Saturday 22 September 2018

Give honey for button battery ingestion? The tale of two anesthetised pigs…

Image result for american yorkshire piglets

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…)


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. [Link to article]

Friday 21 September 2018

Clinical Trial of Fluid Infusion Rates for Pediatric DKA

Dr Annoying Bowtie, RACP

Emergency physicians often get criticised for overhydrating children with DKA. “Too much fluids will cause their heads to explode,” as spoken from an annoying bow tie.

But there has never been good quality evidence to prove fluid administration causes cerebral edema. In fact, a study by Glaser etal. in 2001 showed no association between fluids and bad outcomes.

But as there is no definitive RCT, the debate still rages!

Hopefully this clinical trial will put matters to rest.

After 17 years, Dr Nicole Glaser is back! Now teamed up with the PECARN mega-group, they randomised 1255 children with 1389 DKA episodes to one of 4 treatment arms (please see original paper for further details)

  • Fast administration of 0.9% normal saline
  • Fast administration of 0.45% normal saline
  • Slow administration of 0.9% normal saline
  • Slow administration of 0.45% normal saline

(Just to give an idea of what is fast vs. slow, a 50 kg child would get an infusion started of 300ml/hour vs. 140ml/hour.)

The primary outcome was a decline in mental status (measured by GCS) during treatment. Secondary outcomes included clinically apparent brain injury during treatment and some measures of memory.


No difference. Neither the rate of administration nor the sodium chloride content of the IV fluids resulted in bad outcomes. 

So the debate is over?

Unfortunately, no.

98% of the children recruited in this study started out at GCS 14-15.  We know it is the sickest cohort of DKA that develop bad complications. This study was never going to show a difference. The clear majority were going to get better with any reasonable management... regardless of fluid protocols.

What about the child with a pH of 6.9 and GCS 6? Does the rate of fluid administration matter?


Unfortunately, an adequately powered RCT of severe DKA will never happen. It is simply not feasible. 

Alas, the annoying bow ties will continue...


Kupperman N, Ghetti S, Schunk J, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018;378:2275-87. [link to original full text article]