Button Battery Updates for the Otolaryngologist
Learn about innovations, safety measures, and legislative updates relevant to our role in button battery injury prevention and care.
Kara Meister, MD, Pediatric Otolaryngology Education Committee Chair
Recent advancements in safety measures and legislative efforts aim to mitigate these risks and improve patient outcomes. These developments underscore the role of otolaryngologists in early diagnosis, surgical intervention, and long-term management of potential complications from such injuries while emphasizing the need for increased awareness and advocacy for safer consumer products.
Scientific and Safety Innovations
Innovations, such as color-alert coatings and child-resistant packaging, provide immediate visual and tactile cues to caregivers and healthcare providers. There is also data regarding administration of sucralfate, honey, and jelly/jam to potentially decrease the extent of injury while awaiting surgical intervention.
Pre-Operative Protective Measures
Studies have indicated that administering Carafate, honey, or jam can dampen the extent of tissue injury.1-2 The mechanism of action is thought to be not only coating of the battery and thereby limiting electrolysis but also neutralization of generated hydroxide ions. The advised dose for honey and sucralfate is 10 mL (two teaspoons) every 10 minutes with a maximum of six doses of honey and three doses of sucralfate, respectively. This should not be recommended if the ingestion is thought to have occurred >12 hours prior.
The National Capitol Poison Control Center provides a helpful flowchart for triaging treatment after suspected button battery ingestion.
Bitter Taste and Color Alert Technology
Energizer® has introduced button batteries with a color-alert feature that turns a child's mouth blue upon contact with saliva. Both Energizer and Duracell® have introduced a bitter-tasting coating, which is intended to discourage children from swallowing batteries should a child put them in the mouth. Several manufacturers have also revamped packaging to be more child resistant. [As a personal editorial, I would appreciate button batteries only being sold as a single, rather than having a semi-opened 10-pack in the family storage closet.]
Updated Publications
Recent reviews illustrate the impact and severity of button battery ingestions and subsequent injuries.
Airway Complications
A systematic review published in JAMA Otolaryngology-Head & Neck Surgery in 2022 examined airway injuries resulting from esophageal button battery impaction in children.3 The study found that tracheoesophageal fistulae (n=155) and unilateral vocal cord paralyses (n=16) were the most common airway injuries. Of note, the mean (SD) time from BB ingestion to removal was 5.8 (9.0) days.
Vascular Complications
A systematic review in Pediatrics (2022) described vascular complications following button battery ingestion.4 The study highlighted that aorto-esophageal fistulae (75%) were the most common vascular injuries, with a high fatality rate. Prolonged impaction time was a significant risk factor for fatal vascular outcomes (96 hours versus 144 hours, P <.05).
Late Complications
A systematic review and meta-analysis in Injury Prevention (2024) summarized the complications following button battery ingestions.5 The study reported that esophageal strictures were the most frequent late effect of mucosal injury at 10% of reported cases. The duration of ingestion to removal [OR 3.71 (95% CI 1.11 to 12.42) for ≥10 hours and 5.12 (95% CI 1.79 to 14.67) for ≥12 hours] and battery diameter were significant predictors of complications.
Legislative Updates
New federal regulations like Reese’s Law impose stricter safety standards on battery-containing products, mandating child-resistant compartments and clearer labeling.
Reese's Law: Enacted in 2022, Reese's Law (Public Law 117-171) mandates federal safety requirements for button cell or coin batteries and consumer products containing such batteries, including zinc-air batteries commonly used in hearing aids. The law is named for Reese Hamsmith, who suffered a fatal button battery injury at 18 months of age. The law requires secure battery compartments that are child-resistant, specific labeling on products and packaging, and adherence to performance standards.
U.S. Consumer Product Safety Commission (CPSC) Proposed Rule for Toys: In August 2024, the CPSC proposed additional performance and labeling requirements for toys containing button cell or coin cell batteries. The aim is to enhance protection against accidental ingestion. The new requirements for consumer products containing button batteries now include the following, and have been implemented since 2024:
- Battery compartments containing replaceable button cell or coin batteries must be secured such that they require the use of a tool or at least two independent and simultaneous hand movements to open.
- Button cell or coin battery compartments must not allow such batteries to be accessed or liberated as a result of use and abuse testing.
- The packaging for the overall product must bear a warning.
- The product itself must bear a warning, if practicable.
- Accompanying instructions and manuals must include all of the applicable warnings.
Industry Compliance
Apple® AirTags: Apple has sold more than 55 million AirTags (a small device that helps you locate items you might lose, such as your keys, wallet, or backpack) since their launch in April 2021. Furthermore, there are estimated to be over one billion devices worldwide that use Find My technology, which interfaces with AirTags. In response to Reese's Law, Apple has updated its AirTags and packaging to include warning labels about the dangers of button batteries. The AirTags now feature a warning symbol on the battery compartment, and the packaging includes the mandated warning statements and symbols. Additionally, Apple’s Find My app's battery replacement instructions have been updated to include battery hazard warnings.
Conclusions
As an otolaryngologist, I am encouraged by the increasing innovation, awareness, and regulation surrounding button batteries. However, there are still children suffering nasal, oropharyngeal, esophageal, and airway injuries from button battery injuries at an increasing rate. Our Academy community can drive scientific advancements, influence clinical standards and guidelines, educate our colleagues and patients, and advocate for button battery safety at the regulatory level.
Read the Academy’s Position Statement on Button and Coin Battery Technology.
References
- Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. Laryngoscope. 2017 Jun;127(6):1276-1282. doi: 10.1002/lary.26362. Epub 2016 Nov 9. PMID: 27859311.
- Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2024 Apr;83(4):351-359. doi: 10.1016/j.annemergmed.2023.08.018. Epub 2023 Sep 19. PMID: 37725021.
- Philteos J, James AL, Propst EJ, Ostrow O, McKinnon N, Everett T, Wolter NE. Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review. JAMA Otolaryngol Head Neck Surg. 2022 Jul 1;148(7):677-683. doi: 10.1001/jamaoto.2022.0848. PMID: 35616924.
- Akinkugbe O, James AL, Ostrow O, Everett T, Wolter NE, McKinnon NK. Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review. Pediatrics. 2022 Sep 1;150(3):e2022057477. doi: 10.1542/peds.2022-057477. PMID: 36032017.
- Tran C, Nunez C, Eslick GD, Barker R, Elliott EJ. Button battery exposure in children: a systematic review and meta-analysis. Inj Prev. 2024 Oct 4:ip-2024-045339. doi: 10.1136/ip-2024-045339. Epub ahead of print. PMID: 39366737.