A relatively short post this week as I am still recovering from a COVID-19 infection brought home from Cape Cod a couple weeks ago by my amazing wife, whom I love very much despite this unfortunate attempt on my life. Please go out today and get your vaccine or booster if you haven’t already and qualify. I certainly will be lining up for my next dose just as soon as I’m allowed.

In early 2019, I wrote about new research at the time that revealed a startling increase in pediatric foreign body ingestions and pointed out a few interesting facts and findings from the study:

  1. 20% of kids under age 3 years have swallowed a foreign object.
  2. 3 out of every 4 foreign-body ingestions occur in kids 5 years of age and younger.
  3. With almost 68,000 Poison Center calls, foreign-body ingestions in kids under 6 years was the 4th most common complaint in 2016.
  4. Neodymium magnet toys, tiny and extremely dangerous if ingested, are now back on the market despite efforts by the U.S. Consumer Product Safety Commission and Senator Gillibrand, as well as warnings from the medical community.
  5. Between 1995 and 2015, 759,074 children under 6 years were seen in American emergency departments for suspected or confirmed foreign body ingestions, about 100 every day. There was a 4.4% annual increase.
  6. The number of ingestions in 2015 were 93% higher than in 1995, with an increase from 9 to 18 out of every 10,000 kids in this age group.
  7. Roughly 2 out of every 3 ingestions over this time period involved a coin, mostly pennies, but quarters were much more likely to result in hospitalization.
  8. 10% of children seen for a foreign-body ingestion were hospitalized.
  9. Virtually 100% of ingestions, when the location was known, occurred at home.
  10. Battery ingestions increased from .1% of the total number in 1995 to 8% in 2015, with 86% being the dangerous button variety, and were the 2nd most common cause of hospitalization after coins.

That last point involving button battery ingestion, and new research showing that the problem is getting worse, is the focus of my post today, Kids, it would seem, didn’t learn anything from my previous post. They continue to explore their environment in developmentally appropriate yet potentially harmful ways.

This week, a paper published in Pediatrics on battery-related emergency department visits in the United States has been making the rounds. The American Academy of Pediatrics, when they aren’t shaking in their boots because of attacks from non-expert internet users like Vinay Prasad, are attempting to raise awareness of the dangers of battery ingestions and calling for better safety regulations.

From January of 2010 through December of 2019, there were over 70 thousand ED visits as a result of cylindrical and button batteries in pediatric patients, which works out to roughly 1 in every 10,000 children each year. A significant majority, at 85% of visits, involved button batteries, and 9 out of every 10 ED visits were related to ingestions. The remainder involved children shoving small batteries into their nose, ears, or mouth, which can also cause serious tissue injury.

During this time period, there was a significant increase in how many children were seen in emergency departments, particularly those 5 years of age and younger. From 2010 to 2017, visit rates in that age range increased from 1.7 to 3.8 per 10,000. From 2017 to 2019, this increase did appear to level off, so I guess there may be some reason to be hopeful. But caregivers, as well as battery manufacturers, shouldn’t be complacent.

Why are button batteries so dangerous?

When ingested, or shoved into any body orifice for that matter, a button battery comes into contact with moisture. If lodged in place, the electrical current produced by the battery changes this water into highly alkaline hydroxide ions though hydrolysis, and this leads to a liquefactive necrosis that can progress even after removal of the offending battery. Although the most common injuries involve the esophagus, these batteries can cause destruction of the nasal septum and ear drum as well as important structures in the surrounding facial tissue.

Mild symptoms can begin within minutes of ingestion and there can be severe injury within just a couple of hours. In the new study, 12% of the over 70 thousand children brought to an emergency department for concerns related to batteries required hospitalization, which is a significant increase from previous data collected between 1990 and 2009. Other studies have also found an increase in both morbidity and mortality associated mostly with ingestions. There are more children ending up with major complications such as perforation of the esophagus, erosion into the trachea, scaring that causes blockage of the esophagus, vocal cord paralysis, and injury to nearby blood vessels that can cause catastrophic bleeding.

In 2019, I discussed how multiple factors were likely playing a part in the increase in battery ingestions seen at the time. In addition to better data collection, there are simply many more household electronic devices around these days, a lot of which require small batteries that are easily swallowed by young children. Other changes over the past 30 years, in particular the switch to larger lithium cells, have increased the risk of impaction and injury to surrounding tissue after ingestion.

So these batteries are in pretty much every home these days. In addition to this, they are often far too easy to remove from some packages and devices, sometimes even children’s toys. There have been several public education campaigns over the past few years, and some stricter regulations of the design of battery compartments so that they must a bit more childproof. Manufacturers have even played around with adding non-toxic bitter chemicals to small batteries, though this has never been proven to reduce ingestions.

Perhaps these changes are behind the plateau in ED visits from 2017-2019. Hopefully this isn’t a fluke, but more still needs to be done. On that front, I do have some good news. Just this month, “Reese’s Law” was passed by Congress and signed into law by President Biden. The Consumer Product Safety Commission must now develop child-resistant standards for battery packaging and device battery compartments and there must by information on ingestion risk and child safety instructions on labels.

Conclusion: Keep small batteries out of the reach of those little hands

This conclusion pretty much speaks for itself. Young children are curious and extremely successful at getting into things that could prove harmful. We need to make it as difficult for them as possible. Still, it is unlikely that the risk of battery ingestions will ever go away entirely. If a battery ingestion is suspected, help should be sought immediately. There is also good evidence that honey, as long as a child at least 12 months old and able to swallow safely, can reduce the risk of severe injury to the esophagus.

Author

  • Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.