Single-Center Retrospective Review of the Presentation and Initial Care of Esophageal Button Battery Impactions 2007-2020

OBJECTIVE

The aims of this study were to characterize the patient population and initial presentation and care of esophageal button battery ingestion and provide descriptive data including factors affecting accurate diagnosis, duration of battery exposure, and battery removal.

METHODS

This was a retrospective cohort study from 2007 to 2020 at a single-center, large-volume, urban academic pediatric hospital system. Included participants were children 6 months to 18 years old who underwent removal of an esophageal button battery impaction at our institution.

RESULTS

Our cohort comprised 63 patients; ages ranged from 7 to 87 months with a median of 27 months. Median button battery size was 2.12 cm with 59% lodged in the proximal esophagus. A prolonged impaction, greater than 12 hours, occurred in 46% of patients. Risk ratio analysis demonstrated that lack of caregiver suspicion of ingestion was associated with prolonged impaction (risk ratio, 3.39; confidence interval, 2.15-5.34). Misdiagnosis of button battery ingestion occurred in 10% of cases. The majority of patients, 87%, required transfer from a referring facility with a median total distance of 37 miles (range, 1.4-160 miles) from home to facility where battery was removed.

CONCLUSION AND RELEVANCE

This study describes the initial presentation and care of a large cohort of pediatric esophageal button battery ingestion. It emphasizes the continued need for primary prevention, prompt identification, and removal of these batteries. There are many challenges in caring for these patients involving multiple pediatric disciplines, and guidelines encompassing a multidisciplinary approach would be beneficial.

Comparing Eosinophilic Esophagitis in a Black and Non-Black Pediatric Cohort

OBJECTIVES

To compare presenting symptoms, comorbidities, disease, and treatment characteristics of a black pediatric eosinophilic esophagitis (EoE) group to a non-black pediatric EoE group.

METHODS

A retrospective chart review consisting of pediatric patients diagnosed with EoE between the years of 2010 and 2018 at a single urban pediatric hospital system comprising 143 black pediatric patients compared with 142 non-black pediatric patients with similar distribution of age and sex.

RESULTS

Both groups were majority male, and the median age of diagnosis between the black and non-black group was 5.1 and 6.7 years old, respectively. Comorbidities more commonly seen in the black group included food allergies, atopic dermatitis, asthma, and allergic rhinitis. Black patients were more likely to present with failure to thrive (FTT)/poor growth, whereas non-black patients were more likely to present with abdominal pain. There was no statistically significant difference between the groups in achieving remission using current therapies. The black group had higher rates of nonadherence to medical therapies.

CONCLUSIONS

This is the largest study to date comparing a black versus non-black pediatric EoE population. The black population had more atopic comorbidities and FTT at presentation and had significantly more issues with nonadherence. This new knowledge describing EoE in a minority population will hopefully improve awareness, diagnosis, and management of EoE in this population.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study

BACKGROUND AND OBJECTIVES

High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market.

METHODS

This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019.

RESULTS

Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality.

CONCLUSIONS

Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

Management of esophageal button battery ingestions: resource utilization and outcomes

PURPOSE

Institutions are adopting the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines for pediatric esophageal button battery ingestion (EBBI). Our objective was to evaluate the guidelines' impact on in-hospital resource utilization and short-term clinical outcomes in hemodynamically stable patients after endoscopic battery removal.

METHODS

A single-center retrospective review of all EBBI admissions from 2010 to 2020. Patients were divided into two groups based on adoption of national guidelines: pre-guideline (2010-2015) and post-guideline (2016-2020).

RESULTS

Sixty-five patients were studied (pre-guideline n = 23; post-guideline n = 42). Compared with pre-guideline, post-guideline use of magnetic resonance imaging (MRI) increased (2/23 [8.7%]; 30/42 [71.4%]; p < 0.001). Post-guideline increases resulted for median days (IQR) receiving antibiotics (0 [0, 4]; 6 [3, 8]; p = 0.01), total pediatric intensive care unit admission (0 [0, 1]; 3 [0, 6]; p < 0.001), and total hospital length of stay (5 [2, 11]; 11.5 [4, 17]; p = 0.02). Two patients in the post-guideline group had delayed presentations despite normal imaging: one with TEF and one with aorto-esophageal fistula. All survived to discharge.

CONCLUSION

In EBBI cases managed using the consensus based NASPHAGN guidelines, we report increased resource utilization without improved patient outcomes. Further research should evaluate post-guideline costs and resource utilization.

Evolving Clinical Care in Esophageal Button Batteries: Impact of Expert-Opinion Guideline Adoption and Continued Gaps in Care

BACKGROUND/OBJECTIVES

Esophageal button battery impactions (BBI) in children pose a significant danger to children. Although there are expert-opinion guidelines to help manage this population, few studies detail the impact of guidelines on the clinical care of these patients. With this study, we aimed to describe the care of these patients before and following adoption of guidelines at a single center.

METHODS

Retrospective cohort study of patients with esophageal BBI at a single center, large volume, urban academic pediatric hospital system before adoption of expert-opinion guidelines (2007-2017) and following adoption (2018-2020).

RESULTS

Cohort was comprised of 31 patients before adoption and 32 patients following adoption of guidelines. Patient characteristics did not differ between groups. After 2018, significantly more patients received acetic acid irrigation, initial cross-sectional imaging, and serial cross-sectional imaging. There was also an increase in intensive care unit (ICU) stays, number of intubations, nil per os time, and hospital length of stay. There was no difference in patient outcomes.

CONCLUSION

This study describes a large cohort of pediatric esophageal BBI before and following adoption of guidelines. Findings detail increased adherence to guidelines resulting in more cross-sectional imaging which led to ICU stays, longer length of stays, and more nil per os time. This study emphasizes the need for multi-disciplinary guidelines as well as further multi-institutional study.

PRO-C3, a Serological Marker of Fibrosis, During Childhood and Correlations With Fibrosis in Pediatric NAFLD

Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease in children and may lead to cirrhosis requiring liver transplant. Thus, prompt diagnosis of advanced fibrosis is essential. Our objectives were to examine PRO-C3 (a neo-epitope pro-peptide of type III collagen formation) levels across childhood/adolescence and associations with advanced fibrosis in pediatric NAFLD. This cross-sectional study included 88 children and adolescents with biopsy-proven NAFLD (mean age: 13.9 ± 2.9 years, 71% male) and 65 healthy participants (11.8 ± 4.5 years, 38% male). PRO-C3, and the bone remodeling biomarkers C-terminal telopeptide of type I collagen (CTX-I; bone resorption) and osteocalcin (N-MID; bone formation), were measured in serum by enzyme-linked immunosorbent assay. Fibrosis was assessed by liver biopsy in participants with NAFLD, who were categorized as having advanced (Ishak score ≥ 3) or none/mild fibrosis (Ishak score ≤ 2). Overall, PRO-C3 was similar in participants with NAFLD (median [interquartile range]: 20.6 [15.8, 25.9] ng/mL) versus healthy participants (19.0 [13.8, 26.0] ng/mL), but was significantly lower in older adolescents ≥ 15 years old (16.4 [13.0, 21.2] ng/mL) compared with children ≤ 10 years old (22.9 [18.1, 28.4] ng/mL; P < 0.001) or 11-14 years old (22.4 [18.3, 31.2] ng/mL; P < 0.001). PRO-C3 was also directly correlated with levels of CTX-I and N-MID (r = 0.64 and r = 0.62, respectively; both P < 0.001). Among participants with NAFLD, PRO-C3 was higher in those with advanced fibrosis (median [IQR]: 28.5 [21.6, 37.6]) compared with none/mild fibrosis (20.3 [18.2, 22.8]; P = 0.020) in models adjusted for age, sex, and body mass index z-score. However, associations were attenuated after additionally adjusting for bone-remodeling CTX-I (P = 0.09) or N-MID (P = 0.08). Conclusion: Collectively, these findings show that PRO-C3 levels are higher in children with advanced fibrosis in NAFLD, but are also influenced by age and pubertal growth spurt, assessed by bone remodeling biomarkers, and therefore may not be a reliable biomarker for liver fibrosis in pediatric NAFLD until late adolescence.

Development and repair of aorto-esophageal fistula following esophageal button battery impaction: A case report

Background:

Complications from esophageal button battery impactions remain a real fear for practicing pediatric gastroenterologists and surgeons. This case describes a child who developed an aorto-esophageal fistula 25 days after initial battery ingestion and survived due to prompt placement of an aortic stent via minimally invasive surgery, avoiding an open procedure.

Case presentation:

A 6-year-old female presented acutely with a mid-esophageal button battery impaction witnessed by her parents. Presenting symptoms included chest pain and emesis. Button battery location and size were confirmed on X-ray. She underwent removal with flexible esophagogastroduodenoscopy (EGD) and rigid esophagoscopy. She was admitted to the hospital and received conservative medical management, with serial cross-sectional imaging via chest MRIs to assess the evolution of her injury according to available national guidelines, and was discharged after 12 days of close inpatient monitoring. Despite these measures the patient represented 25 days post-ingestion with hematemesis from a new aorto-esophageal fistula, requiring emergent cardiac catheterization with successful, life-saving aortic stent placement. She remained admitted for an additional 12 days of monitoring as her diet was advanced slowly post-catheterization. Since this second hospitalization she continues to do well, with outpatient follow-up by multiple subspecialists.

Conclusions:

This case highlights the continued uncertainty regarding the risk of developing this complication, as well as gaps in the current literature and guidelines for managing these patients following ingestion and esophageal injury. It also details the unique course following development of this complication and its surgical repair.

Predicting the impacts of sea level rise in sea turtle nesting habitat on Bioko Island, Equatorial Guinea

Sea level is expected to rise 44 to 74 cm by the year 2100, which may have critical, previously un-investigated implications for sea turtle nesting habitat on Bioko Island, Equatorial Guinea. This study investigates how nesting habitat will likely be lost and altered with various increases in sea level, using global sea level rise (SLR) predictions from the Intergovernmental Panel on Climate Change. Beach profiling datasets from Bioko's five southern nesting beaches were used in GIS to create models to estimate habitat loss with predicted increases in sea level by years 2046-2065 and 2081-2100. The models indicate that an average of 62% of Bioko's current nesting habitat could be lost by 2046-2065 and 87% by the years 2081-2100. Our results show that different study beaches showed different levels of vulnerability to increases in SLR. In addition, on two beaches erosion and tall vegetation berms have been documented, causing green turtles to nest uncharacteristically in front of the vegetation line. We also report that development plans are currently underway on the beach least susceptible to future increases in sea level, highlighting how anthropogenic encroachment combined with SLR can be particularly detrimental to nesting turtle populations. Identified habitat sensitivities to SLR will be used to inform the government of Equatorial Guinea to consider the vulnerability of their resident turtle populations and projected climate change implications when planning for future development. To our knowledge this is the first study to predict the impacts of SLR on a sea turtle nesting habitat in Africa.