See “Commentary: Button Batteries in Fidget Spinners: Is It Time to Push the “Panic Button”?” by Bousvaros and Rufo on page 557.
What Is Known
- Complications from button battery ingestions are increasing in the United States.
- The fidget spinner is a relatively new popular toy commonly sold without warning labels regarding potential hazards including those related to button batteries.
What Is New
- We report 2 cases of esophageal injury following button battery-powered fidget spinner ingestion, which to our knowledge has not yet been reported. Ingestion of any part of this toy warrants prompt medical evaluation to evaluate for button battery ingestion until proven otherwise. Unique aspects to ingestion of fidget spinner components are highlighted.
Fidget spinners emerged on the market in early 2017 and became rapidly popular. Initial marketing targeted children with attention deficit hyperactivity disorder; however, these gadgets have drawn the interest of children across wide age ranges, without attention disorders. They are now sold at many venues, often without product warning labels on the packaging advising parents about potential hazards. Fidget spinners may or may not have light sources powered by button batteries. Isolated injuries related to use and misuse have started to surface, leading the US Consumer Product Safety Commission (CPSC) to recently issue formal public safety tips related to its use (1). To our knowledge, injury following button battery ingestion (BBI) from a lighted fidget spinner has not yet been reported.
Complicated BBIs in the United States due to lithium-based batteries are rising at an alarming rate causing significant harm (2–6). When lodged in the esophagus, lithium button batteries may cause caustic injury secondary to release of hydroxide radicals (2). Moreover, full-thickness injury has been reported in as little as 15 minutes (7). Prior publications outline injuries reported secondary to BBI including tracheoesophageal fistulas, esophageal perforations and strictures, vocal cord paralysis and aortoenteric fistulas (AEFs), an acquired high blood flow connection between the aorta and bowel lumen (6) the latter carrying a high risk of mortality.
With the advent of fidget spinners on the commercial market, it is not surprising that manufacturers are incorporating lithium ion batteries into this product. Without proper attention to securing the batteries in this product intended for use by children, a clear and present danger has, however, emerged.
We report on 2 cases of children ingesting a lithium button battery from a lighted fidget spinner, leading to severe morbidity.
A 4-year-old girl with no significant medical history was brought to a local community emergency room immediately after her parents recognized she had swallowed a plastic disc that had dislodged from a fidget spinner toy. She had been mouthing and chewing on the plastic disc for a short period before accidentally swallowing it. The plastic disc housed a 12-mm lithium button battery powering a light-emitting diode (LED) light source. She was initially asymptomatic and a chest x-ray identified the foreign body in the mid esophagus including the button battery (Fig. 1). On the anteroposterior view radiograph (Fig. 1A), a faint halo-sign can be identified, obscured by the other LED components. A portion of the “step-off” sign is better appreciated on the lateral view radiograph (Fig. 1B). The patient was then emergently transported to Cohen Children's Medical Center of New York approximately 3 hours after the initial ingestion and vomited en route, expelling the object. In our emergency room, repeat x-rays of the neck, chest, and abdomen did not show any foreign body. At this point, the patient began to complain of chest pain and refused oral intake. The following morning, about 12 hours post-ingestion, she underwent an upper endoscopy identifying 2 deep ulcerations with black eschar formation in the mid esophagus. A nasogastric tube was placed and she was admitted to the hospital for further medical management. On hospital day (HD) 3, a magnetic resonance imaging (MRI) study of the chest was obtained, demonstrating adequate space between the esophagus and aorta without inflammation encroaching on any large vascular structure. Moderate-sized bilateral pleural effusions were identified, believed to be secondary to the inflammatory injury. The patient was not in respiratory distress related to the effusions. An esophagram with water-soluble contrast was performed to rule out esophageal leak; no evidence of perforation or stricture was found. She was then permitted to start an oral diet, and liquid sucralfate was added due to pain with eating. She was discharged on HD 5 tolerating oral liquids and a soft mechanical diet. Repeat esophagram several weeks after the initial injury was normal.
A previously healthy 3-year-old boy presented locally with chest pain, coughing, gagging and increased oral secretions along with a report of unwitnessed coin ingestion. Chest and abdominal radiographs revealed a disc-shaped metallic object with a double halo, consistent with a 21-mm button battery in the mid thoracic esophagus. Of note, the patient's father reported that he discovered a broken light-up fidget spinner with a missing button battery in the home.
The patient was emergently transferred 36 miles to Children's Hospital Colorado for further management. Endoscopic removal was performed by pediatric surgery approximately 7 hours following the estimated time of ingestion. Rigid esophagoscopy revealed a food impaction proximal to the foreign body. The food was removed using a grasper and the battery was extracted using alligator forceps. The esophagus was then inspected and demonstrated moderate-to-severe esophagitis with circumferential erosions spanning 2 to 3 cm at the BBI site.
The patient was then extubated and recovered in the pediatric intensive care unit. He was made Nil Per Os (NPO) and a Blakemore tube with a manometer and associated equipment remained at his bedside throughout the hospitalization. Staff was retrained to use this potentially life-saving device. On HD 2, an esophagram revealed minimal smooth narrowing at the mid thoracic esophagus with no evidence of a leak. The patient was given a clear liquid diet and advanced to a soft diet. On HD 3, the patient was transferred out of the pediatric intensive care unit. MRI and magnetic resonance angiography (MRA) of the chest revealed mucosal thickening, irregularity, and ulceration involving the mid esophagus at the level of the carina with inflammatory change into the mediastinum, in direct contiguity with the descending aorta (Fig. 2). Therefore, the patient was made NPO again and on HD 5, the patient had an 8-French nasogastric tube placed under fluoroscopy for initiation of transesophageal enteral feeds. Images obtained revealed persistent esophageal narrowing as previously visualized on esophagram.
Repeat MRI/MRA on HD 11, again showed enhancement extending circumferentially around three-quarters of the descending thoracic aorta. No evidence of narrowing or pseudoaneurysm was visualized. The patient remained NPO with transesophageal feeds following the study as findings were again concerning for AEF formation. A third MRI/MRA was obtained on HD 18 to reassess the risk of AEF and aid with management decisions (5). This revealed a decrease in the degree of edema and enhancement surrounding the aorta though there was persistent circumferential peri-esophageal inflammation (Fig. 2). Subsequent upper endoscopy revealed no evidence of ongoing injury. The patient was then started on a soft mechanical diet, which he tolerated well and was discharged on HD 20 on full oral feeds.
Both of the cases described in this report illustrate how quickly and significantly the injury to esophageal and adjacent mediastinal structures can occur. In case 1, moderate size pleural effusions developed from the inflammatory milieu and in case 2, encroaching inflammation on the aortic space ultimately required nearly 3 weeks of hospitalization before minimal risk of an AEF could be determined and safety of oral feedings could be established. To our knowledge, these are the first 2 reports of BBI from a fidget spinner. With the emergence of these popular gadgets, pediatric specialists are likely to see increases in BBI's, as well as ingestions of non-powered fidget spinner parts. Providers are tasked with raising awareness among families of the dangers of BBI and of their ubiquitous presence in seemingly harmless gadgets, such as fidget spinners. It is also important for providers to recognize their critical role in reporting such cases to the CPSC (8) and cases involving BBI to the National Battery Ingestion Hotline (US phone number 202-625-3333). It is especially important to bring attention to newer toys and products, such as fidget spinners, that have limited public danger awareness.
Clinicians should be alerted to the signs and symptoms of dangerous BBI. Unexplained cough and/or upper gastrointestinal bleeding in a toddler should increase suspicion for an unwitnessed foreign body ingestion and consideration of a chest x-ray. Prompt recognition of BBI and activation of a multidisciplinary team is the key to proper management. The Endoscopy committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition has published guidelines to help providers manage foreign bodies, such as BBI, in children. Per these guidelines, extreme caution should be maintained with BBI's (6), both in the immediate phase and for up to several weeks, as fatal AEF has been observed >20 days after removal. The population at the greatest risk is patients <5 years, and those who ingest batteries ≥20 mm in diameter (2,6)
There are several aspects of BBI within a fidget spinner disc that require unique attention. First, a child brought to medical attention reporting ingestion of a fidget spinner disc does not immediately inform the clinician on the inherent danger, as the patient or parent may not be aware if the disc contains a battery and the clinician may incorrectly believe the risk of the plastic disc ingestion is similar to other inert blunt objects; a disc from this toy should be presumed to contain a button battery until proven otherwise. Second, the plastic shell surrounding the battery does not assure protection from caustic injury, as evident in case 1. The clinician must treat an ingestion of this object with the same immediate urgency as a free BBI. The plastic shell can be easily damaged and exposure of the battery to secretions within the esophagus or direct contact with esophageal tissue will invariably lead to caustic injury. Third, as case 2 illustrates, serial MRI examinations may be useful in assessing ongoing risk of AEF and need for conservative management. Finally, the hallmark “halo” and “step-off” radiographic signs may be partially obscured by the other radiopaque elements surrounding the battery. The battery is secured within a metal casing and the other LED components may further distort the crisp distinction between positive and negative battery poles.
In addition to dangers related to the battery components, there have been other concerns regarding fidget spinners raised in the lay press recently. Some fidget spinners have been removed from stores due to concerns over lead content in specific models. There have been other reports of the devices catching fire when being charged. In addition, the CPSC has reported that some have pieces have been found to be a choking hazard (1).
Ingestion of any part of a fidget spinner can be potentially dangerous, and life threatening if it contains a button battery. Similar to high-powered magnet ingestions, the pediatric community has an opportunity to partner with the CPSC to protect children from emerging ingestion hazards through establishing new product-related safety standards or recalls if necessary. As the battery industry attempts to develop safer alternatives to lithium button batteries, such as the green cell proposed by Rossi et al (9), the toy industry should strive to better secure battery compartments in their products.
2. Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics
3. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics
4. National Capital Poison Center. 2017. Available at: http://www.poison.org/battery
. Accessed November 2017.
5. Leinwand K, Brumbaugh DE, Kramer RE. Button battery ingestion
in children: a paradigm for management of severe pediatric foreign body ingestions. Gastrointest Endosc Clin N Am
6. Kramer RE, Lerner DG, Lin T, et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr
7. Tanaka J, Yamashita M, Yamashita M, et al. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol
8. Robinson MS. A public health and data crisis you can help solve: CPSC's Critical Need for NASPGHAN's Data. J Pediatr Gastroenterol Nutr
9. Rossi A, Vignola S, Nason F, et al. Safe energy source in battery operated toys for children. J Pediatr Gastroenterol Nutr