A spoonful of honey

A spoonful of sugar may help the medicine go down, but two spoonfuls of honey every 10 minutes on the way to the E.R. can minimize necrotic damage in a child who has ingested a button battery. Now that’s a message worth singing about.

Debnath Chatterjee, M.D., FASA

Debnath Chatterjee, M.D., FASA, will describe the science behind this novel approach during the Tuesday session “Pediatric Airway Foreign Bodies and Button Batteries: Lessons Learned.” The science was revealed in 2018 by the National Capital Poison Center.

“The rate of significant complications and death following button battery ingestion has increased almost sevenfold over the last few years,” said Dr. Chatterjee. “The new guidelines are important for all health care providers who take care of children, including emergency room physicians, anesthesiologists, gastroenterologists, ENT surgeons and pediatric surgeons.”

Pediatric Airway Foreign Bodies and Button Batteries: Lessons Learned

2:15 – 3:15 p.m.
Tuesday

W208ABC

Dr. Chatterjee is a Pediatric Anesthesiologist at Children’s Hospital Colorado and the University of Colorado School of Medicine. He is an expert on the hazards of button batteries. He represents the American Academy of Pediatrics Section on Anesthesiology at the national Button Battery Task Force. His goal is to spread the word about these small, round, metallic discs through presentations, publications and even the detailed video podcast Update on Button Battery Ingestion Guidelines.

Approximately 3,500 button battery ingestions are reported to the National Capital Poison Center every year. While the number of cases has remained stable over the years, outcomes have changed for the worse. The reason? Larger and more powerful lithium batteries.

“Contrary to popular belief, leakage is not the cause of damage,” explained Dr. Chatterjee. “When a large-diameter lithium button battery becomes entrapped in a young child’s esophagus, the esophageal mucosa bridges the positive and negative terminals, thereby completing the circuit and causing current to flow.”

The voltage created (even by a spent battery) leads to the generation of hydroxide radicals and an increase in local tissue pH, resulting in caustic injury and coagulative necrosis. The higher the voltage of the button battery, the more extensive the damage.

“Visible tissue damage begins within 15 minutes of ingestion. If the button battery is not removed within two hours, the risk of serious complications and death rises,” he explained. “At our institution alone, we have lost four children over the last decade or so.”

Through animal studies, researchers have identified a pantry item that can mitigate the consequences for children who have swallowed a button battery –­ honey. Being a weak acid, it neutralizes the alkaline pH associated with button battery exposure, resulting in more superficial and localized injuries. Sucralfate works equally well.

In 2018, the National Capital Poison Center updated their guidelines accordingly. Honey should be administered immediately and en route to the emergency department if a lithium button battery may have been ingested within the prior 12 hours, the child is 12 months of age or older and is able to swallow. Ten mL of honey should be given by mouth every 10 minutes for up to six doses.

Following X-ray confirmation of a button battery, sucralfate should continue to be administered (10 mL by mouth every 10 minutes for up to three doses) while awaiting endoscopic removal.

“While some anesthesiologists might be hesitant to anesthetize children who have recently ingested honey and/or sucralfate, the risk of ongoing esophageal injury far outweighs the risk of pulmonary aspiration,” said Dr. Chatterjee. “Therefore, NPO guidelines should not be followed, and a rapid sequence induction should be performed.”

Delaying the endoscopic removal of a lithium button battery can lead to major complications, including esophageal perforation, aorto-esophageal fistula, tracheoesophageal fistula, vocal cord paralysis or esophageal stricture.

Of course, button batteries aren’t the only items that cause children to choke. Dr. Chatterjee will also review current guidelines for the anesthetic care of children who have aspirated everything from peanuts to small toys.

In the U.S., choking after foreign body aspiration is the leading cause of unintentional death in infants and the fifth most common cause of unintentional death in older children.

Parents often tell light-hearted stories about the time their child stuck a raisin up his nose or swallowed a coin. It’s easy to laugh when the story has a happy ending.

“As physicians, we have a responsibility to educate parents and caregivers about the risks of serious injury following button battery ingestion in young children,” said Dr. Chatterjee. “It’s no laughing matter.”

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