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Three Part Question

In [children presenting to the paediatric emergency department (ED) with button battery ingestion] can [novel strategies] [mitigate risks of tissue damage].

Clinical Scenario

A 5 year old girl presents to your paediatric ED with a one day history of abdominal pain and an acute episode of haematemesis. Her mother explains that she is unable to locate a button battery she left on the kitchen table. She is tachycardic (heart rate 150 beats per minute) but normotensive (blood pressure 105/55 mmHg). A chest x-ray identifies a button battery in the proximal oesophagus. You are worried about the potential for this child’s haematemesis to worsen and consider whether any novel strategies could be used to mitigate deterioration prior to endoscopic removal.

Search Strategy

Ovid MEDLINE(R) ALL 1946 to March 03, 2021.


((paed* OR ped* OR child*) AND (button OR coin OR disk) AND batter* AND novel).af.

Search Outcome

6 articles were found using the search criteria. 4 of these were responses to the author, so were excluded. The remaining 2 papers are illustrated in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jatana KR et al 2016 USA	Cadaveric porcine model	Animal model	pH neutralisation and tissue necrosis	ReaLemon® and orange juice are the most effective solutions at neutralising pH and reducing tissue necrosis	Cadaveric samples Animal tissue
Anfang RR et al 2018 USA	Live porcine model	Animal model	pH neutralisation and tissue necrosis	Honey and Carafate® are the most effective at neutralising pH and reducing tissue necrosis	Cadaveric samples Animal tissue

Comment(s)

Limited data exists as to which novel strategies could be employed to reduce oesophageal damage in children post button battery ingestion. Only 2 papers were found that discussed button battery ingestion in children and investigated novel strategies to mitigate the devastating effects. Both papers found investigated pH neutralising agents in animal models; no papers were found comparing different strategies in human tissue.

Clinical Bottom Line

More evidence is needed before novel pH neutralising agents can be used in paediatric practise. Given the rapidly progressive morbidity and mortality associated with ingestion of button batteries, novel strategies would be useful before definitive care could be undertaken in theatre. Debate would still exist as to whether such children should be kept ‘nil by mouth’ from an anaesthesia perspective and hence oral intake prohibited. Common household acidic beverages or honey may have clinical utility in this patient cohort in the future.

References

1. Jatana KR et al. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal.
2. Anfang RR et al pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury