Pediatrics: Lessons in Preventing Button Battery Injuries

According to a study published in Pediatrics, it is estimated that between 2010 and 2019, more than 70,000 emergency department (ED) visits in the United States were related to battery ingestion, mouth exposure, and ear or nasal insertion among children under 18 years old. ED visits occurred more frequently among children ages 5 years and younger. Button-type and lithium coin batteries—typically small, round, flat, or disc-shaped—are found in toys, electronic devices, hearing aids, key fobs, digital watches, remote controls, and even musical greeting cards. They accounted for nearly 85 percent of the battery injuries.¹

Incidences of button battery ingestion, aspiration, or insertion may be more prevalent in lower socioeconomic families due to risk factors that include limited or no access to healthcare (lack of insurance), resulting in minimal parent and caregiver education on prevention, recognition, and the need for immediate treatment. Pediatric hospitalizations for treatment of foreign body complications also drive up the cost of healthcare.² The COVID-19 pandemic has played an additional role because families spent more time at home in lockdown and isolation, creating more opportunities for battery injuries.

The majority of ingestions, exposures, and insertions go unwitnessed by the parent or caregiver. Clinicians may be misled by the patient’s initial presentation because symptoms are often nonspecific and mistaken for croup, flu, or asthma in the absence of radiologic confirmation.

The child may have delayed symptoms that can result in delayed care and treatment and lead to serious injury. Injuries and complications include nasal septal perforation, vocal cord paralysis, aspiration pneumonia, esophageal-tracheal fistulas, esophageal perforation, bowel injury, and even death within hours of ingestion.³

The National Capital Poison Center developed the Button Battery Ingestion Triage and Treatment Guideline with an algorithm to assist clinicians in the timely diagnosis and treatment of button battery ingestion.

Case Example

A mother took her three-year-old male child to urgent care with complaints of nasal trauma and swelling. She reported that the child had been struck in the face by a door several days earlier. Although x-rays were negative for fracture, they revealed a foreign body in the child’s left nostril. The radiologist noted on the report that he informed the mother of this finding. The mother later denied that the radiologist had informed her of the foreign body.

The urgent care staff instructed her to take the child to the pediatrician. The child was seen by an advanced practice clinician (APC), but the records from urgent care were not made available and there were no documented attempts by the APC to obtain the records. The mother provided the same history of injury and told the APC that the x-rays were normal. The APC relied on the mother’s information.

On exam, the child was noted to have nasal swelling, bruising around the left eye and bridge of nose, and dried blood around the left nostril and upper lip. Follow-up facial/skull/orbital x-rays were ordered, and the mother was told to return for follow-up in three days.

The mother did not complete the x-rays, claiming she had to wait too long, and was a no-show for the return appointment.

Ten days later, she returned with the child to the pediatrician’s office due to intermittent nosebleeds. The pediatrician observed dried blood around the left nostril, otherwise the exam was normal. The pediatrician diagnosed nosebleeds due to dry weather and nose picking.

The mother was instructed to use nasal saline and Vaseline and to return in one week. (The mother later denied being given these instructions.) The mother returned one month later and was seen by a different pediatrician. The child presented with malodor from the nose with purulent green discharge from both nostrils. The child was referred to an otolaryngologist (ENT), although the mother later stated that she was unaware of the referral.

Two days later, the child presented to the ED with a large nosebleed. He was examined by an ENT, who confirmed a foreign body in the nose and surgically removed it. The child was found to have a large anterior nasal septal perforation as the button battery had decomposed and leaked acid that had eroded through the nasal septum into the bone.

The family filed a lawsuit against the urgent care facility, radiologist, APC, and pediatricians, alleging delayed diagnosis and treatment that resulted in severe infection, anterior septal perforation, and permanent cosmetic deformity that required multiple corrective surgeries.

Contributing factors in this case include the following:

• Failure by urgent care staff to communicate x-ray results. The staff communicated only with the mother and did not communicate results confirming foreign body findings to the pediatrician’s office. The mother subsequently denied that she had been told of the original x-ray results.
• Failure by the APC to obtain medical records from urgent care, reliance on the mother’s inaccurate report of normal x-ray results, and lack of documentation.
• Failure by the second pediatrician to document that the mother did not obtain the x-rays recommended during the previous visit.
• Failure by the mother to provide an accurate history, relay accurate x-ray results, obtain follow-up x-rays that had been ordered, and bring the patient to several appointments.

All of these failures led to the delay in diagnosis and treatment of the foreign body.

Patient Safety Strategies

To minimize misdiagnosis and delays in care and treatment, maintain a high index of suspicion for foreign body ingestion, aspiration, or insertion in the mouth, nose, or ears. It is important to obtain an accurate history, perform a thorough diagnostic workup, and review prior patient records. Thorough documentation serves as a powerful defense in claims alleging misdiagnosis or delayed treatment.

Prevention is key and should include raising community awareness. During well-child visits, take the opportunity to educate parents and caregivers. Post the telephone number of the National Battery Ingestion Hotline—(800) 498-8666—in each exam room and make it readily available to clinicians. Safe Kids Worldwide offers a button battery tip card to download or post on your website.

“Reese’s Law” (Public Law 117-171), passed by Congress in August 2022, requires the U.S. Consumer Product Safety Commission (CPSC) to develop child-resistant safety standards to protect children and other consumers against hazards associated with accidental ingestion of button cell or coin batteries.⁴ The CPSC offers posters on button battery safety.

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.