Ref. No. 01 / BB / PS III / 2021 Dated : 16.06.

2021
From
Dr. G. Hariharan, MS., MCh.,
Professor in Paediatric Surgery ( PS III Unit ),
Institute of Child Health and Hospital for Children,
Egmore, Chennai - 10.
To
The Director of Medical Education,
Kilpauk, Chennai – 10.
Thro’
The Director,
Institute of Child Health and Hospital for Children,
Egmore, Chennai – 10.

Respected Sir,
Sub : Permission to initiate formation of the “NATIONAL BUTTON BATTERY INGESTION
INFORMATION CENTRE & HOTLINE” at Institute of Child Health and Hospital for Children,
Egmore, Chennai - regarding.
At Institute of Child Health and Hospital for Children, we have observed that Button
battery ingestion is one of the leading causes of paediatric poisoning and this has sharply risen
recently in the covid pandemic during lockdown times when infants and children get confined in
their houses.
In this regard, we wish to submit the following facts regarding “Button battery
ingestion” for your kind perusal :-
Many such incidents of button battery ingestion are reported to various hospitals in the
country each year, and these incidents may be vastly under-reported. The most serious injuries are
usually associated with 20 mm diameter batteries, about the size of a coin, because they are likely
to get lodged in a small child’s esophagus. If a coin cell lithium battery becomes lodged in the
esophagus it can cause tissue injury and necrosis within hours, leading to perforation or death if
not removed urgently.
The button battery generates hydroxide ions at the negative pole once ingested. This
accumulation of hydroxide produces a localised alkaline corrosive injury with tissue liquefaction
and necrosis. Corrosive injury can develop within 2 hours of lodgement. The severity of injury is
all dependent on the size of the battery, current produced, length of time it is lodged. Complications
include oesophageal perforation, tracheal-oesophageal fistula, aorta-oesophageal fistula and
stricture formation. The negative battery pole, identified as the narrowest side on the lateral x-ray,
causes the most severe necrotic injury.
Button battery ingestion accounts for 2% of all the foreign body ingestions. Button battery
ingestion is common in children under 15 : highest incidence between 1 and 3 years. Ingestion of
large-sized button batteries ( ≥ 20 mm) in children younger than 4 years is associated with
increased morbidity and mortality. While a small-sized button battery passes uneventfully through
the gut within 2 to 6 days, sometimes taking up to 2 to 4 weeks, large-sized button cells can get
impacted in the gut, the most common site being the esophagus. An impacted button cell can
ulcerate, perforate, lead to fistula formation, or even death.
Button batteries and magnets are high risk objects and require imaging. Button batteries
are ubiquitous, now being increasingly found in household electronic gadgets such as watches,
calculators, hearing aids, penlights, remote control devices, and certain toys. Their smooth and
shiny appearance coupled with their easy accessibility has inadvertently led to their frequent
ingestion or inhalation by children.
A majority of the battery cell ingestions are benign, passing spontaneously through the
gastrointestinal tract. However, they can get lodged in the esophagus or elsewhere in the
gastrointestinal tract where they can be fatal and life-threatening. These button cells, apart from
being ingested, can be inhaled by placing them in the nose or they can be placed in the ear as well.
Most common site of impaction in children is the upper esophageal sphincter where
significant complications can arise. It is a time critical emergency, as complications can occur in
as little as 2 hours. Potentially fatal complications - esophageal perforation, tracheoesophageal
fistula, exsanguination from fistulization to major blood vessels - aorto-esophageal fistula,
esophageal stricture, vocal cord paralysis have been reported and can present in a delayed fashion,
even upto 18 days post removal.
Most common long term complication is esophageal stricture created from the
circumferential luminal injury, often requiring serial dilatations and in severe cases excision of the
scarred segment of esophagus. Other less common but severe complications include recurrent
laryngeal nerve injuries, salivary leak into the neck and mediastinitis.
Hence emergent endoscopic removal is the recommended treatment of an impacted button
battery, and early identification of these patients is paramount. Characteristic X ray imaging of a
button battery in the upper esophagus is of a well-defined densely radio-opaque cylindrical object
with a double ring in an AP view, and a bilaminar appearance in a lateral view. This is important
to differentiate them from a coin, which has a more uniform structure and only a single ring.
Key mechanism of injury in the esophagus is due to electrical injury. Mucosal contact on
both sides of a battery create a flow of electrical current, causing generation of sodium hydroxide
in tissues and leading to local hydrolysis and liquefactive tissue injury with a significant increase
in pH of the surrounding tissue. It is also thought that the alkalotic liquefactive injury continues to
occur hours after the battery has been removed.
Missing the diagnosis of button battery ingestion occurs in 27% of cases, and 92% of fatal
presentations are unwitnessed, mostly in non-verbal children. Batteries of < 20 mm are less likely
to lodge in the oesophagus and cause complications (although relatively bigger batteries in small
children increases risk despite being < 20 mm). Batteries > 20 mm can cause severe local damage
within 2 hours. Smaller batteries can also cause localised damage when placed in aural or nasal
cavities. Age is a risk factor as most fatalities occur in the under 4 year old age group. But
sometimes, the non-mobile infants can be fed by siblings and children who are autistic can have a
prolonged oral phase.
Delayed diagnosis has a worse outcome. A spent battery is less likely to cause as much
damage but this should not alter the risk assessment as batteries can still produce a charge for up
to 10 years. Where oesophageal injury is established, perforation and fistulae may not be evident
for up to 28 days. Strictures take weeks or months to form.

An ingestion of button battery is suspected even if the child is asymptomatic but the care
giver has noted or suspected an ingestion and brought the child to hospital (shiny object seen in
the mouth or batteries missing from a device).

If unwitnessed or delayed, consideration of a button battery ingestion needs to be

considered if the presenting complaint is:
 ➢ Airway obstruction, drooling.
➢ Acute stridor or recurrent stridor (including acute or persistent croup).
➢ Unexplained wheeze.
➢ Cough, gagging, or choking when eating and drinking.
➢ Fever (usually indicates oesophageal perforation).
➢ Dysphagia or sore throat.
➢ Chest discomfort.
➢ ‘Off food’ or partial food refusal (while a common complaint there is often a cause identified,
if no cause is found consider FB ingestion).
➢ Vomiting (still possible as can be a partial obstruction).
➢ Unexplained nasal, ear, rectal, vaginal or eye discharge/bleeding – these batteries can be
stuck in many places.
➢ Haematemesis, melena, haematochezia or epistaxis (all late signs – also epistaxis can be a
false positive – unless the battery is up the nose this is likely haematemesis from a battery in
the oesophagus, don’t be fooled).
In our institution, we propose to maintain a “NATIONAL BUTTON BATTERY
INGESTION INFORMATION CENTRE & HOTLINE” involving the departments of
Paediatric Emergency Medicine, Paediatric Radiology, ENT, Paediatric Medical
Gastroenterology, Paediatric Pulmonology, Paediatric Intensive Care Unit, Paediatric Surgery
etc. in Institute of Child Health and Hospital for Children, Egmore, Chennai – 10 which will be
a phone call-based facility with an aim at providing fast, free and authentic information to the
concerned on 24 X 7 basis about button battery ingestion including its management. It will be
the first of its kind in entire India.
The public, primary care physicians and emergency care providers across the country may
call on the phone numbers provided for this purpose to save the lives of infants and children with
suspected button battery ingestion and to prevent such incidents by creating awareness and
educating about the proper storage and handling of such button batteries.

“NATIONAL BUTTON BATTERY INGESTION INFORMATION CENTRE &

HOTLINE”
The “National Button Battery Ingestion Information Centre” proposed in the Department
of Paediatric Surgery will be in the lines of the “National Poisons Information Centre (NPIC)
maintained by the Department of Pharmacology, All India Institute of Medical Sciences (AIIMS),
New Delhi-110029 ( https://www.aiims.edu/en/departments-and-centers/central-
facilities.html?id=167 ). It will be a phone call-based facility with an aim at providing fast, free
and authentic information to the concerned on 24 X 7 basis about button battery ingestion including
its management. It will be the first of its kind in entire India. The Hotline will be a Toll Free No.
for e.g., 1800 ###108, Landline Tel No.- 044 - 2####108. As soon as a call is received requesting
advice on Button Battery Ingestion, the Information Centre will advise per the Triage and
Treatment Guideline as follows (https://www.poison.org/battery/guideline ) :-
 It will also be web-based in the lines of
https://triage.webpoisoncontrol.org/#!/exclusions. A detailed proposal will be submitted
subsequently.

Other activities of this Information Centre will be :

• IEC activities through TV and other media to inform & sensitise the parents and
the public on this issue ;
• To initiate measures to bring legislation for "Buy back" for nominal cost ( under
electronic waste management) by the branded companies ;
• To initiate measures to bring Law enforcement to sell these products ONLY on
returning the exhausted cells by the retailers and wholesalers ;
• To initiate measures to bring the sale of all these battery and corrosive items under
law like Explosives Acts and ban the sales through routine retailers like watch
repair shops.

Hence we request you Sir to grant permission to initiate formation of the

“NATIONAL BUTTON BATTERY INGESTION INFORMATION CENTRE &
HOTLINE” at Institute of Child Health and Hospital for Children, Egmore, Chennai.

References :

1. Bhangu JS, Bajwa SS, Anand S, Kalsi K. Button battery ingestion: A therapeutic
dilemma and clinical issues in management. J Sci Soc 2016;43:30-3.
2. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Button-
Battery.aspx
3. https://www.aiims.edu/en/pharmacology_npic.html
4. Bhangu JS, Bajwa SS, Anand S, Kalsi K. Button battery ingestion: A therapeutic
dilemma and clinical issues in management. J Sci Soc 2016;43:30-3.
5. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Button-
Battery.aspx
6. https://www.aiims.edu/en/pharmacology_npic.html
7. Button battery ingestion: A therapeutic dilemma and clinical issues in management
BhanguJashanjot Singh, BajwaSukhminder Jit Singh, Anand Smriti, Kalsi
KanwalpreetYear : 2016 | Volume: 43 | Issue Number: 1 | Page: 30-33
8. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Button-
Battery.aspx
9. Button battery ingestion: A therapeutic dilemma and clinical issues in management
BhanguJashanjot Singh, BajwaSukhminder Jit Singh, Anand Smriti, Kalsi
KanwalpreetYear : 2016 | Volume: 43 | Issue Number: 1 | Page: 30-33
10. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Button-
Battery.aspx
 Thanking You,

Yours sincerely,

( Dr. G. Hariharan )

Advance Copy submitted to :

1. The Mission Director,
National Health Mission – Tamil Nadu
Teynampet, Chennai - 600 006.
2. The Director of Medical Education,
Kilpauk, Chennai – 10.
3. The Dean,
Madras Medical College, Chennai – 3.

Copy to :

1. The Professors & HODs, Departments of Paediatric Surgery, Paediatric Emergency

Medicine, ENT, Anaesthesia, Paediatric Pulmonology, Paediatric Intensive Care Unit
Paediatric MGE, Paediatric Medicine
2. The Administrative Officer,
3. The Resident Medical Officer