Consultant Paediatric Gastroenterologist, Christos Tzivinikos, discusses the worrying increase in button battery ingestion (BBI) in children and how this can be prevented.
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 children1 and an increasing number of cases being reported worldwide2,3, due to the wide abundance of button batteries (BBs) in consumer electronics, BBI remains an issue too few people understand or are aware of.
Button batteries 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 Prevention Trust (CAPT) have provided useful guidance on where button batteries can be found. BBs 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 themself 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 aged under six, with a peak at the age of one, which is also when the highest risk of complications occurs.2,10 Worryingly, new research from Great Ormond Street Hospital (GOSH) revealed that button battery ingestion 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 two 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 which 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 20mm button battery 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 the risk of severe complications and death.
To effectively treat and manage BBI, early recognition is critical due to the extremely narrow two-hour time frame 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 BBI understanding, BB product design and innovation, and driving policy.
Improving awareness of BBI amongst 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) have also produced a helpful video for parents regarding safe use of button batteries.
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 button battery ingestion. 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.
Button battery 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 European Portable Battery Association (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 which committed to preventing button battery ingestion in children. Additionally, ESPGHAN and its Public Affairs Committee has now formed a task force which regularly meets to review the progress of awareness, prevention and management initiatives.
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.
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.
- Boystownpediatrics.org. 2021. Button Batteries Ingestion – Symptoms and Complications. [online] Available at: <www.boystownpediatrics.org/knowledge-center/button-batteries-are-dangerous-when-swallowed> [Accessed 18 November 2021].
- Litovitz, T., Whitaker, N., Clark, L., White, N. and Marsolek, M., 2010. Emerging Battery-Ingestion Hazard: Clinical Implications. PEDIATRICS, 125(6), pp.1168-1177.
- Jatana, K., Litovitz, T., Reilly, J., Koltai, P., Rider, G. and Jacobs, I., 2013. Pediatric button battery injuries: 2013 task force update. International Journal of Pediatric Otorhinolaryngology, 77(9), pp.1392-1399.
- Litovitz, T., Whitaker, N. and Clark, L., 2010. Preventing Battery Ingestions: An Analysis of 8648 Cases. PEDIATRICS, 125(6), pp.1178-1183.
- Eliason, M., Ricca, R. and Gallagher, T., 2017. Button battery ingestion in children. Current Opinion in Otolaryngology & Head & Neck Surgery, 25(6), pp.520-526.
- Ibrahim, A., Andijani, A., Abdulshakour, M., Algain, S., Abu Thamrah, A., Ali, M., Marwah, H., Aldaher, A., Bashir, S., Alsaleem, B., Asery, A. and Al-Hussaini, A., 2019. What Do Saudi Children Ingest?. Pediatric Emergency Care, Publish Ahead of Print.
- Khorana, J., Tantivit, Y., Phiuphong, C., Pattapong, S. and Siripan, S., 2019. Foreign Body Ingestion in Pediatrics: Distribution, Management and Complications. Medicina, 55(10), p.686.
- Diaconescu, S., Gimiga, N., Sarbu, I., Stefanescu, G., Olaru, C., Ioniuc, I., Ciongradi, I. and Burlea, M., 2016. Foreign Bodies Ingestion in Children: Experience of 61 Cases in a Pediatric Gastroenterology Unit from Romania. Gastroenterology Research and Practice, 2016, pp.1-6.
- Kramer, R., Lerner, D., Lin, T., Manfredi, M., Shah, M., Stephen, T., Gibbons, T., Pall, H., Sahn, B., McOmber, M., Zacur, G., Friedlander, J., Quiros, A., Fishman, D. and Mamula, P., 2015. Management of Ingested Foreign Bodies in Children. Journal of Pediatric Gastroenterology & Nutrition, 60(4), pp.562-574.
- Varga, Á., Kovács, T. and Saxena, A., 2018. Analysis of Complications After Button Battery Ingestion in Children. Pediatric Emergency Care, 34(6), pp.443-446.
- Festa, N., Thakkar, H., Hewitt, R., Dhaiban, M., Muthialu, N., Cross, K. and De Coppi, P., 2021. Foreign body ingestion during the COVID-19 pandemic: a retrospective single centre review. BMJ Paediatrics Open, 5(1), p.e001042.
- Litovitz, T., Holm, K., Clancy, C., Schmitz, B., Clark, L. and Oderda, G., 1993. 1992 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. The American Journal of Emergency Medicine, 11(5), pp.494-555.
- Mubarak, A., Benninga, M., Broekaert, I., Dolinsek, J., Homan, M., Mas, E., Miele, E., Pienar, C., Thapar, N., Thomson, M., Tzivinikos, C. and de Ridder, L., 2021. Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. Journal of Pediatric Gastroenterology & Nutrition, 73(1), pp.129-136.
- Lahmar, J., Célérier, C., Garabédian, E., Couloigner, V., Leboulanger, N. and Denoyelle, F., 2018. Esophageal lesions following button-battery ingestion in children: Analysis of causes and proposals for preventive measures. European Annals of Otorhinolaryngology, Head and Neck Diseases, 135(2), pp.91-94.
- Duracell. 2021. Duracell Batteries UK | The World’s #1 Consumer Battery Company. [online] Available at: <www.duracell.com/en-us/press/duracell-debuts-breakthrough-child-safetyfeature- lithium-coin-batteries/> [Accessed 18 November 2021].
- Australian Competition and Consumer Commission. 2021. Button and coin batteries. [online] Available at: <www.productsafety.gov.au/standards/button-and-coin-batteries> [Accessed 18 November 2021].
- GOV.UK. 2021. OPSS supports new standard for battery safety. [online] Available at: <www.gov.uk/government/news/opss-support-new-standard-for-battery-safety> [Accessed 18 November 2021].
Consultant Pediatric Gastroenterologist
European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)
This article is from issue 20 of Health Europa Quarterly. Click here to get your free subscription today.