P0877 - Button Battery Ingestion: What Do You Do?

A 16 month-old male presented with 1-2 months of worsening cough. He had no fever, vomiting, drooling, choking, wheezing, stridor, or changes in his voice. His mother did not witness a foreign body ingestion. He was alert, active, breathing comfortably with clear breath sounds, had a clear oropharynx and no muffled voice. Parental concern prompted a chest x-ray which revealed an esophageal button battery.

He was rapidly taken to the operating room where an upper endoscopy revealed a lithium battery lodged below the upper esophageal sphincter with surrounding mucosal erythema and soft tissue overgrowth. After removal of the battery, he was admitted to the PICU where he remained sedated and intubated due to the severity of his injury. Chest MRI revealed extensive esophageal mucosal erosion and circumferential tracheal wall thickening. On hospital day 7, a nasogastric tube was placed after an esophagram did not reveal a tracheoesophageal fistula. He was extubated on day 10, tolerated a clear liquid diet by day 17, advanced to a soft diet by day 23, and regular diet by day 26. Serial MRI revealed improvement in ulceration, mediastinal inflammation, and normalization of vascular and tracheal wall thickening. He was discharged home on hospital day 27.

Foreign body ingestions, especially button batteries, pose a life-threatening risk to children. Clinical management is highly variable, therefore in 2015, NASPGHAN published a guideline on button battery ingestion management. Since publication, there has been a growing adherence to the guidelines however, ambiguity remains regarding management and the implications of certain findings.

As in our case, serial MRI/CT is recommended for presence of significant mediastinal edema/inflammation on initial imaging, however, there is little published data regarding the clinical implications of the imaging findings. Our case illustrates that although the patient’s initial injury was severe, he was ultimately discharged home on a regular diet and recovered without long term complications.

Furthermore, this case highlights a gap in current guidelines regarding nutrition modality and diet advancement for patients with button battery associated esophageal injury. NASPGHAN guidelines suggest diet advancement in cases without significant injury after exclusion of a leak. However, this does not address indications for enteric tube placement, timing of feeding trials, nor diet advancement in moderate/severe esophageal injury. The National Capital Poison Center, while more specific about the timing of the esophagram and the length of a soft diet, is also general in its feeding initiation recommendations. It is unclear in the case of our patient, whether earlier introduction of an enteric tube would have led to earlier diet advancement without increased risk. Given the high impact of button battery ingestions including rising severity since 2003, there is a need for further evidence-based protocols for management of post-removal button battery ingestions.