The Risks of Kids Swallowing Foreign Objects — Including Batteries


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By Dr. Bharath Nath, Pediatric Surgeon, Fairfax Neonatal Associates’ Pediatric Surgical Group


Dear Reader,

In the center of Philadelphia is a museum that houses some of the most fascinating exhibits in the world. The museum is the Mutter Museum of the College of Physicians of Philadelphia, and it is one of a few museums that is dedicated exclusively to the history of medicine.

The collections housed within are truly remarkable, including everything from myriad preserved surgical specimens, early surgical instruments, a skull collection from a renowned Viennese phrenologist, and even a plaster cast of Chang and Eng Bunker, conjoined twins from Thailand who toured the United States in 1829.

One exhibit, though, maybe quite unusual at first glance. It consists of 2374 small objects. The vast majority are coins, although alongside these are bits of jewelry, bones, screws, nuts, pins, small toys, and many other sundry items. As diverse as this collection is, all the objects have something in common, for each of them was at some point lodged inside a person’s airway or esophagus, and each of them was pulled out by a pioneering American surgeon name Chevalier Quixote Jackson.

Born immediately after the civil war, Chevalier Jackson would go on to study medicine at Jefferson Medical College prior to further studies in laryngology in England. In practice in Philadelphia, Jackson pioneered endoscopic techniques of removing accidentally ingested foreign objects, inventing instruments and methods that are still used for these purposes to this day.

Jackson was famous for his possessiveness over the removed objects, keeping virtually everything he ever removed from the throat of a patient, and these objects are what you see today, housed in glass cabinets and wooden drawers. Prior to Jackson’s innovations, removal of a foreign body was essentially impossible, requiring major thoracic operations in an era where mortality from such an undertaking was astronomical.

To this day, it is a common occurrence that a child will come into the emergency department having ingested a coin, aspirated a peanut, or swallowed a piece of jewelry, and require urgent endoscopic intervention to remove the object. The fundamentals of the techniques used haven’t changed all that much and today, most kids are able to go home immediately after the foreign object has been removed. However, there are two specific scenarios of ingestion that are significantly more dangerous. These involve objects that are products of more recent times. Sadly, one such case has recently received national attention.

Reese Hamsmith was a 17-month child who was brought to a pediatrician’s office in Texas with significant wheezing and what seemed like signs of an upper respiratory infection. Her pediatrician initially thought that her symptoms seemed consistent with croup. Shortly after returning home, her mom noticed that a battery was missing from a remote control. This wasn’t a cylindrical AAA battery; it was a flat, shiny, button battery.

As soon as she noticed this, Reese’s mom brought her to the emergency department, where X-rays confirmed that Reese had swallowed the battery, and worse still, it had become lodged in her esophagus. A flat object, such as a coin, can easily fit into the mouth of a toddler, and can readily be swallowed.

A small object will continue to travel into the stomach. Most often, if an object can pass into the stomach, it can pass through the entire digestive tract and eventually be recovered in the toilet. Certain objects, though, such as quarters or the larger button batteries, are a perfect size to cause trouble. They are just small enough to be swallowed, but just large enough that once swallowed they become trapped at parts of the esophagus that cannot stretch quite as much, because they are limited by surrounding structures of the lower neck and upper chest.

The real tragedy is what happens next.

When filled with food, the esophagus will seem like a hollow tube. But when nothing is filling it, its walls will collapse flat, like an empty sock. As the esophageal walls collapse, they come into contact with the positive and negative terminals of the button battery, which are essentially the front and back flat surfaces.

The tiny amount of salts in saliva provide enough of a conducive environment that a complete circuit is formed, and the battery then discharges its voltage. As the current is discharged, tissue is burned. Furthermore, caustic ions accumulate at the negative pole of the battery, which leads to further tissue damage that can continue even after the battery has been removed.

The consequences of these injuries can be devastating. If the burn is severe but has not penetrated the esophagus, it can still result in severe scarring of the esophagus, which may require extensive reconstructive surgery to enable a child to eat and drink. A burn through the esophagus can result in a life-threatening infection in the chest, which may require major surgery to control. In the most severe cases, the burn can penetrate to surrounding structures, including the aorta, the largest blood vessel in the body, and catastrophic bleeding will quickly follow.

In cases of an ingested battery, urgent removal and neutralization of the corrosive burn are critical. In Reese Hamsmith’s case, although she was taken to the operating room urgently and the battery removed, her injuries were too severe, and she sadly did not survive. Her story has come to national attention recently as her mother has sought to transform the tragedy of Reese’s death into a push for increased safety standards around button batteries.

Some of the interventions that can be made are relatively simple, including improved labeling and safety warnings on battery packaging. Others are more complicated to implement, such as ensuring that devices that contain button batteries have child-proof mechanisms, such as screws or locks, that make it more difficult for a curious toddler to remove the battery. Regardless of these interventions, the most important first line of defense against these injuries will always be a parent who knows the danger that these seemingly innocuous objects pose and can make efforts to prevent their child from having access to them.

While button batteries have received more attention recently, the second type of critical ingestion is those that involve rare earth magnets. These exceptionally strong magnets are often found in toys, although they can be found in a variety of objects around the house, including some types of hanging artwork, electronics, or even in upholstery coverings. They are also sold online as toys. I can attest that they are fun to play with, as you can arrange them into all sorts of fun shapes and marvel at how they stick to one another. Sadly, I can also attest to the damage they can cause when they are ingested.

These magnets are so strong that when two of them are ingested, particularly at different times, they can stick to one another with enough force that they can cause perforations to form in the gastrointestinal tract. While most kids with these types of injuries will survive, most will need major abdominal operations, with potentially life-long consequences. While our final data is still pending, we seem to have noted an increased incidence of these types of injuries as well over the past several months.

There is no question that the changes in all our lives during the COVID-19 pandemic have caused significant stress in our children. Perhaps that stress, coupled with the fact that the vast majority of kids have spent more time in their homes over the past year than ever before, has contributed to the significant increase in these critical ingestions that our surgical group has seen over the past year.

In an effort to ensure that kids with these sorts of critical ingestions can get care in a timely fashion, our pediatric surgical group has spent the past six months collaborating with other medical and surgical specialties to create a ‘best practices’ standard for the emergency management of kids with critical ingestions. As we know, time is truly of the essence as a button battery injury can evolve over just a few hours, and a few hours difference can lead to dramatically different outcomes in cases of intestinal perforation.

Sincerely,
Dr. Bharath Nath


Fairfax Neonatal Associates’ Pediatric Surgical Group provides advanced expertise, inpatient consultations, evaluations, and surgical treatment for unborn infants, newborns, babies, children, and teens.

Learn more about Dr. Bharath Nath, this post’s author here, and all of Fairfax Neonatal Associates’ providers here. Connect with their Pediatric Surgical Group online or by calling (703) 560-2236.


 



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