See “Button Battery Powered Fidget Spinners: A Potentially Deadly New Ingestion Hazard for Children” by Khalaf et al on page 595; See “Fidget Spinners Can Be a Pain in the Neck” by McClain et al on page e110 and See “Fidget Spinner Ingestion” by Tipnis and Ciecierega on page e111.
No matter how hard parents try, it is almost impossible to completely prevent children from harming themselves. Children can trip down stairs, choke on a piece of food, put foreign objects up their nose, or get hit by a car while riding their bicycle. In the modern era, public health interventions have, however, been implemented to improve child safety. Sometimes, this involves developing a safety feature, such as a seat belt, infant seat, bike helmet, or “childproof cap” on medications. Other times, however, limiting consumer access to unsafe products can reduce morbidity and mortality in children. Three such products that have been limited or banned by federal or state agencies include firecrackers, heavy metal “lawn darts,” and most recently high-powered neodymium magnets. The ban on neodymium magnets was the result of targeted focus of a strong effort by North American Society for Pediatric Gastroenteroloy, Hepatalogy, and Nutrition (NASPGHAN) and the American Academy of Pediatrics to prevent ingestion of these products that led to endoscopies, bowel damage, and intestinal surgeries in hundreds of children in the United States and across the world (1,2). Recent evidence shows that the magnet recall has reduced the number of patients coming to emergency departments for magnet ingestions, though pediatric gastroenterologists continue to be called emergently to remove these objects (3).
For every hazard that is reduced however, another hazard may enter the marketplace. The important series of papers in this month's Journal of Pediatric Gastroenterology and Nutrition describe cases of button battery ingestion, where the button battery was hidden inside a “fidget spinner” that was broken open by a child, and the battery swallowed (4–6). Children underwent emergent evaluation and were found to have significant esophageal or gastric ulceration that required endoscopy, imaging, and medical management. Fortunately, the most feared complications of button battery ingestion (esophageal perforation or aorto esophageal fistula) did not occur with any of these children. As is well known, button battery ingestion can, however, lead to these life-threatening complications. According to the authors, these “fidget spinners” did not have any warning label that they contained button batteries, nor did they discuss the potential life-threatening complications of battery ingestion. Having an unlabeled button battery in a toy or product that children can handle and break poses a potential danger to children.
Which should a pediatrician or other provider do when faced with such a hazard to children? A provider who simply treats the individual child and ignores advocating on a public health level is doing our community a dis-service. This is one clear area where public advocacy can be beneficial. The first step an physician in the United States should take when coming across such a hazard is to notify the United States Consumer Product Safety Commission at their website (www.cpsc.gov) by clicking on the link on the right side of the screen: “report an unsafe product.” Details on the ingestion can then be provided to the regulatory agency. This is the primary tool through which the Commission identifies potential hazards. It is unlikely that the commission will react if a single case is noted. Multiple cases will, however, often get their attention, as we learned from the high-powered magnet advocacy effort of a few years ago. In addition, we would suggest contacting your local NASPGHAN counselor or advocacy committee member because our NASPGHAN advocate often meets with other groups that may be central to the effort, including the Consumers Union and the American Academy of Pediatrics.
Once a regulatory authority is notified of a potential hazard, they have a number of options. The first option is to take no action. If they do not believe that the product is truly unsafe or if the product is not widespread, they may decide no action is warranted. The second option is to require the manufacturer to issue warnings. The problem with warnings is that they are often not read, particularly by toddlers or young children. Warnings may come in fine print and on packages that are quickly discarded. While some parents may read warnings that are on packaging, others may not even open the package themselves, or a parent may not read English well. A third action a regulatory agency may take is to force product redesign, such as the case with “childproof caps.” Button batteries for the most part now come in packages that are difficult to open except by an adult. The fourth option for a regulatory agency, and the most challenging, is to issue a recall or a ban on the product. Such a task is difficult, as it may sometimes mean that a manufacturer is financially penalized and can no longer make the product. To ban a product, an agency needs to prove that the product is not only hazardous, but also is utilized largely by children as a toy and serves no other useful purpose. With respect to button batteries, even though they do cause childhood injury, the public has decided that the benefit of having button batteries available for cameras and watches far exceeds the rare though severe risks when children ingest them
In summary, the articles in Journal of this issue describe another potential hazard for children who ingest foreign bodies. Assuming more cases like this will be forthcoming, at some point in time, the regulatory authorities will most likely request that at a minimum fidget spinners with button batteries be labeled. In the meantime, in toddlers that present with a history of unexplained sudden abdominal or chest pain, the physician should inquire if any fidget spinners are in the home. In the appropriate patient, evaluation for button battery ingestion with plain film should be considered, and emergent endoscopy should be performed as indicated.
1. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr
2. Bousvaros A, Bonta C, Gilger M, et al. Advocating for child health: how the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition took action against high-powered magnets. J Pediatr
3. Rosenfield D, Strickland M, Hepburn CM. After the recall: reexamining multiple magnet ingestion at a large pediatric hospital. J Pediatr
4. Khalaf RT, Gurevich Y, Marwan AI, et al. Button battery powered fidget spinners: a potentially deadly new ingestion hazard for children. J Pediatr Gastroenterol Nutr
5. McClain A, Jackson DW, Robson J. Fidget spinners can be a pain in the neck. J Pediatr Gastroenterol Nutr
6. Tipnis NA, Ciecierega T. Fidget spinner ingestion. J Pediatr Gastroenterol Nutr