1. Know the who, what, and why
In the 2024-2025 National Battery Ingestion Hotline annual report, national NPDS data showed 2,705 disc battery ingestion exposures after confirmed non-ingestions were excluded; 1,690 were in children ages 0-5 years and 303 were in children ages 6-12 years.
Larger batteries – especially 20 mm lithium coin cells in young children – are the classic high-risk setup for esophageal injury, though smaller cells can still cause serious injury, especially in infants. For comparison, a dime is 18 mm, a nickel 21 mm, and a quarter 24 mm in diameter.
The most common sources of reported battery ingestions were hearing aids and games/toys, but they are also found in common household items such as watches, remote controls, flashlights, AirPods/earbuds, fitness/heart monitors, thermometers, etc.
The main mechanisms of injury are electrical discharge and leakage of battery contents, which cause corrosive tissue damage and, ultimately, pressure necrosis with resulting battery adherence that can lead to ulceration and perforation.
2. Location, location, location
The areas of physiologic narrowing within the esophagus are most prone to impaction in children (the upper esophageal sphincter, the level of the aortic arch, and the lower esophageal sphincter). Tissue injury can happen as early as two hours post-ingestion, with more severe damage after 8 to 12 hours, and risk rises with time, battery size, charge, and orientation.
Once beyond the esophagus, many asymptomatic batteries pass, but management still depends on location, symptoms, age, size, magnet co-ingestion, dwell time, and whether the battery may have lodged in the esophagus first.
3. What to do when you suspect it
Ask about the battery type and size, time of ingestion, number of batteries, known magnet co-ingestion, and history of esophageal/airway anomalies. Presentation may be nonspecific: fever, vomiting, poor appetite, lethargy, irritability, cough, wheeze, concern for dehydration. Any symptoms above and beyond that should only increase your suspicion (chest pain, hematemesis, abdominal pain, drooling/dysphagia, respiratory distress, etc.). Keep your index of suspicion high!
For suspected but unconfirmed ingestion in a child >12 months old who is able to swallow and ingestion time is <12 hours, the National Capital Poison Center recommends 10 mL (2 teaspoons) of honey by mouth every 10 minutes for up to 6 doses. If x-ray confirms an esophageal battery and the child can swallow, consider sucralfate suspension 1 g/10 mL: 10 mL PO every 10 minutes for up to 3 doses until sedation for endoscopy. If timing of ingestion is unknown or the child is symptomatic, keep them NPO.
Obtain STAT radiographs from the nose to rectum. On AP views, button batteries look like a double-ring or halo. On lateral views, button batteries look like a step-off at the separation between the positive and negative poles.
Mobilize your resources:
- Possible difficult airway? Consider early ENT and pediatric anesthesia involvement.
- IV access may be difficult – consider the risks and benefits in the case of prolonged ingestion with concern for dislodgement if the child gets agitated.
- Consider your institution’s operative and postoperative monitoring level of care capabilities. Recognize and initiate the transfer process early if needed.
- Involve your specialists immediately: ENT, Anesthesia, GI, Surgery, PICU
- Utilize the National Battery Ingestion Hotline: 1-800-498-8666
Additional Resources:
National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline
RMPDS/National Battery Ingestion Hotline annual report
Sethia et al., Current management of button battery injuries
Anfang et al., pH-neutralizing esophageal irrigations
Dr. Nanditha Shivaprakash, MD, is a Pediatric Emergency Medicine physician at Newton Wellesley Hospital/Mass General Brigham. She can be reached at nandithashivaprakash@gmail.com.
