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South Australian Paediatric Clinical Practice Guidelines 

Ingested foreign bodies  
 (including button batteries) 

  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 
 
 Note: This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of 
published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the 
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and   
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape 
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this 
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in 
unison. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s). 

 Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe 
health care experience for Aboriginal children, young people and their families. 
Aboriginal children are born into strong kinship structures where roles and 
responsibilities are integral and woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide 
rates in the world.  The over representation of Aboriginal children and young 
people in out of home care and juvenile detention and justice system is intolerable. 
 
The accumulated effects of forced removal of Aboriginal children, poverty, 
exposure to violence, historical and transgenerational trauma, the ongoing effects 
of past and present systemic racism, culturally unsafe and discriminatory health 
services are all major contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making 
well informed clinical decisions based on cultural considerations. 

     



     Ingested Foreign Bodies (including button batteries) 
 

 

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Purpose and Scope  
The management of Ingested Foreign Bodies (including button batteries) Clinical Guideline is 
primarily aimed at medical staff working in any primary care, local, regional, general or tertiary 
hospitals. It may however assist the care provided by other clinicians such as nurses. The 
information is current at the time of publication and provides a minimum standard for the 
identification, assessment (including investigations) and management of ingestion of foreign 
bodies; it does not replace or remove clinical judgement or the professional care and duty 
necessary for each specific case. 

Flowchart - Management for Ingested Foreign Bodies 

High Risk

  Button batteries in the 
oesophagus

  Large object &gt; 6x 2.5cm
  Lead
  2 magnets, or magnet + metal
  Children with pre-existing GI 

abnormalities

Suspected FB ingestion

  High risk/unknown 
object

  Symptomatic
  Unreliable history

5ischarge with advice

Likely radio-opaque 
or unknown Likely radio-lucent

X-ray Symptomatic Asymptomatic

Seen Not seen Discuss with ENT, 
Paediatric surgical or 

Gastroenterology team

Stomach or beyond Oesophagus

Low Risk Object

Discharge with 
advice

High Risk Object

Referral to local 
Paediatric 

Gastrointestinal 
and Surgical 

service

Upper obstruction 
or button battery

Lower obstruction 
and low risk object

Urgent Paediatric 
ENT/Surgical 

referral

Observation/trial 
dislodgement. 

Discuss with local 
paediatric surgical 

service and 
consider 

observation/trial of 
dislodgement.

Yes No

 



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Table of Contents 

Definitions and Abbreviations .................................................................................................... 4 

Management Summary for Ingested Foreign Bodies ................................................................ 5 

Introduction .......................................................................................................................... 5 

Symptoms ............................................................................................................................. 5 

Assessment .......................................................................................................................... 5 

Management ......................................................................................................................... 6 

Complications ...................................................................................................................... 6 

Ward Management Considerations ........................................................................................... 7 

Airway ................................................................................................................................... 7 

Breathing .............................................................................................................................. 7 

Circulation ............................................................................................................................ 7 

Monitor for: ........................................................................................................................... 7 

Documentation ..................................................................................................................... 8 

Transfer and retrieval guidelines for Button Battery Impaction outside of WCH ....................... 8 

The SAFE approach to children with possible button batteries ingestions .................. 8 

The Problem .............................................................................................................................. 8 

Suspect possible button battery ingestions in children .............................................................. 9 

Assess all possible button battery ingestions with x-ray imaging as soon as possible ............. 9 

In general practice/rural and remote locations .......................................................................... 9 

Fast transport to the WCH ......................................................................................................... 9 

For acute witnessed ingestions ................................................................................................. 9 

For delayed presentations with battery impaction ..................................................................... 9 

Extract battery and evaluate the extent of injury ....................................................................... 9 

For delayed or occult button battery presentations ................................................................. 10 

References ............................................................................................................................... 10 

Acknowledgements .................................................................................................................. 10 

Document Ownership &amp; History ............................................................................................... 11 

 

 

 
 

 

 



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Definitions and Abbreviations  
ABC 
assessment 

Airway 
&gt; Check consciousness 
&gt; Assess ability to take a deep breath 
&gt; Assess ability to speak in a full sentence   can the patient speak a full 

sentences, just phrases, single words, or not at all 
&gt; Assess if the airway is clear 
Breathing 
&gt; Look, listen and feel for the movement of air 
&gt; Assess the adequacy of the breathing process   is their sufficient rate and 

volume of air being moved? 
&gt; Assess work of breathing (patient effort versus efficacy) 
&gt; Listen to the chest (through Auscultation) and identify any variances of 

normal breathing. Normal breathing should sound like soft air movements; 
absent breath sounds is very bad; wheezes suggest bronchospasm; 
crackles and rales indicate pulmonary oedema or infection. 

Circulation 
&gt; Examine for life- threatening haemorrhage 
&gt; Assess perfusion (level of consciousness, skin colour, pulse rate and 

blood pressure 
&gt; Assess the pulse manually   is it regular or irregular, what is the rate (15 

seconds x 4), skin colour, temperature, central and peripheral cap refill. 

ATS &gt; Australian Triage Scale 

ENT &gt; Ear, Nose and Throat 

FBC &gt; Fluid Balance Chart 

GI &gt; Gastrointestinal 

GIT &gt; Gastrointestinal tract 

WCH &gt; Women s and Children s Hospital  

  



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Management Summary for Ingested Foreign Bodies 
Introduction 

Ingestion of a foreign body by a child is a common presentation to primary care and 
emergency departments. Most foreign body ingestions are benign and require no specific 
management. However some foreign bodies such as disc batteries and magnets may cause 
life threatening injury and require urgent removal.  

The number of children presenting to heath facilities with a disc/button battery exposure is 
increasing.  Severe injuries and fatalities are particularly associated with oesophageal 
impaction of a button battery following ingestion.  A charged battery lodged in a moist 
environment produces a severe local caustic injury.  Even spent button batteries have enough 
residual charge to cause injury. 

The greatest risk of an ingested button battery becoming impacted and causing damage in 
the oesophagus is with 20mm 3V coin batteries in children less than five years of age as 
these are the most likely to lodge in the oesophagus due to their size and carry the highest 
charge. The time frame to oesophageal perforation from a new 3V battery can be as short as 
2 hours from the time of ingestion.  However, smaller batteries can also become impacted 
and risk factors include children under 12 months and those with pre-existing oesophageal 
conditions.  Damage following impaction continues after battery removal with delayed 
complications including trachea-oesophageal fistula, spinal erosion and fistulae into 
vessels/cardiac structures.   

Therefore a button battery impacted in the oesophagus of a child is a time critical emergency 
requiring both urgent battery extraction and aftercare in consultation with paediatric 
gastroenterology and general surgical service at the WCH. Batteries inserted into an orifice or 
situated in other areas of the digestive tract are less time critical but still require prompt 
assessment and specialist advice and follow up care.   

Symptoms 

Ingestion of a foreign body is not always witnessed, suspected by caregivers or disclosed by 
children. Symptoms of foreign body ingestion may be non-specific and may not occur for 
some time after ingestion. 

Key features that may suggest foreign body/disc battery ingestion include: 

&gt; Sudden onset of symptoms 

&gt; Choking, drooling and/or gagging 

&gt; Young children may point to the neck/throat as a site of pain  

Ingestion of a foreign body/disc battery should also be considered with the following clinical 
presentations: 

&gt; Persistent or atypical croup/cough/stridor 

&gt; Unexplained wheezing and respiratory distress 

&gt; Chest pain 

&gt; Unexplained gastrointestinal bleeding and /or abdominal pain 

&gt; Epistaxis 

&gt; Regurgitation or drooling 

&gt; Vomiting without fever and diarrhoea 

&gt; Unexplained food refusal or difficulty swallowing 

Assessment 

All children suspected of disc battery ingestion that present to an emergency department 
should be triaged at ATS priority 2 and seen by a medical officer within 10 minutes. 

An initial airway, breathing and circulation (ABC) assessment should occur looking for signs 
of airway obstruction, respiratory distress and shock followed by appropriate resuscitation. 



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The child should be kept fasting until the position and nature of foreign body is identified and 
a treatment plan is in place. 

The nature of the object ingested should be established. If the object is unknown, metallic or 
there is any suspicion of disc battery ingestion, an AP x-ray of the entire GI tract from nose to 
rectum should be performed. 

Management 

If single or multiple metallic foreign bodies are discovered on history or X-ray, the possibility of 
disc battery or magnets must be considered.  

All multiple magnet ingestions must be referred for paediatric general surgery and 
gastroenterology review as urgent removal is indicated. 

There is emerging evidence that honey may reduce the severity of mucosal injury for 
oesophageal impacted batteries. It should be administered from time of first contact as 
first aid measure until battery removal.   10ml every 10 minutes is recommended 

The Poisons Information Service is available for advice at any stage on 131126. 

Specialist advice should be sought for all symptomatic foreign body ingestions and high risk 
objects including oesophageal batteries, large objects, lead and magnets as per flowchart.  

Although it is rare for pointed objects to puncture the gut mucosa these ingestions should be 
discussed with the on call WCH paediatric surgeon.  

If the battery is located in the stomach it would be expected to pass through the remainder of 
the GIT. However a child &lt; 6 years who has swallowed a battery more than 15mm in 
diameter will require follow up x-rays.  If the battery has not passed from the stomach by 48 
hours it is unlikely to do so.  Endoscopic removal should be considered 

Parents and care givers should be counselled to return promptly for re-assessment if 
symptoms of abdominal pain, gastrointestinal bleeding or fever develop.  

Complications 

Complications from disc battery ingestion are rare but potentially severe and life threatening. 
These include 

Tracheo-oesophageal fistula 

Vocal cord paralysis 

Oesophageal stenosis 

Mediastinitis 

Spondylodiscitis 

Aspiration pneumonia 

Vascular perforation 

Gastric haemorrhage 

Gastric and intestinal perforation 

If there is evidence of mucosal injury at endoscopy these complications should be observed 
for and investigated accordingly. 

  



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Magnet ingestion is also associated with a risk of severe injury particularly where multiple 
magnets have been ingested. Enteroenteric fistula, peritonitis and bowel ischaemia/necrosis 
have all been described.  

Risk factors for adverse outcomes include: 

Disc battery &gt; 20 mm 

Age &lt; 4 years 

Ingestion of multiple batteries 

Unwitnessed ingestions 

Misdiagnosis or delayed diagnosis 

Delay in removal  

Co-ingestion of a magnet 

Ward Management Considerations 
Patient needs to be monitored for signs of complications with foreign body ingestion.  Key 
signs and symptoms to monitor include: 

Any of the following signs / symptoms MUST to be escalated  
URGENTLY as per hospital policy / procedure 

Airway 

&gt; Persistent or atypical croup/cough/stridor 

&gt; Regurgitation or drooling 

&gt; Choking and/or gagging 

Breathing 

&gt; Unexplained wheezing and/or respiratory distress 

&gt; Shortness of breath 

Circulation 

&gt; Hematemesis 

&gt; Melena 

&gt; Gastrointestinal bleeding 

&gt; Epistaxis 

Monitor for: 

&gt; Uncontrolled abdominal pain 

&gt; Persistent vomiting (observe for clots and fresh blood) 

&gt; Fever 

&gt; Young children may point to the neck/throat as a site of pain  

&gt; Chest pain 

&gt; Unexplained food refusal or difficulty swallowing. 

  



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Documentation 

Use the following description and/or codes for documenting blood loss on unit specific Fluid 
Balance Chart. 

 

 

 

 

 

 

 

 

 

Transfer and retrieval guidelines for Button Battery Impaction 
outside of WCH 
The SAFE approach to children with possible button batteries ingestions 

Suspect possible button battery ingestions in children.   

Assess all possible button battery ingestions with urgent neck to bottom x-ray imaging. 

Fast transport of the child with an impacted oesophageal button battery directly to an 
appropriate extraction centre 

Extract battery as a surgical emergency 

This plan has been developed in response to the 2015 Coronial recommendations following 
the death of a four year old girl who ingested a 20mm battery unbeknownst to her parents.  
The battery lodged in her oesophagus and she died days later due to haemorrhage from an 
aorto-oesophageal fistula.   

The Problem 
The problems associated with the geography of the state are complicated by limitations in X-
ray availability to make the diagnosis of button battery ingestion in rural and remote areas. 

In addition button battery presentations in children fall into two groups: 

1) Acute/Obvious presentations:  Child is brought to hospital or their GP by a parent 
from a witness, or suspected, button battery ingestion within 24 hours of the event. 
 

2) Delayed/Occult presentations:  Child is brought to hospital or their GP by a parent 
with non-specific symptoms related to an impacted battery with the parents being 
unaware of the risk following ingestion or unaware that ingestion has taken place at 
all.   

The management and transport priorities are different for the two groups of children. 

At any time, advice and assistance with possible button ingestions/insertions can be obtained 
from: 

  MedSTAR kids retrieval service 13 STAR (137827) 
  Poisons Information on 131126 
  Women s and Children s Hospital PED or Gastroenterology service or 

paediatric general surgical service 81617000 

OUTPUT DESCRIPTION 

Urine 
  Pale red/Rose 
  Bright red 
  Clots visible  

  
  
 

Vomit 
  Dark red 
  Bright red 
  Clots visible 
  Flecks / streaks red 

 

Stool 
  Dark red 
  Bright red 
  Clots visible 
  Black 

 



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Suspect possible button battery ingestions in children 
Concern from a child s parents about possible button battery ingestion should be taken 
seriously and investigated urgently with x-ray imaging from neck to bottom.  If there is no local 
x-ray availability MedSTAR kids retrieval service 13 STAR (137827) will be able to assist by 
facilitating transport of the child, to the most appropriate site that can perform an x-ray to 
confirm or exclude a button battery ingestion or insertion.  

Children with unknown battery ingestions are at the highest risk of vascular and cardio-
respiratory complications at or after extraction, because batteries may have been lodged for 
days to weeks.  In these situations parents of children with non-specific symptoms are likely 
to present with their children directly to their GP, or the Emergency Department.  

Features of occult ingestion can be non-specific. See page 5. 

Assess all possible button battery ingestions with x-ray imaging as 
soon as possible  
Where there is a battery impacted in the oesophagus MedSTAR can facilitate discussion with 
the paediatric gastroenterologist and surgeon on call at WCH and arrange urgent transfer for 
extraction.  

Batteries inserted into orifices should be discussed with the relevant speciality service at 
WCH.  

In general practice/rural and remote locations 
For GPs in Adelaide and surrounds discuss the case with the WCH paediatric general 
surgery, gastroenterology unit and/or PED and send the child directly to the WCH Paediatric 
Emergency Department for urgent x-ray imaging.   

In rural and remote areas contact MedSTAR for assistance in getting the child to the nearest 
facility that can urgently perform x-ray imaging.  If the button battery is not impacted in the 
oesophagus further advice can be obtained from the paediatric general surgery on call about 
the child s management. 

Fast transport to the WCH 
Children with a button battery lodged in the neck or oesophagus require urgent transport to 
the WCH.   

For acute witnessed ingestions with battery impaction less than 24 hours 
duration, transfer should be arranged with the South Australian Ambulance 
Service/MedSTAR Kids retrieval service.  

For delayed presentations with battery impaction  
Management will need to be determined by discussion with the Paediatric general surgery or 
Gastroenterology Service at WCH.  

Extract battery and evaluate the extent of injury 
Children with button battery impactions are taken immediately to the theatre for removal of the 
battery.  Ongoing consultation with the paediatric general surgery and gastroenterology 
service at WCH can facilitate disposition and follow up care.  Caustic damage can persist with 
late catastrophic events occurring days to weeks after battery removal and injury may not be 
evident on the initial endoscopy. 



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For delayed or occult button battery presentations the presence of any 
GIT bleeding, may represent a  herald bleed  (a small haemorrhage that precedes a 
catastrophic haemorrhage) and may indicate a possible aorto-oesphageal fistula.  Removing 
the battery in this context may precipitate uncontrollable bleeding. In cases where there is 
potential bleeding from an aorto-oesphageal fistula, the transport and best site for initial and 
ongoing management will need to be determined by discussion with the Paediatric 
Gastroenterology/Surgery Service at WCH through MedSTAR. 

References 
1. Kramer R, et al Management of Ingested Foreign Bodies in Children A Clinical 

Report of the NASPGHAN Endoscopy Committee Journal of Pediatric 
Gastroenterology and Nutrition 2015;60:562-574 

2. Jayachandra S, Eslick G A systematic review of paediatric foreign body ingestion: 
Presentation, Complications and Management. International Journal of Pediatric 
Otorhinolaryngology 2013;77:311-317 

3. Anfang RR et al pH-neutralizing Esophageal Irrigations as a Novel Mitigation 
Strategy for Button Battery Injury. Laryngoscope, 2018,Jun 11 

Acknowledgements 
The South Australian Child and Adolescent Health Community of Practice gratefully 
acknowledge the contribution of clinicians and other stakeholders who participated throughout 
the guideline development process particularly:  

Write Group Lead 
Dr Malcolm Higgins 

Other major contributors 
Dr Rebecca Cooksey 
Alexandra Manna 
Dr David Moore 
 
SAPCPG Reference Group Members 
Dr Gavin Wheaton 
Dr Malcolm Higgins 
Dr Brett Ritchie 
Dr Brian Coppin 
Dr John Craven 
Dr Noha Soliman 
Dr David Thomas 
Dr Keiko Morioka 
Dr Gillian Watterson  
Dr Shirley Sthavan 
Carol La Vanda 
Carey Aylmer 
Rachael Sobczak 
Susan Cameron 
  



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Document Ownership &amp; History 
Developed by: SA Child &amp; Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 
Endorsed by: SA Safety and Quality Strategic Governance Committee 
Next review due:  05/04/2023   
ISBN number:  978-1-74243-903-7 
PDS reference:  CG311 
Policy history: Is this a new policy (V1)?  Y 
 Does this policy amend or update and existing policy?   N 
 If so, which version? 
 Does this policy replace another policy with a different title?  N 
 If so, which policy (title)?  
 

Approval 
Date Version 

Who approved 
New/Revised Version Reason for Change 

05/04/2019 V1 
SA Health Safety &amp; Quality 
Strategic Governance 
Committee 

Original CAHCOP approved version 

 



	Definitions and Abbreviations
	Management Summary for Ingested Foreign Bodies
	Introduction
	Symptoms
	Assessment
	Management
	Complications

	Ward Management Considerations
	Airway
	Breathing
	Circulation
	Monitor for:
	Documentation

	Transfer and retrieval guidelines for Button Battery Impaction outside of WCH
	The SAFE approach to children with possible button batteries ingestions

	The Problem
	Suspect possible button battery ingestions in children
	Assess all possible button battery ingestions with x-ray imaging as soon as possible
	In general practice/rural and remote locations
	Fast transport to the WCH
	For acute witnessed ingestions with battery impaction less than 24 hours duration, transfer should be arranged with the South Australian Ambulance Service/MedSTAR Kids retrieval service.
	For delayed presentations with battery impaction
	Extract battery and evaluate the extent of injury
	For delayed or occult button battery presentations the presence of any GIT bleeding, may represent a  herald bleed  (a small haemorrhage that precedes a catastrophic haemorrhage) and may indicate a possible aorto-oesphageal fistula.  Removing the batt...
	References
	Acknowledgements
	Document Ownership &amp; History

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