NHS England: Neonatal choking hazard from colostrum syringe caps (26 January 2026)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

The National Patient Safety Team were notified by a trust Medical Device Safety Officer (MDSO) of an incident where a baby ingested the cap off a purple colostrum syringe. The baby was being fed expressed colostrum by the parent who was unaware of the presence of the cap when the feed started . Colostrum is the first breast milk the mother produces providing important nutritional benefits for newborns.

When pressure was placed on the syringe plunger accidental cap dislodgement occurred and the baby required surgery to remove the cap. Despite the purple colour, the syringe was not licenced for the administration of colostrum.

Collaboration with the MHRA resulted in the issuing of a device safety information alert. Working with key midwifery and neonatal stakeholders, a safety communication on reducing the risk of choking was issued to maternity and neonatal units.

When advised of the safety issue, the manufacturer ceased production of the syringe and have introduced a new licenced colostrum collection and administration syringe. The new syringe does not have a cap and is available to order from the NHS Supply Chain.  This intervention should reduce the risk of accidental ingestion of syringe caps.