Button-battery and magnet ingestion — formative SAQs

1. First 60 seconds

"This child has a suspected oesophageal button battery with stridor and drooling. I call the senior paediatrician, endoscopist, anaesthetist and ENT or surgical teams now, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. I keep the child nil by mouth, give oxygen, position for airway safety, and prepare to protect the airway if the stridor worsens or haematemesis develops. Stabilisation precedes diagnosis, and the time since ingestion is already two hours, so the removal clock is running." ^{[1] [5]}

2. The radiograph and its signs

"I request a single radiograph from nasopharynx to anus in AP and lateral views. This localises the battery, confirms oesophageal versus gastric position, distinguishes it from a coin, and counts any magnets. The three signs I look for on a button battery are the halo sign and double-ring on the AP view, caused by the step between the larger positive and smaller negative casings, and the step-off or notch at one edge on the lateral view. A neck-only or chest-only film would miss a battery at the cricopharyngeus or a magnet in the stomach." ^{[1] [2]}

3. The honey adjunct

"The child is over twelve months and is drooling but, if able to swallow safely with no airway compromise, no suspected perforation, no sepsis and no honey allergy, I give honey 10 millilitres, roughly two teaspoons, by mouth every ten minutes for up to six doses while awaiting endoscopy. The alternative is sucralfate 1 gram per 10 kilograms. The limit is absolute: the adjunct is a bridge that reduces pH at the negative pole, it never replaces or delays endoscopic removal, and honey is contraindicated in infants under twelve months because of the botulism risk. The human evidence is limited to case series and porcine models, so I present it as a promising bridge, not a proven standard." ^{[6] [7]}

4. Mechanism and surveillance

"The battery, bathed in oesophageal mucus, acts as a galvanic cell and splits water at its negative pole, generating hydroxide that causes alkaline liquefaction necrosis. Direct-current and pressure necrosis add to the injury. Alkali liquefies tissue, so the injury penetrates deeply and continues after the battery is removed, because tissue weakened by the burn may necrose and perforate days to weeks later. The child needs admission for serial review of delayed perforation, fistula and stricture, because an aorto-oesophageal fistula can present as massive haematemesis days to weeks after an apparently successful removal." ^{[1] [6]}