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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, jferrante@cpsc.gov, 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.

* Generally, a battery with a diameter greater than its height is referred to as button or coin-size, depending on its width (e.g., a button battery with the width of a nickel coin is approximately 21 mm in diameter).

Hospital EDs are grouped into five strata, with four based on size (i.e., annual number of ED visits) and a fifth representing children's hospitals.

§ Battery types include button and cylindrical (e.g., AA, AAA, C, and D).

Death certificate collection takes time. As of July 2011, DTHS was considered 97% complete for 2007, 87% complete for 2008, 73% complete for 2009, and 34% complete for 2010.

** CPSC staff did not analyze NEISS data from 1995 to 1996 because the sample frame and sample changed in 1997.

†† NEISS data for 1997 were not sufficient to provide a reliable estimate. The trend analysis was an F-test of the year effect on the estimates adjusted for changes in the population.

§§ The designation CR2032 defines a 3-volt lithium battery that is 20 mm in diameter (approximately the size of a nickel) with a height of 3.2 mm.

¶¶ Database available at http://www.poison.org/battery. Possible duplicate cases cannot be confirmed without more detailed incident information.

*** Additional information available at http://www.poison.org/battery/guideline.asp.

††† Additional information available at http://www.cpsc.gov/about/cpsia/cpsia.html.

§§§ Specifications for the small parts test cylinder are described in 16 CFR § 1501.4. Additional information available at http://www.cpsc.gov/businfo/regsumsmallparts.pdf.

¶¶¶ Additional information available at http://www.astmnewsroom.org/default.aspx?pageid=2620.

**** Additional information available at http://www.poison.org/battery/tips.asp.

†††† Three deaths in children associated with battery ingestion occurred since the compilation of data for this report. Two cases were identified in 2011. The first case involved a boy aged 3 years who died after ingesting a button battery. The battery became impacted in his esophagus and caused acute esophageal bleeding because of an esophageal-aortic fistula. In the second case, a girl aged 13 months died after she swallowed a 2-cm (or 20-mm) watch battery and it lodged in her esophagus. Most recently, in 2012, a boy aged 4 years died after complications from swallowing a button battery. The boy complained of pain in his throat 4 days after reportedly swallowing a battery, and a battery was located in his stomach and removed without incident. The boy remained in the hospital and suffered complications, including an esophageal leak. He died 32 days after ingestion of the button battery.


What is already known on this topic?

Injuries to children caused by batteries have been documented in the medical literature and by poison control centers for decades. 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.

What is added by this report?

During 1997–2010, an estimated 40,400 children aged <13 years were treated in hospital emergency departments for battery-related injuries. Nearly three quarters of the injuries involved children aged ≤4 years; 10% required hospitalization. Moreover, a 2.5-fold increase in these cases was observed from 1998 to 2010. Fourteen battery-related fatalities were identified, all in children aged <4 years. Button batteries were confirmed to be involved in 12 of the 14 cases.

What are the implications for public health practice?

To improve medical outcomes, health-care providers should be aware of the injuries associated with ingestion of button cell batteries. Given the increasing use of such batteries, public health and health-care providers should include warnings of the dangers of button cell battery exposures when counseling parents. To prevent serious injury and death, button batteries and products containing button batteries (e.g., remote controls) should be kept away from young children unless the batteries are secured safely in the product.


TABLE 1. Estimated number of emergency department–treated battery injuries involving children aged <13 years, by selected characteristics — National Electronic Injury Surveillance System (NEISS), United States, 1997–2010*

Characteristic

Injuries

No.

(95% CI)

Age group (yrs)

<1

3,100

(2,000–4,200)

1

9,700

(7,600–11,800)

2

6,600

(4,800–8,300)

3

5,400

(4,100–6,700)

4

4,400

(2,900–5,900)

5–8

7,900

(5,900–9,900)

9–12

3,300

(2,100–4,500)

Sex

Male

23,500

(18,100–28,900)

Female

16,900

(13,600–20,200)

Disposition

Treated and released

32,200

(28,500–44,000)

Hospitalized

3,900

(2,700-5,200)

Battery type

Button

23,400

(18,000–28,700)

Cylindrical

4,600

(3,400–5,700)

Unknown

12,400

(9,300–15,600)

Total§

40,400

(32,100–48,700)

Abbreviation: CI = confidence interval.

* All the estimates and 95% CIs are rounded to the nearest 100.

Those who left against medical advice were not included because the number of observations was not sufficient for a reliable estimate.

§ Categories might not sum to totals because of rounding.

Of the total estimated cases, 3,900 were unconfirmed ingestions that could not be positively excluded.


FIGURE. Estimated annual number of emergency department–treated battery injuries involving children aged <13 years — National Electronic Injury Surveillance System (NEISS), United States, 1998–2010*

The figure shows the estimated annual number of emergency department- treated battery injuries involving children aged <13 years in the United States, during 1998-2010. 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.

* NEISS data for 1997 were not sufficient to provide a reliable estimate.

Alternate Text: The figure above shows the estimated annual number of emergency department- treated battery injuries involving children aged <13 years in the United States, during 1998-2010. 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.


TABLE 2. Summary characteristics of battery ingestion deaths in children — selected databases, United States, 1995–2010*

Case

Age

Sex

Year

Battery type

Intended use

Location

Symptoms

Cause of death

Incident information

1

16 mos

Female

1998

Disc

Unknown

Esophagus

Unknown

Exsanguination/arterio-esophageal fistula

Unknown

2

15 mos

Female

2002

3-volt lithium CR2016

Possibly a toy watch

Proximal esophagus

Vomiting, black stools, hemorrhaging

Exsanguination/aortic-esophageal fistula

Became symptomatic >5 hours after ingestion. Battery identified by radiograph approximately 19 hours after symptoms developed. Child died approximately 13 hours after battery removal.

3

2 yrs

Male

2004

Flat round

Radio remote control

Esophagus

Coughing, choking, abdominal pain, respiratory distress, unconscious

Exsanguination and perforation of esophagus and aorta

Child treated and released from emergency department (ED) for coughing/choking episode and abdominal pain. Returned 8 days later unconscious and in respiratory distress, and died.

4

19 mos

Male

2005

Button size

Garage door opener

Esophagus and stomach

Difficulty breathing, pneumonia, listless, diaphoretic

Hemorrhagic shock/ aorto-esophageal fistula

Became symptomatic approximately 1 day after batteries discarded in trash (suspected that child retrieved from there). At ED, a radiograph showed one battery each in stomach and esophagus. Both removed. Child released, but returned to hospital approximately 1 week later and died during exploratory surgery.

5

1 yr

Male

2006

Alkaline

Remote car alarm

Esophagus

Fever, loss of appetite, suspected croup

Anoxic encephalopathy from complications of a tracheo-esophageal fistula.

Child taken to hospital after 2 days with fever. Diagnosed with croup and sent home. Two days later returned to hospital, where a radiograph showed a battery in the esophagus. Battery removed, but child died 6 days later.

6

7 mos

Female

2007

Disc

Unknown

Esophagus

Unknown

Massive hematemesis/Acute fistulous erosion of preexisting esophageal ulcer into carotid artery

No details. Esophagoscopic removal of battery.

7

16 mos

Female

2008

Disc

Unknown

Esophagus

Unknown

Hemorrhagic shock/esophageal erosion with hemorrhage

Unknown

8

2 yrs

Male

2009

Watch

Unknown

Unknown

Acute hemorrhage/ esophageal ulceration

Unknown

9

2 yrs

Female

2009

3-volt lithium CR2032

Hand held game

Esophagus

Chest/Stomach pain, vomiting blood

Gastroesophageal hemorrhage/aorto-esophageal fistula

Child taken to hospital for chest pain. Radiograph showed battery in esophagus. After removal, symptoms continued and child died 18–19 days later.

10

13 mos

Male

2009

3-volt lithium CR2032

Unknown

Esophagus/stomach

Influenza-like symptoms, altered eating habits, inability to retain food, hemorrhaging

Esophageal ulceration/ tracheo-esophago-aortic fistula

Child diagnosed with a viral infection after several doctor visits. After lack of improvement, an initial radiograph was negative, but 1 week later, a battery was identified in the stomach, which was surgically removed, and child was released without complications. Child hemorrhaged to death 2 days later.

11

3 yrs

Female

2009

Coin

Unknown

Mid-trachea

Unknown

Bronchopneumonia and blood aspiration

Unknown

12

2 yrs

Female

2010

Flat, round disc

Unknown

Upper thoracic esophagus

Sore throat, dysphagia, choking, shortness of breath, tachypneic, dark bowel movements, listless

Esophageal perforation/bleeding

Child with sore throat treated for strep by pediatrician. Taken to ED 5 days later, where a radiograph identified a foreign object lodged in the esophagus. Battery removed in hospital, where child died 2 days later.

13

2 yrs

Female

2010

CR2023

Unknown

Clot in stomach

Feeling ill, vomiting blood

Cardiovascular collapse attributed to esophageal damage, necrosis, and hemorrhage

Ingestion time unknown, but child became ill and vomited blood. After transfer from initial hospital, her condition deteriorated, and endoscopy showed an esophageal tear. Died at hospital.

14

2 yrs

Female

2010

Unknown

Unknown

Abdomen

Coughing blood, unresponsive

Esophageal perforation

Child at daycare when she began coughing blood and became unresponsive. Chest radiograph showed an eroded battery. Ingestion time unknown.

* U.S. Consumer Product Safety Commission staff members searched non–National Electronic Injury Surveillance System databases for the period 1995–2010 and found no deaths before 1998. Databases included 1) Injury and Potential Injury Incident File; 2) Death Certificate Database; and 3) In-Depth Investigation File.

Whether the battery identified in this medical examiner/coroner report (CR2023) exists is unclear; the last two digits might have been transposed.


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