Risk of death and serious harm from delays in recognising and treating ingestion of button batteries

A stage one warning has been issued to raise awareness of the risk of death and serious harm from delays in recognising and treating ingestion of button batteries.

The alert has been issued to providers of NHS funded care to highlight that when a button battery is swallowed severe tissue damage can result from a buildup of sodium hydroxide (caustic soda) caused by the electrical current discharged from the battery, and not as commonly supposed, from leakage from the battery.

The sodium hydroxide causes tissue burns, often in the oesophagus (food pipe), which can then cause damage to major blood vessels, resulting in catastrophic haemorrhage.

A review of incident reports over a four year period identified five cases where severe tissue damage occurred after apparent delays in suspecting, diagnosing or treating button battery ingestion in small children; sadly in one case this resulted in death.

The risk affects all age groups, although most cases involve children under the age of six who mistake the battery for a sweet and older people with confusion or poor vision who mistake the battery for a pill. Older children and adults may also ingest batteries as a means of self-harming.

The swallowing of button batteries needs to be treated as a medical emergency. Removal of the battery alone may be insufficient action to prevent further damage as symptoms can manifest up to 28 days later. Patients need expert input, and careful monitoring and follow-up. One further incident described the death of a child from late complications after they had been treated and sent home.

Dr Mike Durkin, NHS England Director of Patient Safety, said: “As these types of batteries are common in toys and gadgets that may be given as presents, the risk of children swallowing them increases during the Christmas period. We are therefore issuing this alert so NHS staff, particularly those working in general practice and emergency settings, are aware of the urgent need to recognise where a battery may have been swallowed and to provide appropriate treatment and follow-up care.”

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

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