Paeds SAQs · acute-care-resuscitation-and-toxicology
Button-battery and magnet ingestion — formative SAQs
Two MedVellum formative short-answer questions on the child with suspected button-battery or magnet ingestion: confirming ingestion and time, the two-hour endoscopic removal target for an oesophageal battery, the honey and sucralfate adjunct regimen with its eligibility and limits, the high-risk status of two or more magnets, and the recognition of delayed life-threatening complications such as aorto-oesophageal fistula. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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Target exams
SAQ 1 — A drooling three-year-old with a battery
Question 1 — 10 formative marks; suggested time 15 minutes [1]
A three-year-old is brought in drooling and refusing drinks. The parent found a remote control with a missing twenty-millimetre lithium battery two hours ago. The child is alert, has a soft stridor at rest, and is drooling pooling secretions. The heart rate is 130, saturation 97 percent in air. [1]
- State what you do in the first 60 seconds and why. (2 marks)
- Describe the single radiograph you request and the three radiographic signs you look for. (2 marks)
- State the honey adjunct regimen, its eligibility, and its limits. (3 marks)
- Explain the tissue-injury mechanism and why the child needs surveillance after removal. (3 marks)
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1
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]
SAQ 2 — A well school-age child with two magnets
Question 2 — 10 formative marks; suggested time 15 minutes [9]
A six-year-old is brought in because a parent found a building-set magnet box open and believes two small magnets were swallowed about four hours ago. The child is well, has no abdominal symptoms, and the radiograph shows two round densities, one in the stomach and one in the proximal jejunum. [9]
- State the risk classification and why symptoms do not reassure you. (2 marks)
- Describe the mechanism by which the magnets injure the bowel. (2 marks)
- State what you will and will not do, with the removal and observation triggers. (4 marks)
- Explain the aorto-oesophageal-fistula teaching point in relation to batteries, and how it shapes discharge advice after any battery removal. (2 marks)
Full-credit answer — SAQ 2
Reveal full-credit answer for SAQ 2
1. Risk classification
"This is a high-risk multiple-magnet ingestion. Two magnets, or a magnet paired with a ferrous object, can attract across opposing bowel walls and cause fistula, perforation, obstruction, volvulus and ischaemia. The child being well does not reassure me, because the magnets can sit silently in separate loops for hours to days before attracting through the walls, so the magnet count, not the symptom count, drives the decision." [9] [12]
2. Mechanism
"The two magnets attract one another across the walls of adjacent bowel loops, compressing and trapping the intervening tissue. The compressed wall becomes ischaemic, ulcerates, and eventually fistulates, perforates or twists into a volvulus. Because they may sit in separate loops before coming into apposition, a well child can harbour a catastrophic injury." [9] [12]
3. What I will and will not do
"I will remove the magnets if they are within endoscopic reach in the stomach or proximal duodenum, with surgical standby. If they are beyond endoscopic reach and the child is asymptomatic, I will observe closely with surgical standby and repeat imaging, removing them if they fail to progress or if any symptoms develop. I will not give laxatives, because moving magnets or raising intraluminal pressure can precipitate obstruction or bring attracting magnets into apposition. I will not induce emesis for the same reason. I will keep the child nil by mouth, establish access, and mobilise paediatric surgery early." [9] [2]
4. Aorto-oesophageal-fistula teaching point and discharge advice
"The leading cause of death after button-battery ingestion is delayed great-vessel injury, classically an aorto-oesophageal fistula that presents as massive, often fatal haematemesis days to weeks after an apparently successful removal. The lesson is that the injury can continue after the battery is out. After any battery removal I therefore admit for delayed-complication surveillance, arrange follow-up endoscopy, and give the family a safety net naming the warning signs of chest pain, fever, haematemesis, dysphagia and abdominal pain, with the route back to care. I run prevention and safeguarding in parallel." [1] [6]
References
- [1]Mubarak, Marwan Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper Journal of pediatric gastroenterology and nutrition, 2021.PMID 33555169
- [2]Kramer, Robert E Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee Journal of pediatric gastroenterology and nutrition, 2015.PMID 25611037
- [5]Goh, Samuel Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal The Laryngoscope, 2024.PMID 38934450
- [6]Schmidt, Yannick M The use of honey in button battery ingestions: a systematic review Frontiers in pediatrics, 2023.PMID 37842023
- [7]Chiew, Andis Graeme Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model Annals of emergency medicine, 2024.PMID 37725021
- [9]Altokhais, Turki Magnet Ingestion in Children Management Guidelines and Prevention Frontiers in pediatrics, 2021.PMID 34422734
- [12]Han, Younghoon Ingestion of multiple magnets in children Journal of pediatric surgery, 2020.PMID 31937446