key: cord-0731556-zg5coodz
authors: Sethia, Rishabh; Gibbs, Hannah; Jacobs, Ian N.; Reilly, James S.; Rhoades, Keith; Jatana, Kris R.
title: Current management of button battery injuries
date: 2021-04-15
journal: Laryngoscope Investig Otolaryngol
DOI: 10.1002/lio2.535
sha: a2e2e38f12e86eb7d593cd3ce32066f31c9bfc5c
doc_id: 731556
cord_uid: zg5coodz

Button batteries (BB) are found in common household items and can lead to significant morbidity and mortality in the pediatric population when ingested. BBs are made of various chemistries and have a unique size and shape that yield significant injury when lodged in the pediatric esophagus. BBs create a local tissue pH environment of 10 to 13 and can induce liquefactive necrosis at the negative pole. This initial injury can progress with further tissue breakdown even after removal. Unfortunately, patients may present with vague symptoms similar to viral illnesses and there is not always a known history of ingestion. Plain film X‐ray can be diagnostic. Exposure can lead to caustic injury within 2 hours. Thus, timely endoscopic removal is the mainstay of treatment. Novel mitigation and neutralization strategies have been implemented into treatment guidelines. These include the preremoval ingestion of honey or sucralfate and intraoperative irrigation with acetic acid. Depending on the severity of injury following removal, careful consideration should be given for potential delayed complications including fistulization into major vessels which often leads to death. The National Button Battery Taskforce and several industry members have implemented prevention strategies such as educational safety outreach campaigns, child‐resistant packaging changes, and warning labels. Governmental regulation and industry changes are key to limit not only the amount of BB ingestions, but also the devastating consequences that can result. Anonymous reporting of BB injuries through the Global Injury Research Collaborative has been made convenient and centralized through the advent of a user‐friendly smartphone iOS/App Store and Android/GooglePlay application called the “GIRC App”; all specialists who manage foreign body cases should contribute their cases to help prevent future injuries. BB ingestion must be recognized and treated promptly using a multidisciplinary approach to optimize outcomes for these patients. Ultimately, a safer BB technology is critically needed to reduce or eliminate the severe and life‐threatening injuries in children. LEVEL OF EVIDENCE: 5

Button battery (BB) ingestion is an important topic of concern for many medical professionals who may commonly encounter these patients in practice. Although a majority of ingestions occur in the pediatric population, an extensive analysis of over 8000 patients revealed approximately 1600 adult ingestions from 1990 to 2008. 1 Therefore, current review of this topic is relevant to both pediatric and adult health care professionals. The provider must quickly recognize and appropriately manage BB aspiration, ingestion, or insertion to prevent severe complications that may arise as a result of prolonged exposure. In addition, providers should be aware of the latest additions to the treatment guidelines including mitigation and neutralization strategies based on the latest available data. Smaller BBs can also be inserted into the nasal cavity, ear canal, or aspirated into the tracheobronchial tree which can lead to morbidities such as nasal septal or tympanic membrane perforations and airway obstruction issues.

In addition, severe esophageal injuries and death have been reported with both lithium and non-lithium BB. This topic has also been presented in detail for emergency medicine providers. 2 For the purposes of this review, we will focus on the most relevant current management information for those medical professionals who manage these cases. This article provides an overview on BB ingestion, aspiration, and insertion, summarizes the latest management guidelines, and discusses the latest innovations in BB injury prevention.

BBs trace their history to as early as 1945, when Ruben and Mallory who founded the original company that eventually went on to become Duracell invented the zinc-mercuric oxide alkaline buttontype cell. 3 As BBs were introduced into mainstream culture over the next several decades, more and more BB injuries were noted prompting a need for systematic tracking and guidance. In 1982, the National Battery Ingestion Hotline (NBIH) was formed through the National Capital Poison Center (NCPC) as a 24/7 hotline. Health care providers or the public with suspected BB injuries are able to call 1-800-498-8666 for assistance. The data that has been collected and published since its inception has informed clinical triage, treatment algorithms, and prevention strategies. In 2018, the NBIH was eventually transitioned to the Rocky Mountain Poison Center. BB injury statistics and treatment algorithms can be found at www.poison.org/ battery. 4 In 1983, a year after formation of the NBIH, the U.S. Consumer Product Safety Commission (CPSC) issued a warning on BBs. 5 After several decades of extensive BB injury, outcomes data collection and analysis by the NBIH and NCPC, 4, 6 and publication of a comprehensive review of over 8000 cases in the journal Pediatrics, 1 a group of physicians presented the concerning information on BB injuries to the CPSC in March 2011. 7 Just a few months later in June, S. 1165, the Button Cell Battery Safety Act of 2011 was introduced to the U.S. Senate. This legislation aimed to enforce BB industry safety standards by mandating child-resistant packaging and consumer warnings with CPSC regulation. 8 The legislation was not enacted by Congress despite in-person lobbying efforts by multiple pediatric otolaryngologists. In 2012, the Centers for Disease Control published an extensive report highlighting a 2.5-fold increase in battery-related injuries in children <13 years old from 1995 to 2010, citing over 20 000 children treated in Emergency Departments (EDs) for BB injuries. 9 Also in 2012, the National Button Battery Task Force (BBTF) was formed through the American Academy of Pediatrics (AAP) and the American Broncho-Esophagological Association with the following mission statement 10 :

A collaborative effort of representatives from relevant organizations in industry, medicine, public health, and government to develop, coordinate, and implement strategies to reduce the incidence of button battery injuries in children.

Importantly, the BBTF has for several years employed a multidisciplinary approach to education, research collaboration, data collection and analysis, management algorithms and practice guideline development and dissemination, governmental advocacy, industry standard development, and hazard elimination which has resulted in numerous meaningful changes to minimize the risk of BB ingestion injuries. The work completed by the BBTF has also resulted in several national and international awards. 11, 12 A central tenet of the BBTF is that consumers including parents and childcare providers must be aware of the hazard to help with primary prevention of the injuries.

BBs are disc-shaped metallic objects with similar appearance to coins and can become lodged in the pediatric esophagus leading to significant injury given their unique size, shape, and chemical properties F I G U R E 1 As shown, button batteries can vary significantly in shape, size, chemistry, and voltage (1.5-3 V). Reproduced with permission from K. R. Jatana ( Figure 1 ). 11 The most commonly ingested lithium BB imprint code is the CR 2032. 11 "CR" refers to the chemical identification for lithium/ manganese dioxide and "2032" refers to a diameter of 20 mm and a thickness of 3.2 mm. Lithium is popular due to its ability to store 3 V, long shelf life, and largest capacitance relative to size. 13, 14 As a result, the 20-mm diameter lithium BB has become increasingly prevalent in the marketplace. When this battery is ingested, the size of the BB can predispose to esophageal impaction and the effects of lithium can lead to significant caustic injury to surrounding tissues and serious complications. Thus, there has been an increase in severity of BB ingestion injuries thought to be related to this spike in lithium, larger diameter BBs. 1, 11, 15 Other common BB chemistries include alkaline, zinc air, and silver oxide. Smaller diameter, lower voltage, and nonlithium BBs can also contribute to similar types of severe injury and death, 16, 17 but at a slightly slower rate. 15, 18 Diameter is not absolute, as even new smaller lithium 12.5-mm BBs have been lodged in the esophagus of an otherwise healthy 2.5-year-old girl with no underlying esophageal pathology. 19 1.3 | BBs: Where are they found?

BBs are found in a wide range of common household electronic devices which poses a risk of BB injury to many children with access to these items. In a large retrospective analysis of over 8000 battery ingestion cases from the NBIH data, the most common intended use of ingested batteries was hearing aid or cochlear implant at 36.3% followed by game/toy, watch, calculator, flashlight or other similar small light source, remote control, and key chain. Although rare, even unexpected items such as toothbrush, lighted shoe, bookmark, and thermometer have been implicated in BB ingestion. 1 Table 1 22 Importantly, this population appears to be especially vulnerable to more severe complications. 15 Figure 2 summarizes national data on moderate, major, or fatal outcomes associated with BB ingestion.

Data from the U.S. National Electronic Injury Surveillance System analyzed from 1990 to 2009 have shown an increasing incidence of ED visits related to BB ingestions, reporting a child may present to the ED with a BB every 3 hours. 23 This trend has also been shown in analysis of French ED visits from 1999 to 2015. 24 With increasing incidence of BB ingestion, especially in the young population, an increase in morbidity and severe mortality is expected. Numerous reports have confirmed increasing incidence of the severity of BB ingestions. 9, 15, 24 This is likely attributed to an increase in more technologically advanced electronics in the household over the past two decades combined with the increase in production of the larger-diameter, 3-V lithium batteries in the marketplace. 11, 15, 25 According to the NCPC large retrospective study, an alarming 12.6% of children younger than 6 years who ingested a 20-mm diameter lithium BB developed a major complication such as esophageal perforation or stricture, tracheoesophageal fistula, fistulization into major vessels, vocal cord paresis and paralysis, or spondylodiscitis. 1 Since 1977, there have been at least 65 fatalities associated with BB ingestion. All of the reported fatalities occurred in patients ≤4 years of age. 26 Younger children are at greatest risk given smaller size of the pediatric esophagus trapping FBs as they explore new objects with their mouths which can lead to devastating consequences. Especially concerning is that 56.2% of the major outcome cases associated with BB injuries were unwitnessed. 15 In addition, the prevalence of these injuries is very likely to be underreported. 27, 28 Therefore, review of the epidemiologic data highlights the importance of BB ingestion as an increasingly important and severe topic in health care, especially in the pediatric population. 5-9. 30 This was mostly related to battery ingestion but also cases of insertion into the ear or nose. This is quite concerning and demonstrates that this age group is also at risk.

The esophagus contains anatomically narrowed regions more likely to harbor BB impaction, most commonly at the level of the thoracic inlet. 31 Although new BBs are 3.2 times more likely to produce a clinically significant outcome of tissue damage than used BBs, any BB with a residual charge of at least 1.2 V has the ability to cause tissue damage. 11 Thus, even "dead" or "spent" BB unable to power electronics have enough retained capacitance to cause significant injury. A multitude of factors contribute to BB damage including the duration and location of the impaction, the size, orientation, and voltage of the BB, the size of the esophagus, and any potential underlying esophageal pathology of the patient. 32 Previous theories have posited that BB tissue damage occurs secondary to pressure injury, leakage of toxic contents, and electrolysis of water. However, studies have consistently shown that the primary mechanism of tissue injury is the electrolysis and production of hydroxide ions. 18 lemon, and orange juice demonstrated limited tissue damage to various degrees. 18 Then, using both in vitro cadaveric and in vivo porcine models, piglets were randomized to receive 10 mL of honey, sucralfate (Carafate), or saline 10 minutes after BB placement in the esophagus and every 10 minutes thereafter. Honey is a palatable, viscous weak acid found in most households and sucralfate is a cherryflavored weakly acidic suspension with mucosal protective effects found in hospitals as it is used to treat ulcers. The honey and sucralfate appeared to form a physical barrier between the BB and surrounding tissue, neutralized the esophageal tissue, and reduced esophageal burns. One week after ingestion, half of the saline control group developed esophageal perforations whereas none of the piglets treated with honey and sucralfate developed perforations. 35 Irrigation of the alkaline tissue with 50 to 150 mL of 0.25% sterile acetic acid after BB removal was proposed to prevent delayed injury. A recent study using a cadaveric goat model also found a statistically significant reduction in mucosal injury with the application of honey compared with BBs alone. Progression of the injury was further diminished with the application of acetic acid after BB removal. 36 Despite a longstanding belief that neutralization causes thermal injury and thus should be avoided, porcine and goat experiments demonstrated minimal increase in esophageal temperature (0 C-3 C) and no thermal injury. 35, 36 This neutralization strategy was then applied clinically in a series of six pediatric patients who received 0.25% sterile acetic acid irrigation following BB removal. All patients were reported to have improved mucosal appearance, and none developed esophageal perforation or stricture. This positive outcome was thought to be secondary to immediate pH neutralization and prevention of alkaline-induced liquefactive necrosis 19 As a result of these experiments, recent changes to the NCPC treatment algorithm guidelines were made. 37 In one notable case, a 15-month-old boy ingested two 3-V lithium

BBs that became lodged in the upper esophagus. The authors describe a "macaroon sign" on radiographic imaging with the two BBs parallel to one another with positive poles facing each other. The negative poles were thus facing outwards toward the esophageal tissue creating a circumferential injury. Eight hours after ingestion, the BBs were removed endoscopically and 100 mL of 0.25% acetic acid was used to neutralize the tissue. The patient subsequently recovered with a significantly better clinical outcome than predicted without development of stricture which the authors attribute to neutralization. 38 2 | CLINICAL CONSIDERATIONS

When BB ingestion is known, it is important to obtain a thorough history including information regarding battery type, charge state, number of batteries ingested, time of ingestion, magnet co-ingestion, and any history of esophageal pathology or previous surgery. Unfortunately, many BB ingestions are unwitnessed and this information is unknown. 15 Furthermore, symptoms associated with BB ingestions are often vague and present similarly to common viral respiratory or gastrointestinal illnesses. 39, 40 Finally, a majority of severe outcomes occur with unwitnessed ingestion and patients are often asymptomatic until a complication occurs. 24, 41 Thus, the clinician is often presented with a challenging scenario and must rely on astute clinical investigation and radiographic imaging to obtain the diagnosis.

The frequency of symptoms appears to vary by study, with one study reporting that the most common symptoms associated with BB ingestion are dysphagia, fever, and cough 40 and another reporting vomiting, difficulty feeding, and cough. 39 Infants and toddlers may also present with irritability, anorexia, dyspnea, and drooling, whereas older children may be able to localize symptoms such as throat, chest, or abdominal pain or may be able to give FB ingestion history. 40 imaging is an essential tool in the prompt diagnosis of BB ingestion given that BB ingestions are often unwitnessed and present with vague symptoms. If there is a known BB ingestion, X-ray should be obtained in all patients except those who are greater than 12 years old, asymptomatic, and the BB is known to be smaller than 12 mm. 37 Chest XR with both anterior-posterior (AP) and lateral views should be obtained immediately in all other patients with suspected or known BB ingestion to determine if present and the anatomic location. As BBs are round, opaque FBs with a similar radiographic appearance to coins, providers should use magnification to "zoom in" and assess for the classic "double ring" or "halo" sign in the AP view and "step-off" in the lateral view ( Figure 4 ). 46 Notably, the AP view is most reliable as some slimmer BBs on lateral view do not have a classic "step-off" appearance, or the film may not be precisely perpendicular to the plane of the BB. 11 The negative pole yields the most severe tissue damage and thus, identifying its orientation can be important to predict which structures are at risk for injury and development of complications. The 3N's is a simple mnemonic that has been proposed to remind clinicians where to anticipate the most damage, "Negative-Narrow-Necrotic" (Figure 5) referring to the negative BB pole orientation identified as the narrowest side on lateral chest XR causes the most severe necrotic injury. 11 

It is important to predict, promptly detect, and treat potential severe complications that may be associated with BB ingestions. Reported complications include esophageal stenosis or perforation, mediastinitis, tracheoesophageal fistula (Figure 7) , vocal cord paresis and paralysis, Fatalities related to gastric BBs are exceedingly rare, and likely related to esophageal injury in transit. 57 As discussed, symptoms of BB ingestion are nonspecific and can easily be attributed to viral or bacterial infections. Unfortunately, several patients with BB ingestion-related fatalities were initially misdiagnosed. 26 Reported symptoms that could indicate development of severe complications in addition to those mentioned earlier include hematemesis, melena, sialorrhea, stridor, and aphasia. 24 In addition, several factors have been shown to predict long-term complications of BB ingestion; these include the esophageal location and orientation of the BB negative pole, the anatomic location of the most severe esophageal injury, the estimated duration of impaction, and the properties of the specific battery. 58 Clinicians should utilize these predictive factors to stratify their management and follow-up plans.

The latest NCPC guidelines for BB ingestion can be reviewed at:

www.poison.org/battery/guideline. 37 Recent additions regarding preremoval mitigation and intraoperative neutralization strategies have been added to the guidelines to reflect the most updated literature supporting their use. 18, 19, 35 

As with any pediatric FB case, the patient must first be stabilized Pre-removal At home and during transport: 10 mL (two teaspoons) honey every 10 min until arrive at hospital. Avoid honey in children <1-year-old. In hospital or clinical setting: 10 mL (two teaspoons) sucralfate (Carafate) every 10 min until BB removal can occur. This can be initiated even before X-ray confirmation for witnessed or highly suspected ingestions. Up to six doses in prehospital setting and three additional doses in clinical setting are recommended by National Capital Poison Center (NCPC) guidelines; providers should use clinical judgment for giving additional doses if going to be further delay (ie, prolonged transport to a different facility). Warning: These are mitigation strategies and not a substitute for prompt esophageal BB removal.

Esophageal BB is an acute surgical emergency, proceed to operating room regardless of nil per os (NPO) status. Anesthesia: Rapid sequence induction. Endoscopic approach with direct visualization is preferred with either flexible or rigid esophagoscopy. Consider direct laryngoscopy and bronchoscopy to evaluate for laryngotracheal airway injury (existing or developing tracheaesophageal fistula), especially in cases where negative pole faces anterior direction (BB step-off anterior). Consider general potential acute complications such as esophageal perforation, tracheoesophageal fistula, vocal cord paresis or paralysis, proximity to major vascular structures (arterial fistula). If no visible esophageal perforation exists, perform endoscopic irrigation of site of tissue injury using 50-150 mL of 0.25% sterile acetic acid while simultaneously suctioning excess irrigation. If suspect perforation or severe circumferential injury present, consider nasogastric tube placement while in the operating room (OR).

Remember tissue injury may progress after BB removal. Consider esophagram to rule out perforation prior to starting oral intake. Consider contrast imaging of chest (MRI, CTA) if severe injury exists and to assess for proximity to major vascular structures (i.e. aorta, etc) Monitor for potential delayed complications: esophageal perforation, tracheoesophageal fistula, aortoesophageal fistula, vocal cord paresis or paralysis, mediastinitis, spondylodiscitis or esophageal stricture. These BB complications can sometimes present days to weeks later. Consider need for serial imaging, endoscopy, or stool guaiac tests. multidisciplinary approach is often required and involving the appropriate teams early is critical.

If lithium BB ingestion is known or suspected within the prior 12 hours and the child is ≥12 months, 10 mL (2 teaspoons) of commercial honey should be given by mouth (PO) every 10 minutes immediately and en route to the ED for up to 6 doses. Alternatively, sucralfate (Carafate suspension, 1 g/10 mL) can be administered with the same dosing and frequency. These efforts can start after arrival until XR can be obtained. An additional three doses can be given from the time of XR confirmation of BB lodged in esophagus until sedation is given for endoscopy. Children <12 months of age should not be administered honey or sucralfate. These strategies should be avoided if the BB was in place for over 12 hours as the risk of esophageal perforation increases after this time period. 51 Transportation to the ED should not be delayed to give honey. 37 

BB removal should occur without delay to minimize tissue damage and potential complications. Standard NPO guidelines should not be followed as the risk of ongoing BB esophageal injury is thought to significantly outweigh the risk of pulmonary aspiration. Rapid sequence induction and intubation are recommended. 32 Patients can also be stratified into severe, intermediate, or low risk based on age, BB size, location of BB impaction, symptoms, and history of esophageal pathology. This risk stratification should determine the specialization of the OR, availability of specialists, intraoperative monitoring, and postoperative level of care. 60 Blood product administration should be available if needed based on clinical concern. The anesthesia guidelines have been updated to accommodate the latest NCPC guidelines. 32 When evidence of significant hematemesis or hemoptysis is present preoperatively, early involvement of cardio-thoracic surgery and cardiopulmonary bypass/ECMO (extracorporeal membrane oxygenation) team may be life-saving. In these cases, doing the BB removal in a specialized cardiac OR setting with all relevant teams immediately available is an important consideration. 

If the BB is found to be lodged in the esophagus, immediate removal is warranted. If the BB is found to be in the stomach or beyond and a magnet was co-ingested, removal should be performed endoscopically ideally and if required, surgically. Certain patients with gastric BB or beyond may be observed if they are asymptomatic, >6 years of age, and the BB was <15 mm. Symptomatic patients or those with BBs that remain in the stomach 4 days postingestion should undergo removal. Ultimately, the decision requires evaluation in a case-by-case basis taking into account ingestion timing and risk factor stratification (potential for in-transit esophageal injury that needs to be endoscopically assessed), such as in higher-risk patients ≤5 years of age or with BB size ≥20 mm. 32 

BB aspiration leading to airway FBs should be emergently removed using direct laryngoscopy and bronchoscopy in the OR. Preremoval mitigation strategies do not apply to airway BBs.

If mucosal injury was present following BB removal from the esophagus, patients must be observed for delayed complications such as tracheoesophageal fistula, esophageal stricture or perforation, mediastinitis, vocal cord paralysis, tracheal stenosis or tracheomalacia, empyema, lung abscess, pneumothorax, spondylodiscitis, or exsanguination from large vessel fistula. A contrast esophagram can be obtained to rule out perforation. Based on severity and location of the injury, as well as battery position and orientation, and using previously reported predictive factors, 58 BBTF organized a national "Day of Action" during which medical professionals used the hashtag #ButtonUpBatteries to unify and share BB information on social media. These platforms allow for rapid and widespread dissemination of knowledge to the public and to health professionals who may care for these patients. In addition, members of National BBTF have attended numerous society meetings and conferences to educate medical professionals on this topic. 11 

To improve ease, access, and detail associated with reporting FB cases, a nonprofit 501(c)(3), Global Injury Research Collaborative (GIRC, www.globalirc.org), provides free access to injury reporting apps designed for medical professionals. In the App Store and GooglePlay as "GIRC App" can be used by various health care team members to efficiently collect pertinent FB injury information ( Figure 9 ). In a recent survey administered to 400+ physicians who managed over 32 000 pediatric FB injuries, only 11% of BB and 4% of overall FB injury cases were reported to an existing data source. In addition, 92% of respondents stated they would contribute more to injury statistics if it were more convenient, thus highlighting the need for better reporting mechanisms. 27 With the "GIRC App," a more modern, user-friendly method of reporting is now accessible for free download via the App Store and Google Play. Reporting includes FB picture, dimensions, location, hazard severity, and patient follow-up and should take medical professionals less than 2 minutes to enter relevant injury data. This unique combination of data are not captured through other injury databases anywhere in the world. Trainees, including residents and fellows can participate in this effort. Since no personal health information is requested, the information is Health Insurance Portability and Accountability Act (HIPAA) compliant and submitted reports are deidentified from user. 63 

Major BB industrial companies such as Energizer and Duracell have implemented several modifications to minimize the risk of BB injury in children. For example, they have added child-resistant double packaging which requires use of scissors to remove the initial packing layer as well as warning label stickers to keep BBs away from children. [64] [65] [66] More recently, Duracell has released three lithium BBs (CR2016, CR2025, CR2032) with a nontoxic bitter coating designed to try to help prevent accidental ingestions in children. 66, 67 This is an application of a taste deterrent on the BB that, to our knowledge, has not been previously reported in the medical literature. As younger children are often most vulnerable to severe complications, taste aversion provides a possible prevention tool. However, it is still unknown what injury prevention impact this will have on BB ingestions given bitterants have not always prevented ingestion of other hazards. 68 71 In 2017, the U.S. CPSC enacted a mandatory standard by updating ASTM F963-17, the standard consumer safety specification for toy safety to include use of warning labels and instructions informing consumers of BB risks for BB-requiring toys intended for F I G U R E 9 The Global Injury Research Collaborative smartphone application ("GIRC App") provides an efficient, secure way for providers to report their foreign body injury cases (www.globalirc. org). This centralized database can help to prevent future injuries. It is available for no charge to medical professionals, both on the App Store (iOS) and GooglePlay (Android). Search "GIRC App," download, and register to start reporting injuries children <14 years old as well as new testing requirements. 72 Unfortunately, these "child-resistant" standards do not extend to the many other BB-containing household items that pose a significant risk for injury to children.

Despite lobbying efforts by several pediatric otolaryngologists and members of the National BBTF, legislation that would have provided regulations for the BB industry failed to be enacted in 2012. 8 Today, medical professionals on the National BBTF continue to encourage lawmakers to reconsider formal legislation to minimize BB injuries.

All providers who care for these patients are well-suited to play a key role in the lobby process and opportunities are continually available to participate; these medical specialists can be advocates for injury prevention by reporting each BB injury case they see to the GIRC App.

Primary prevention of BB injuries by modifying the BB design to be safer would prove most effective in eliminating the BB ingestion hazard. Studies have shown that quantum tunneling composite-coated batteries conduct energy in high pressure powered electronics but not in low pressure settings such as the pediatric esophagus. This can prevent the hydrolysis reaction and subsequent liquefactive tissue necrosis. 73 Introduction of this coating provided a promising foundation for manufacturers to explore and adopt BB design alteration to try to prevent injuries. Landsdowne Labs LLC (https://www. landsdownelabs.com) is a leader in this space, dedicated to innovating a safer BB design to reduce the hazard severity with its ChildLok TM technology. The development of a novel BB design that reduces or eliminates the severe injuries seen in children is critical for a long-term solution.

Other potential opportunities for BB injury prevention include the development of similar standards for nonlithium as exist for lithium BB.

Active warning labels on all products that contain BBs, child-resistant packaging for products. A salivary amylase-activated dye coating could stain the lips and mouth with a designated color. Appearance of this color could prompt caregivers to seek emergent medical evaluation and could minimize duration of exposure. 11 

BBs are commonly found in many household items and present a severe risk of injury to children upon ingestion. When lodged in the esophagus, BBs induce an alkaline reaction in as little as 2 hours that can lead to caustic injury. The mechanism is related to liquefactive necrosis and can occur even after removal resulting in delayed, severe morbidity and mortality. Diagnosis is challenging as BB ingestion is often unwitnessed and patients present with vague symptoms. Treatment involves prompt endoscopic removal. Mitigation strategies with pre-removal use of honey and sucralfate and intraoperative use of acetic acid irrigations are new additions to the management guidelines aimed at neutralizing the pH and preventing propagation of tissue damage. Numerous prevention efforts have been implemented to minimize BB injury and are continually ongoing. It is important that medical professionals who manage these cases consistently report the relevant details of these injuries. Ultimately, reduction in esophageal BB hazard severity through innovation can help prevent morbidity and mortality in children.

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