Our local Guru of EBM, Brian Doyle, hosts a monthly Journal Club for the locals. In the spirit of consolidating knowledge and sharing this with the world, with permission, here is a re-post of one of the articles discussed.
For more juicy journals served on a platter, head over to Brian's JC blog: EmergencyMedJc
Anfang RR, Jatana KR, Linn RL, et al. pH-Neutralizing Esophageal Irritations as a Novel Mitigation Strategy for Button Battery Injury. Laryngoscope 2018 Jun 11. doi: 10.1002/lary.27312.
Believe it or not, UpToDate recommends honey as first aid for button battery ingestions.
Perhaps we should look at the evidence.
We know button batteries can cause nasty and sometimes lethal caustic oesophageal injury.
This study was a cadaver and live American Yorkshire piglet model looking at potential pH neutralizing agents prior to definitive endoscopy.
In vitro, they tested the final tissue pH of cadaver oesophagus after installation of various products. They included different kinds of honey, Carafate, apple juice, orange juice, Powerade, Gatorade, maple syrup, simulated saliva and 0.9% sodium chloride control.
In the lab, the honey and Carafate seemed to work the best and underwent further study.
Bring on the live pigs!
9 anaesthetised pigs had a button battery placed in their oesophagus for an hour. (Poor creatures.) Serial irrigations of study solution occurred every ten minutes starting at the five-minute mark.
2 pigs got honey, 3 got Carafate, and 4 got saline control.
On day 7, the unfortunate piglets were euthanized and histology obtained.
Honey was the big winner! They had much less depth of injury. Half of the saline piglets had delayed oesophageal rupture.
This little piggy went to market… to get honey! Give honey for button battery ingestion.
This recommendation is based on TWO anesthetised pigs that got honey.
This is extremely low-quality evidence.
One should only change practice based on such low-quality evidence if the treatment or therapy was considered to be extremely low risk.
Perhaps honey is extremely low risk. But are we certain?
Would care get delayed in finding and administering honey? Does honey impair endoscopy? What about aspiration or honey induced mediastinitis? Will kids get nasal-oesophageal tubes to administer honey? Would we tend to delay endoscopy because they "got the honey?”
Perhaps risk may be minimal… But changing practice based on two honey glazed pigs??
(ok… I’d give the honey too… I can’t believe I just said that…)
About The Author
Dr Brian Doyle is an emergency physician originally from the United States but now very much calls Tasmania his home. Unfortunately, it will now be a bit more difficult to deport him from the country as he passed his Australian citizenship test a few years ago. (He was able to answer that Phar Lap won the Melbourne rather than the Davis Cup). His main interests are mostly the clinical aspects of emergency medicine but also in education, ultrasound and critical appraisal of the literature. He spends much of his time annoying people to help out with conferences.