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Button battery ingestion in children: A growing problem

2nd December 2021

Button battery ingestion (BBI) in children can be devastating, potentially leading to severe morbidity and even death.

Despite being the most harmful type of battery when swallowed by children,1 and an increasing number of cases being reported worldwide,2,3 due to the wide abundance of button batteries in consumer electronics, BBI remains an issue too few people understand or are aware of.

BBs are used to power many household items including toys, gadgets, watches, medical devices (hearing aids, thermometers, glucometers), small appliances (key fobs, remote controls) and many other electronic devices. The Child Accident Prevent Trust (CAPT) have provided useful guidance on where button batteries can be found. BB are accessible throughout their lifecycle; including when purchased new, from appliances, and at the end of life. A study has shown that in around 60% of cases, batteries are directly taken from an electrical device by the child itself, while around 30% of the children ingest loose batteries. In approximately 10% of cases, the batteries were obtained from the packaging.4 Currently in Europe, only toys are required to have durable, secure battery compartments.

According to recent data there has been a seven-fold increase in the relative risk of severe morbidity due to BBI in the last two decades.5 Of all children worldwide presenting with foreign body ingestion, the percentage of children with battery ingestion is estimated to be as high as 7–25% (approximately).6–9 Most BBI cases occur in children below 6 years of age, with a peak at 1 year of age, which is also when the highest risk of complications occurs.2,10 Worryingly, research from Great Ormond Street Hospital revealed that BBI in children rose significantly during the lockdown period in the UK.11

Dangers and impact
The tragic case of Harper-Lee Fanthorpe, who died from BBI at the age of just 2 in May 2021 has served as a reminder of the devastating impact BBI can have. The small, shiny surface and round shape of BBs make them both appealing and easy to swallow, particularly for young children. Once consumed, BBs can trigger a chemical reaction that results in a penetrating burn. Importantly, problems caused by BBs are not usually due to chemicals leaking from the battery but driven by the battery itself reacting with bodily fluids, such as mucus or saliva. This creates a circuit that releases a strong alkali that can burn through the throat or stomach and potentially cause further damage to other internal organs.

BBs are particularly dangerous when stuck in the oesophagus, and studies have shown that 12.6% of children who ingested a 20-mm BB suffered severe or fatal injuries.12 This danger is compounded by the fact that BBI diagnosis is particularly challenging, as many ingestions go unwitnessed by parents or carers, and children (depending on age) may not be able to say what has happened. Furthermore, in contrast to the devastating burn occurring inside, the symptoms of ingestion are variable and non-specific, mimic other common childhood illnesses and evolve over the period that the battery is located in the oesophagus. These factors can often lead to delayed diagnosis. Subsequently including battery ingestion in the diagnosis of unexplained symptoms is paramount to avoid unnecessary delay and increasing the risk of severe complications and death.

To effectively treat and manage BBI, early recognition is critical due to the extremely narrow 2-hour time window for removal of batteries impacted in the oesophagus. ESPGHAN has recently published a clinical paper on BBI, developed by its Button Battery Task Force, which includes a medical algorithm providing clinicians with a step-by-step guide on the treatment pathways for BBI.13

Solutions and action
Perhaps the most pressing BBI matter to address is prevention and the urgent need for solutions and action. There are four core elements on this which are set out here: improving public awareness, increasing HCP understanding, BB product design and innovation, and driving policy.

Public awareness
Improving awareness of BBI among parents, carers and the general public, and educating them on how to mitigate the risks of it happening is a key step forward. This will help increase cautiousness when it comes to products containing button batteries or properly disposing of old batteries, but above all it will help push them towards seeking early medical attention when they suspect an ingestion may have taken place. Increasing public awareness will be challenging, not least because it will require the involvement of industry, media, schools, and the Government in addition to medical professionals. However, ESPGHAN is already helping lead the way with this process, developing a short guide for parents, and there are plans for additional resources to be published next year. The European Portable Battery Association (EPBA) has also produced a helpful video for parents regarding safe use of button batteries.

HCP understanding
Currently, clinical understanding and process is not geared towards early diagnosis of BBI in children, as many in the medical community are not well informed. It is vitally important that medical professionals are able to identify a button battery impacted within the oesophagus and are aware of the diagnostic and management approach when a child presents with a battery ingestion. This includes considering BBI as a potential diagnosis, particularly for unexplained symptoms, and ensuring all healthcare professionals are equipped with the knowledge and guidance to address BBI appropriately. This could be achieved by giving more attention to this subject in medical school, post-graduate paediatric, emergency and family medicine training. Furthermore, resources need to be developed by experts and distributed to the medical community. ESPGHAN has recently finalised a short, visual and easy-to-use clinical advice guide on BBI. Collaboration amongst clinical networks is also required to develop and promote strategies for recognising unwitnessed cases, expediting care and managing complications in centres with specific expertise in button battery injury.

BB product innovation
Mitigating the risk of BBI injury also needs to be driven by battery and product design and innovation. One study has calculated that almost 70% of the ingestions can be prevented with screw-secured compartments and individual blisters for batteries.14 Another solution that has been explored is making the battery less attractive for children and while there is currently limited data of its impact on BBI, bitter coatings have been created and are being developed.15

Collaborating with industry on this issue is critical, and ESPGHAN has been working alongside a coalition of other organisations, including the EPBA, to ensure a clear understanding of the hazards that come with poorly secured products and how we effectively tackle those hazards. Earlier this year, the group joined forces to publish a joint statement that committed to preventing button battery ingestion in children. Additionally, ESPGHAN and its Public Affairs Committee has now formed a task force that regularly meets to review the progress of awareness, prevention and management initiatives.

Policy
Lastly, there is an important overarching role for regulatory agencies and policymakers to play on this issue, through evaluating current legislation and implementing national strategies on improving awareness and the safety of button batteries. Recent legislative developments in Australia16 and in the UK17 have hinted towards kickstarting this process. The Australian regulation, due to come into effect in June 2022, replicates existing requirements in international toy standards and includes the requirement for child resistant button battery packaging alongside durable and secure battery compartments for products powered by button batteries. However, these isolated examples can only go so far, and the situation demands widespread action in Europe and across the Globe.

Conclusion
Ultimately, urgent action on BBI is essential and it is required now. The sudden, devastating and potentially fatal impact BBI can have on children simply cannot be ignored and it is imperative on us all to ensure we protect future generations from this completely unnecessary burden. The reality is that we are at the beginning phase of resolving this problem, however, encouragingly we have the knowledge and tools to help significantly reduce BBI cases. We now need the concerted will to implement these properly at the public, medical, industry and policy level.

References

  1. Boystownpediatrics.org. 2021. Button Batteries Ingestion – Symptoms and Complications. [online] www.boystownpediatrics.org/knowledge-center/button-batteries-are-dangerous-when-swallowed (accessed November 2021).
  2. Litovitz T et al. Emerging Battery-Ingestion Hazard: Clinical Implications. Pediatrics 2010;125(6):1168–77.
  3. Jatana K et al. Pediatric button battery injuries: 2013 task force update. International J Pediatr Otorhinolaryngol 2013;77(9):1392–9.
  4. Litovitz T, Whitaker N, Clark L. Preventing Battery Ingestions: An Analysis of 8648 Cases. Pediatrics 2010;125(6):1178–83.
  5. Eliason M, Ricca R, Gallagher T. Button battery ingestion in children. Curr Otolaryngol Head Neck Surg 2017;25(6):520–6.
  6. Ibrahim A et al. 2019. What Do Saudi Children Ingest? A 10-year retrospective analysis of ingested foreign bodies from a tertiary care centre. Pediatr Emerg Care 2019; Jul 24 [ePub ahead of print].
  7. Khorana J et al. Foreign Body Ingestion in Pediatrics: Distribution, Management and Complications. Medicina 2019;55(10):686.
  8. Diaconescu S et al. Foreign bodies ingestion in children: Experience of 61 cases in a pediatric gastroenterology unit from Romania. Gastroenterol Res Pract 2016;2016:1982567
  9. Kramer R et al. Management of Ingested Foreign Bodies in Children. J Pediatr Gastroenterol Nutr 2015;60(4):562–74.
  10. Varga Á, Kovács T, Saxena A. Analysis of complications after button battery ingestion in children. Pediatric Emergency Care 2018;34(6):443–6.
  11. Festa N et al. Foreign body ingestion during the COVID-19 pandemic: a retrospective single centre review. BMJ Paediatrics Open 2021;5(1), p.e001042.
  12. Litovitz T et al. 1992 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993;11(5):494–555.
  13. Mubarak A. Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. J Pediatric Gastroenterol Nutrition 2021;73(1):129–36.
  14. Lahmar J et al. Esophageal lesions following button-battery ingestion in children: Analysis of causes and proposals for preventive measures. Eur Ann Otorhinolaryngology Head Neck Dis 2018;135(2):91–4.
  15. Duracell. Duracell Batteries UK. The World’s #1 Consumer Battery Company. [online] www.duracell.com/en-us/press/duracell-debuts-breakthrough-child-safetyfeature- lithium-coin-batteries/ (accessed November 2021).
  16. Australian Competition and Consumer Commission. 2021. Button and coin batteries. [online] www.productsafety.gov.au/standards/button-and-coin-batteries (accessed November 2021).
  17. GOV.UK. 2021. OPSS supports new standard for battery safety. [online] www.gov.uk/government/news/opss-support-new-standard-for-battery-safety (accessed November 2021).