QUAD #3 Pt.2: Complications of Button Battery & Caustic Ingestion with Dr. Phil Putnam

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello everyone. This is Kim Pribben, and I'd like to welcome you back to the continuation of our Quad series. In October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia series. In this session, we hear from pediatric gastroenterologist, Dr. Bill Putnam from Cincinnati Children's Hospital. About the complications of caustic ingestions in children. We know that the incidence of severe complications following a button battery ingestion has continued to significantly rise over the last 20 years. It is important to correctly identify symptoms of ingestion when evaluating a patient. Presenting symptoms after button battery ingestion are quite variable, anything from pain and bleeding to dysphagia and feeding problems, sometimes sore throat, respiratory distress, hoarseness. Remember that an asymptomatic child with a witnessed ingestion deserves the same workup as a symptomatic child. Non-verbal kids with abrupt onset of symptoms such as drooling or feeding problems should be worked up for foreign body ingestion. The duration of symptoms for witnessed ingestions is usually pretty short. Unwitnessed ones can be days to weeks. The risk of developing complications from a button battery impaction in the esophagus is increased by the diameter of the battery, the voltage of the newer batteries being higher than it used to be. The location of the impaction is crucial to whether there's going to be a through and through injury, the duration of exposure, and the mechanism of injury. The mucosal electrochemical burn that happens on the negative pole side of the battery that determines the local concern, but there is also pressure necrosis at the margins, if a small child ingests a large battery and it doesn't get promptly removed. This was a very nice review of the potential complications by the ESPGAN society reminding us that batteries are not only ingested, they can be inserted. So nasal septal perforation, other intranasal injury, tympanic membrane perforation from sticking it in your ear. Other complications include TEF, lung hemorrhage, pulmonary stenosis, pneumonia, mediastinitis, and periorbital cellulitis. The GI tract ones are pretty obvious, esophageal perforation or stenosis, gastric perforation, gastric outlet obstruction, and even small intestinal perforation are possible. Once the battery is removed, recovery can take weeks to months. While the initial mucosal injury may appear to heal well, complications can present within hours of removal, or as in the case of strictures, may take weeks to develop. There can be pain or dysphagia, trouble feeding, trouble handling secretions, mediastinal soiling from perforation or a leak, airway compromise and fever, but then the longer term concerns of perforation and mediastinitis can develop. Within weeks, there can be total healing, there can be stricture formation. A 2018 study from the Netherlands looked at the distribution of severe complications from button battery ingestions between 2008 and 2016. They found that of the 16 most serious injuries, all patients were under five years of age, and the batteries were over 20 mm in size. Just to note that in our own National Capital Poison Center data, 25 of the 62 fatalities reported to them from button battery ingestions were related to or caused by aorto esophageal fistulas. In summary, it is important to correctly identify symptoms of ingestion early on, regardless of whether or not the ingestion or insertion was witnessed. Kids are at greater risk for serious complications when the battery diameter is greater than 20 mm in size, ages less than five years, and varies based on the location of the impaction. Finally, button battery ingestions continue to have variable presentation and the potential to cause severe injuries or death. Thank you for watching. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.