 hours of ingestion Subspecialty consultation (pediatric gastroenterologist, otolaryngologist, or general surgeon) is required with whichever specialist is available for timeliest removal Poison control guidelines recommend administration of either honey or sucralfate to minimize tissue injury Honey For use only in children older than 12 months Give 10 mL of honey PO every 10 minutes for up to 6 doses while en route to the emergency department Sucralfate Sucralfate suspension 1 g/10 mL—give 10 mL PO Additional 10-mL doses may be given every 10 minutes up to 3 total doses Do not delay removal to administer honey or sucralfate Do not administer if the button battery is known to have been in the esophagus for more than 12 hours given the risk of perforation is already present For button batteries in the esophagus for more than 12 hours Consult a general and/or cardiothoracic surgeon and/or an otolaryngologist in addition to a gastroenterologist to comanage removal Button batteries beyond the esophagus Timing for removal of button batteries beyond the esophagus (and particularly in the stomach) is controversial Specific treatment strategies may vary among experts

Summary Most ingested foreign bodies in children will pass spontaneously; a few will require endoscopic or surgical management Patients may be asymptomatic or present with nonspecific GI (gastrointestinal) and/or respiratory complaints, including dysphagia, feeding intolerance, drooling, abdominal pain, and vomiting Identifying the type of foreign body, its location within the GI tract, time since ingestion, and associated symptoms determine need for endoscopic or surgical intervention Plain radiographs with frontal and lateral projections of the neck, chest, and abdomen are helpful in most cases of suspected foreign body ingestion; a CT scan can help identify radiolucent objects Button battery ingestions must be immediately located and emergently removed if in the esophagus Oral administration of honey (not recommended for children younger than 1 year) or sucralfate is recommended for asymptomatic children after acute button battery ingestion en route to the emergency department but should not delay removal Other objects that require urgent removal include multiple high-power magnets proximal to the duodenum, esophageal foreign bodies with airway compromise, sharp objects in the esophagus, and superabsorbent polymers in the stomach or esophagus Multiple magnets and some sharp objects that pass beyond endoscopic reach may warrant inpatient observation and serial imaging to monitor for progression and complications Admit patients with ingested esophageal foreign bodies, including coins and impacted food bolus, to monitor for spontaneous clearance before endoscopy; monitoring in the hospital is recommended for patients with high-risk lesions after removal of a button battery from the esophagus

Follow-up Acute monitoring Asymptomatic coin or blunt object Esophageal Reassess clinically and radiographically within 12 to 24 hours in consultation with a pediatric gastroenterologist Removal is recommended within 24 hours if not spontaneously passed on repeat radiographs Gastric and small bowel Have caregivers monitor stool for passage Repeat radiograph of the abdomen every 2 weeks if not seen to pass in stool Refer to a pediatric gastroenterologist if the object has not passed in the stool within 4 weeks or fails to progress on radiographs Asymptomatic button batteries beyond the esophagus Gastric If the child is 5 years or older and/or the button battery diameter is less than 20 mm, then may manage with outpatient observation unless symptomatic Repeat radiograph in 48 hours for button batteries 20 mm or larger if not endoscopically removed Repeat radiograph in 10 to 14 days for button batteries less than 20 mm if fail to pass in stool Endoscopic removal is recommended if GI symptoms (gastrointestinal) develop, or button batteries have not passed the stomach by the time of repeat radiograph (after 48 hours for button batteries more than 20 mm and after 10-14 days for button batteries less than 20 mm) Repeat abdominal radiograph in 2 weeks if stool passage is not documented Refer to a pediatric gastroenterologist if GI symptoms develop at any time or the battery does not progress on radiographs Esophageal button batteries after removal Subspecialists may recommend a serial CT scan or MRI after removal of impacted esophageal button batteries Recommend home caregiver monitoring for signs of upper GI tract bleeding, including hematemesis, in the weeks to months after removal or passage of a button battery Signs of upper tract GI bleeding may indicate vascular fistula and mandates emergent evaluation and GI consultation Asymptomatic magnets Solitary magnet in the stomach and beyond Repeat radiographs in 1 to 2 weeks to document passage if not seen in stool Multiple magnets beyond the stomach Obtain serial radiographs every 8 to 12 hours document progressive movement of magnets through the GI tract

2.

Elsevier ClinicalKey Clinical Overview

Special Considerations Type of surgical intervention will vary depending on the type of anatomical abnormality, presence of obstruction, and associated symptoms For esophageal foreign bodies, esophagogastroduodenoscopy is the method of choice to retrieve them Button battery ingestion cases in which the battery is lodged in the esophagus require emergent removal In other foreign body ingestions, timing for removal will depend on the patient's age, type of object, and associated symptoms Interventions for esophageal strictures include: Balloon dilatation If chronically recurring: Injection of steroids or mitomycin over the stricture site Stricture surgical resection with anastomosis has been used For achalasia, interventions include pneumatic balloon dilatation, laparoscopic Heller myotomy, or peroral endoscopic myotomy. The use of oral medication or lower esophageal sphincter botulinum toxin injection is not typically indicated

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Wang HC, Hu SW, Lin KJ, Chen AC. BMC Pediatrics. 2022;22(1):96. doi:10.1186/s12887-022-03142-3. Copyright License: CC BY

Publish date: February 4, 2022.

BACKGROUND: Accidental swallowing of a foreign body occurs more frequently in children than in adults. Among these cases, button battery impaction in the esophagus may cause severe complications. While prevention is always ideal, if button battery impaction is suspected, immediate diagnosis and retrieval are important. CASE PRESENTATION: We introduce a novel method for retrieval of a button battery after ingestion by a 2.5-year-old child. When the patient arrived at our center, the battery was incarcerated in the upper esophagus. The battery could not be removed, despite the use of several methods such as alligator forceps under endoscopy and net retrieval. We decided to use a novel method that combined endoscopic balloon extraction and forceps retrieval. This resulted in a push-and-pull... (truncated preview)