Button Battery Safety Issues Paper

From 1st November 2015 to 31st October 2018 there were 1239 button battery calls to Australian Poison Information Centres. After the removal of re-calls (subsequent calls about a single exposure), cases of confirmed non-ingestion/insertion
(eg. battery found during the phone call), veterinary exposures and coding errors there were 1080 cases remaining. Of these 915 were accidental paediatric exposures, 119 were unintentional adult exposures and there were 46 deliberate self-harm exposures. There was no apparent change in trend throughout this time period.
In the following 10 month period, November 2018 - August 2019, NSW PIC was consulted on 142 cases regarding button batteries, including 100 paediatric cases. 92 of these cases involved children aged 4 years and under. 133 of these cases were either in or referred to hospital and hospital staff were advised by PIC to immediately perform an X-ray to confirm the location of the button battery thus reducing the risk of significant harm. (The remaining 9 calls did not involve a suspected or actual ingestion or insertion or were questions related to a historical exposure). NSW PIC takes approximately 50% of calls nationally so this would extrapolate to around 284 national calls involving button batteries during this period and 266 emergency department presentations. This data demonstrates that button battery ingestions are still a frequent occurrence in our community, particularly in young children aged 4 years and under who are involved in around 65% exposures.
The average cost for a non-admitted ED presentation is $517 (as per Australian Government Department of Health. Medicare Benefits Schedule Book 2018 [cited 2018 18th September]). This extrapolates to more than $137,000 in costings from presentations to Australian hospital emergency departments in a 10-month period without taking into account any further investigations, complications or follow-up required.

NSW Poisons Information Centre believes the recommendation
“(a) have a battery compartment (or other enclosure) that is secured (preferably with a captive screw, a bolt or mechanism) such that it requires a tool to gain access to the batteries, “
is preferable to the following option
(b) have a battery compartment that requires two or more independent AND simultaneous actions to remove its cover.
Data from NSW PIC demonstrates that many children are still accessing button batteries from a wide range of sources, including toys. We have serious concerns that the type of compartments in option (b) would not necessarily prevent young children from accessing button batteries.
NSW PIC data demonstrates that many children are able to access medicines from bottles with child-resistant lids which require two independent and simultaneous actions (ie: push down and twist) to open. Since January 2014, NSW PIC has received more than 6000 calls regarding children under the age of five years accessing paracetamol liquid from bottles with “child-resistant” lids.

Recommendation: Information must be available at point of sale (including on-line) indicating that the product (or any included peripheral device) requires button batteries to operate and that these are hazardous to young children.

NSW PIC agrees than information and warnings should always be included in the instruction leaflets and at the point of sale, however, we have concerns that instruction leaflets are often not read and that warnings at point of sale may not be seen by the end consumer of the product. We do not believe that warnings at point of sale are sufficient. Warning labels should also be clearly visible on the product and/or packaging.
Mandatory labelling of all products containing button batteries with the following statement or similar “ If you suspect your child has swallowed or inserted a button battery immediately call the 24-hour Poisons Information Centre on 13 11 26 for fast, expert advice ” would be our recommendation. Oesophageal impaction of button batteries can lead to severe injury in as little as two hours so prompt medical attention is imperative to prevent harm. A general warning label is not sufficient.

NSW Poisons Information Centre believes the following recommended safety actions should be mandatory:

Retailers should prioritise ‘range reviews’ of categories of goods powered by button batteries and eliminate items that do not comply with this Code. Stock audits should also be conducted to confirm that product ranges have been cleared of unsafe button-battery powered devices

Retailers can ensure they only procure button batteries and products containing button batteries that as a minimum meet the ‘essential requirements’ in this Industry Code by referencing it in their product specification documents, pre-shipment inspection protocols, design briefs, etc.

Manufacturers and down-stream suppliers of button battery-powered devices can reduce the risk of young children accessing batteries by carrying out suitable use and reasonably foreseeable misuse tests on the goods.

Packaging or instructions of products should be marked with a warning alerting consumers to the dangers of young children ingesting/inserting button batteries. “If you suspect your child has swallowed or inserted a button battery immediately call the 24-hour Poisons Information Centre on 13 11 26 for fast, expert advice ” is our recommended warning.

When offering button batteries for sale, retailers MUST select brands of batteries that are supplied in suitable child-resistant packaging and are marked with warnings alerting consumers to the hazards to young children.

Retailers should alert consumers to button battery hazards by offering clearly visible safety information at the points of display in stores. Shelf-ready unit displays for button batteries are one suggested vehicle for safety messaging.

The implementation of the above mandatory requirements would likely have an impact on Australian suppliers and retailers, however, we feel this is warranted given the significant risk of harm these products pose, particularly to young children.

A Poisons Information Centre (PIC)-led protocol to direct initial medical management of button battery exposures helps reduce delays and improve outcomes. NSW PIC calls ahead to local hospitals to ensure X-ray availability/diversion to a different hospital which results in reduced delays in treatment for this time-critical exposure. Oesophageal impaction of button batteries can lead to severe injury in as little as two hours so prompt medical attention is imperative to prevent harm.

The most effective way to reduce the number of injuries and fatalities caused by button batteries is to reduce the likelihood of accidental access by young children to button batteries in products and from packaging.
In NSW PIC study (November 2015- Oct 2018), batteries came from toys in 27% of cases, with hearing aids, watches, torches and remote controls being other common sources. Our calls in the period following this have also involved button batteries from a wide range of products, including toys. In some cases the source of the button battery was never identified. Given the prevalence of button batteries in a wide range of products a mandated safety standard across all battery compartments is necessary to reduce the number of accidental exposures involving young children.

NSW Poisons Information Centre believes that mandatory safety standards and information standards for child resistant packaging and labelling are essential to reduce the number of injuries and fatalities caused by button batteries.
Product labelling advising to call PIC immediately on 131126 following ANY suspected ingestion or insertion of a button battery is the most effective way to minimise harm. Without prompt medical attention severe injury may occur in as little as 2 hours.
NSW PIC study (November 2015- Oct 2018) identified inconsistent triage from a range of first responders, and knowledge gaps regarding button battery dangers amongst some healthcare professionals. Callers to NSW PIC are always advised to present immediately to hospital and NSW PIC calls ahead to local hospitals to ensure X-ray availability/diversion to a different hospital. This intervention results in reduced delays in treatment for this time-critical exposure.
Given their potential to cause serious corrosive injury if ingested or inserted NSW PIC considers button batteries should be treated the same as other “agents with potential to cause serious corrosive injury”. As per the Poisons Standard, these products are required to be labelled with advice to call the 24 hour PIC phone number 131126 following ingestion or other exposures.

NSW Poison Information Centre studies have shown ingested button batteries come from many sources. Whilst the larger diameter, higher voltage, lithium-type batteries are most often implicated in serious adverse outcomes, we feel that child resistant packaging and labelling requirements should be mandated on all button batteries to minimise the risk to consumers. Current NSW PIC practice is to refer ALL suspected ingestions of button batteries to hospital for an immediate X-ray regardless of the size or type of button battery. Calls to PIC show it is not always possible to determine the exact type or size of button battery ingested and in some cases the source of the button battery cannot be identified. No button battery, regardless of its size or voltage can be deemed to be totally risk-free if ingested or inserted.

NSW PIC feels that ALL consumer products which do NOT meet mandated safety standards (especially safety standards for the security of battery compartments) and information standards for child resistant packaging and labelling should be banned from supply in Australia to reduce the number of injuries and help prevent further fatalities caused by button batteries.

NSW Poisons Information Centre believes that mandatory safety standards and information standards for child resistant packaging and labelling are essential to reduce the number of injuries and fatalities caused by button batteries and we feel that an additional cost to suppliers / relevant supplier segment is warranted given the significant risk of harm these products pose, particularly to young children.

NSW PIC does NOT think any button battery products should be exempt from mandatory safety or information standards.
In NSW PIC study (November 2015- Oct 2018), batteries came from toys in 27% of cases, with hearing aids, watches, and remote controls being other common sources. Our calls in the period following this have also involved button batteries from a wide range of products, including toys. In some cases the source of the button battery was never identified. Given the prevalence of button batteries in a wide range of products NSW PIC believes a mandated safety standard across all button battery compartments is necessary to reduce the number of accidental exposures involving young children. Given their potential to cause serious harm if ingested or inserted NSW PIC considers button batteries should be treated the same as other “agents with potential to cause serious corrosive injury” which are all required to be labelled with advice to call the 24hour Poisons Information Centre phone number 131126 following ingestion or other exposures.