Injuries from Batteries Among Children Aged <13 Years — United States, 1995–2010

Injuries to children caused by batteries have been documented in the medical literature and by poison control centers for decades (1,2). Of particular concern is the ingestion of button batteries,* especially those ≥20 mm in diameter (coin size), which can lodge in the esophagus, leading to serious complications or death (3–5). To estimate the number of nonfatal battery injuries among children aged <13 years, U.S. Consumer Product Safety Commission (CPSC) staff analyzed 1997–2010 data from the National Electronic Injury Surveillance System (NEISS). To identify fatal battery exposures, other CPSC databases covering 1995–2010 were examined, including the 1) Injury and Potential Injury Incident File; 2) Death Certificate Database (DTHS); and 3) In-Depth Investigation File (INDP). From 1997 to 2010, an estimated 40,400 children aged <13 years were treated in hospital emergency departments (EDs) for battery-related injuries, including confirmed or possible battery ingestions. Nearly three quarters of the injuries involved children aged ≤4 years; 10% required hospitalization. Battery type was reported for 69% of cases, and of those, button batteries were implicated in 58%. Fourteen fatal injuries were identified in children ranging in age from 7 months to 3 years during 1995–2010. Battery type was reported in 12 of these cases; all involved button batteries. CPSC is urging the electronics industry and battery manufacturers to develop warnings and industry standards to prevent serious injuries and deaths from button batteries. Additionally, public health and health-care providers can encourage parents to keep button batteries and products containing accessible button batteries (e.g., remote controls) away from young children.

NEISS data are collected from 96 hospitals, each with a minimum of six beds and a 24-hour ED (6), which are selected as a stratified probability sample of all hospitals in the United States and its territories.† To obtain national estimates, a sample weight is assigned to each case based on the inverse probability of selection for the sample. NEISS cases were identified using product codes 884 (batteries), 891 (unspecified batteries), and 892 (non–motor-vehicle batteries).§ Battery exposures described in this report include battery ingestion (i.e., an oral exposure), batteries placed in the nose, and acid burns from ruptured batteries. Narratives were examined to exclude cases not meeting this definition (e.g., injuries sustained [such as scalp laceration] from being physically hit with a battery and suspected ingestions that were ruled out by radiographs or other means). Cases identified as confirmed oral exposures included those 1) with a diagnosis of foreign body ingestion; 2) confirmed by radiography or a battery found in the stool; and 3) with an affirmative statement in the narrative of a child swallowing, chewing, or sucking on a battery. Other cases that could not be confirmed as battery ingestions, but could not be excluded as noningestions, also were included. NEISS narratives for these types of cases included the following language: 1) "possibly" or "might have" ingested/swallowed; or 2) suspected ingestion. Of the total 40,400 estimated cases, 3,900 were unconfirmed ingestions that could not be positively excluded.

The Injury and Potential Injury Incident File is a database consisting of injury or potential injury reports to CPSC from various sources, including news clips, consumer complaints, and medical examiners and coroners. The INDP file provides incident details from follow-up interviews with patients and witnesses. The DTHS database collects death certificates for certain causes of death from 50 states, New York City, the District of Columbia, and some U.S. territories.¶

During 1997–2010, an estimated 40,400 children aged <13 years were treated in hospital EDs for battery-related injuries (Table 1).** Moreover, a statistically significant increasing trend was observed in the yearly estimates (p<0.001), with a 2.5-fold increase in these cases, from 1,900 in 1998 to 4,800 in 2010 (Figure).†† Most of the children were treated and released or examined and released without treatment; approximately 10% required hospitalization. Nearly 72% of all the estimated exposures seen in EDs involved children aged ≤4 years. The battery was identified for 69% of the estimated injuries and among those, 58% of injuries were caused by button-type batteries and 11% by cylindrical batteries. The battery source was identified in 17% of the NEISS cases and included toys, flashlights, remote controls, watches, hearing aids, and light-up jewelry.

Additional CPSC databases covering 1995–2010 were searched for battery-related deaths in children aged <13 years, resulting in the identification of 14 battery-related deaths, all involving children aged <4 years (Table 2). Thirteen deaths occurred during 2002–2010, with only one documented earlier, in 1998. Button-type batteries were involved in 12 deaths, with 10 described as coin, disc, or flat round batteries and four of these specifically associated with 20-mm, 3-volt lithium batteries such as the CR2032.§§ The remaining two deaths likely were associated with button types because of similarities in the incident scenarios (e.g., nonspecific symptoms with delayed diagnosis or a battery lodged in the esophagus) or causes of death (e.g., esophageal perforation with bleeding).

In four of the fatal cases, patients were misdiagnosed and released, delaying identification and treatment (Table 2). For example, a boy, aged 2 years, was treated and released from the ED for coughing/choking episodes and abdominal pain (Table 2 [case 3]). Eight days later, he was brought back to the ED unconscious and in respiratory distress. He subsequently died from bleeding associated with a perforated esophagus and aorta caused by ingestion of a round, flat battery from a remote control. Additionally, in three cases previously reported (4; National Battery Ingestion Hotline database, unpublished data, 2012), children sent home after battery removal suffered a fatal hemorrhage several days to weeks later (Table 2 [cases 4, 9, and 10]).

Reported by

Jacqueline Ferrante, PhD, Div of Health Sciences; Craig O'Brien, MS, Div of Hazard Analysis; Cheryl Osterhout, PhD, Div of Health Sciences, Consumer Product Safety Commission. Julie Gilchrist, MD, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Corresponding contributor: Jacqueline Ferrante, [email protected], 301-504-7259.

Editorial Note

The findings in this report highlight the growing problem of battery ingestions, especially of button batteries, by children aged <13 years. As the use of these batteries expands, so do the estimated number of ED-treated battery exposures in children, with the vast majority of these involving ingestions. This information is consistent with recent reports showing an increase in severe or fatal outcomes with button battery ingestions from 1985 to 2009 (7). At least five deaths identified in this report appear to be documented in the National Battery Ingestion Hotline database.¶¶

Three proposed mechanisms of battery-induced injury include 1) leakage of caustic alkaline electrolyte; 2) ischemic necrosis caused by direct pressure; and 3) production of an external electrolytic current that hydrolyzes tissue fluids, creating hydroxide at the negative pole (4,5,7). Medical experts have attributed severe injuries and death to the latter mechanism when button batteries get lodged in the esophagus rather than passing through the gastrointestinal tract (3,7). Another complicating factor arises when incidents are not witnessed or the diagnosis or treatment of battery ingestion is delayed as it was in at least nine of the 14 fatal cases (Table 2).

Typical symptoms associated with battery ingestion are relatively nonspecific, making the diagnosis difficult, particularly when ingestions go unwitnessed. These include vomiting, abdominal pain, fever, diarrhea, respiratory distress, and dysphagia (5). Serious complications and death are associated most frequently with 3-volt lithium, coin-size batteries ≥20 mm in diameter (7). Since a battery lodged in the esophagus can cause serious burns in only 2 hours, and fatal hemorrhage has occurred >2 weeks after endoscopic removal, health-care providers have developed management guidelines for button battery ingestion (3).***

To protect children, the CPSC sets safety standards for toys. Under Section 106 of the Consumer Product Safety Improvement Act of 2008,††† the American Society for Testing and Materials (ASTM) international voluntary standard for toy safety, known as F963-11, became mandatory. ASTM F963-11 requires that batteries be inaccessible (e.g., secured in compartments with screws) in all toys intended for children aged <3 years and in all toys using batteries that fit within the small parts test cylinder§§§ for children aged <12 years. The latter requirement recognizes that smaller batteries, which can be easily ingested, should be kept inaccessible to all children and that older siblings might leave their toys accessible to younger siblings. Recently, ASTM issued a new safety standard for children's jewelry, F2923-11, which has a similar requirement to prevent button battery access by children.¶¶¶ Legislation also is under consideration in Congress to address the potential risk of unintentional ingestion of button cell batteries by requiring that child-resistant battery compartment closures are used on all consumer products using button cell batteries. Measures that might protect children from battery-related injuries include child-resistant packaging for batteries, changing to child-resistant closures on all consumer products that use button batteries, and warnings regarding the dangers of ingestion on packages of button cell batteries and in literature accompanying all consumer products that use button cell batteries. At least three deaths in this report involved devices not intended for use by small children. Additionally, increased public awareness through public health and health-care providers could reduce exposure to and injuries from these batteries.

The findings in this report are subject to at least three limitations. First, NEISS case narratives are brief, and detailed information is not always provided unless a follow-up investigation is conducted. Second, NEISS documents only ED visits; it does not capture incidents involving untreated persons or patients treated in doctors' offices or outpatient facilities. Finally, the fatality data in this report are a case series based on available CPSC databases and might underrepresent the extent of the problem.

Parents and caregivers should be aware of the potential hazards associated with battery exposure (particularly ingestion of button batteries) and ensure that products containing them are either kept away from children or that the batteries are secured safely in the product.**** Because delays in diagnosis and treatment can lead to serious complications and death, children suspected of having ingested a battery should get prompt medical attention. It is also important to recognize that children might be reluctant or unable to say that they ingested a battery or gave one to a sibling. Additional battery hazard information is available at http://www.cpsc.gov/cpscpub/prerel/prhtml11/11181.html.††††

References

1. Temple DM, McNeese MC. Hazards of battery ingestion. Pediatrics 1983;71:100–3.
2. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2,382 cases. Pediatrics 1992;89:747–57.
3. Brumbaugh DE, Colson SB, Sandoval JA, et al. Management of button battery-induced hemorrhage in children. J Pediatr Gastroenterol Nutr 2011;52:585–9.
4. Hamilton JM, Schraff SA, Notrica DM. Severe injuries from coin cell battery ingestions: 2 case reports. J Pediatr Surg 2009;44:644–7.
5. Slamon NB, Hertzog JH, Penfil SH, Raphaely RC, Pizarro C, Derby CD. An unusual case of button battery-induced traumatic tracheoesophageal fistula. Pediatr Emerg Care 2008;24:313–6.
6. Schroeder T, Ault K. The NEISS sample (design and implementation), 1997 to present. Bethesda, MD: US Consumer Product Safety Commission; 2001. Available at http://www.cpsc.gov/neiss/2001d011-6b6.pdf. Accessed August 23, 2012.
7. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010;125:1168–77.