NHS England and NHS Improvement Patient Safety have received information on the risk of ‘twist off caps’ from oral sucrose vials inadvertently falling into infants’ mouths causing a choking hazard.

The trigger incident reads:

Baby had been admitted with bronchiolitis. Baby was being treated for the condition but was showing a gradual slow deterioration and a decision was made to transfer them to resus for intubation. As procedure was commencing on inspection of the oropharynx a plastic object was visible. The object was removed prior to intubation and it was noted that it appeared to be the cap off a sucrose vial.

Oral sucrose is a mild analgesic which is effective in decreasing short-term pain and distress during minor procedures. Small amounts of sweet solutions (oral sucrose) are placed on the infant's tongue to reduce procedural pain.

A brief presentation about this incident can be downloaded below. For any questions about this please contact Becky Wilson-Crellin.

Download the Presentation

British Association of Perinatal Medicine (BAPM) is registered in England & Wales under charity number 285357 at 5-11 Theobalds Road, London, WC1X 8SH.
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