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Spoonful of honey helps a button battery go down

HoneyA team of ear, nose, and throat specialists has demonstrated that eating honey after swallowing a button battery has the potential to reduce serious injuries in small children.

"Our recommendation would be for parents and caregivers to give honey at regular intervals before a child is able to reach a hospital, while clinicians in a hospital setting can use sucralfate before removing the battery," Jacobs said.

Based on findings in laboratory animals, the research suggests that this common household product may significantly reduce morbidity and mortality from highly caustic batteries.

"Button batteries are ingested by children more 2,500 times a year in the US, with more than a 12-fold increase in fatal outcomes in the last decade compared to the prior decade," said co-principal investigator, Dr Ian N Jacobs, director of the Centre for Paediatric Airway Disorders and a paediatric otolaryngologist at Children's Hospital of Philadelphia (CHOP). "Since serious damage can occur within two hours of ingesting a battery, the interval between ingestion and removal is a critical time to act in order to reduce oesophageal injury."

Jacobs collaborated with researchers at CHOP and co-principal investigator, Dr Kris R Jatana, a paediatric otolaryngologist and director of paediatric otolaryngology quality improvement at Nationwide Children's Hospital.

Because of their size, candy-like shape and shiny metallic surface, button batteries have posed a risk for toddlers for decades. When the battery reacts with saliva and tissue of the oesophagus, it creates a hydroxide-rich, alkaline solution that essentially dissolves tissue. Children with an oesophageal button battery may present with symptoms of sore throat, cough, fever, difficulty swallowing, poor oral intake or noisy breathing. This can cause severe complications like oesophageal perforation, vocal cord paralysis and erosion into the airway or major blood vessels. The longer it takes for the battery to be removed, the higher the risk for these children, particularly those without access to hospitals with specialised anaesthesiologists and endoscopists experienced in removing foreign objects.

The research team wanted to determine successful interventions for mitigating these injuries in both a home and clinical setting and test their effectiveness in a live animal model, in this case, laboratory pigs. Specifically, the researchers sought palatable, more viscous liquids that could create a protective barrier between the tissue and the battery, as well as neutralise harsh alkaline levels. The team screened various options, including common household beverages such as juices, sodas, and sports drinks, in laboratory experiments.

"We explored a variety of common household and medicinal liquid options, and our study showed that honey and sucralfate demonstrated the most protective effects against button battery injury, making the injuries more localized and superficial," said Jatana. "The findings of our study are going to be put immediately into clinical practice, incorporated into the latest National Capital Poison Centre Guidelines for management of button battery ingestions."

Prior published studies by this team had tested weakly acidic liquids like lemon juice as a proof of concept. However, many children do not enjoy drinking lemon juice. By contrast, the sweet taste of honey is much more palatable to young children.

However, the authors caution against using these substances in children who have a clinical suspicion of existing sepsis or perforation of the oesophagus, known severe allergy to honey or sucralfate, or in children less than one-year-old due to a small risk of botulism.

"While future studies could help establish the ideal volume and frequency for each treatment, we believe that these findings serve as a reasonable benchmark for clinical recommendations," Jacobs said. "Safely ingesting any amount of these liquids prior to battery removal is better than doing nothing."

"Button batteries are commonly found in households, and they should always be stored in a secured container, out of reach of children," said Jatana. "Parents and caregivers should check all electronic products in the home and make certain that the battery is enclosed in a compartment that requires a tool to open and periodically check to ensure it stays secure over time."

Abstract
Objectives/Hypothesis: Ingestion of button batteries (BB) can rapidly lead to caustic esophageal injury in infants and children, resulting in significant morbidity and mortality. To identify novel mitigation strategies, we tested common weakly acidic household beverages, viscous liquids, and Carafate® for their ability to act as protective esophageal irrigations until endoscopic removal of the BB.
Study Design: Cadaveric and live animal model.
Methods: Apple juice, orange juice, Gatorade®, POWERADE®, pure honey, pure maple syrup, and Carafate® were screened using a 3 V lithium (3 V‐CR2032) BB on cadaveric porcine esophagus. The most promising in vitro options were tested against a saline control in live American Yorkshire piglets with anode‐facing placement of the BB on the posterior wall of the proximal esophagus for 60 minutes. BB voltage and tissue pH were measured before battery placement and after removal. The 10 mL irrigations occurred every 10 minutes from t = 5 minutes. Gross and histologic assessment was performed on the esophagus of piglets euthanized 7 ± 0.5 days following BB exposure.
Results: Honey and Carafate® demonstrated to a significant degree the most protective effects in vitro and in vivo. Both neutralized the tissue pH increase and created more localized and superficial injuries; observed in vivo was a decrease in both full‐thickness injury (i.e., shallower depths of necrotic and granulation tissue) and outward extension of injury in the deep muscle beyond surface ulcer margins (P < .05).
Conclusions: In the crucial period between BB ingestion and endoscopic removal, early and frequent ingestion of honey in the household setting and Carafate® in the clinical setting has the potential to reduce injury severity and improve patient outcomes.

Authors
Rachel R Anfang, Kris R Jatana, Rebecca L Linn, Keith Rhoades, Jared Fry, Ian N Jacobs

[link url="https://www.chop.edu/news/ingesting-honey-after-swallowing-button-battery-reduces-injury-and-improves-outcomes"]Children’s Hospital of Philadelphia material[/link]
[link url="https://onlinelibrary.wiley.com/doi/full/10.1002/lary.27312"]Laryngoscope abstract[/link]

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