To describe the epidemiology of battery-related emergency department (ED) visits among children aged <18 years in the United States from 2010 to 2019 and compare with previous study findings.
Data on ED visits were obtained from the National Electronic Injury Surveillance System. Using narrative descriptions and diagnosis codes, battery-related cases were coded into four exposure routes: (1) ingestion, (2) mouth exposure, (3) ear insertion, and (4) nasal insertion.
An estimated 70 322 (95% confidence interval: 51 275–89 369) battery-related ED visits among children aged <18 years occurred during the study period, or 9.5 per 100 000 children annually. Button batteries were implicated in 84.7% of visits where battery type was described. A statistically significant increase in the ED visit rate occurred from 2010 to 2017 (P = .03), followed by a nonstatistically significant decrease from 2017 to 2019. The ED visit rate was highest among children aged ≤5 years compared with those 6 to 17 years (24.5 and 2.2 per 100 000 children, respectively). The mean patient age was 3.2 years (95% confidence interval: 2.9–3.4). Ingestions accounted for 90.0% of ED visits, followed by nasal insertions (5.7%), ear insertions (2.5%), and mouth exposures (1.8%).
Pediatric battery-related ED visit rates continued to significantly increase from 2010 to 2017, with children aged ≤5 years having the highest rates. Prevention efforts have not significantly reduced injury rates; therefore, regulatory efforts are needed. Ultimately, hazard reduction or elimination through safer button battery design is critical and should be adopted by the battery industry.
Button batteries are a potential source of serious injury among children, especially when ingested. If lodged in the esophagus, devasting injury can result within hours. Previous studies suggest that button battery ingestions among children aged ≤5 years are increasing.
An estimated 7032 battery-related emergency department visits occurred annually among children aged <18 years from 2010 to 2019, more than twice the number reported from 1990 to 2009. The visit rate demonstrated a statistically significant increase from 2010 to 2017.
In 2019, foreign body ingestion (FBI) was the fourth leading cause for calls to poison control centers for children aged 5 years and younger in the United States.1 Young children use their senses to explore their environments and often put objects into their mouths, ear canals, or nasal passages.2,3 As toddlers become increasingly mobile and curious, their risk of FBI increases.4,5
Previous studies have identified batteries, when ingested, as important sources of serious injury and death among young children.5–14 Button batteries (BBs) are small, disc-shaped cells used to power an increasing number of consumer electronic devices found in the home, including toys, digital watches, hearing aids, and remote controls. BBs are often easy to remove from such devices and can lead to devastating injury in as little as 2 hours after ingestion.10,13,15 Although larger lithium cells (≥20-mm diameters) present greater risks of lodging in the esophagus,13,15,16 smaller 1.5 voltage, nonlithium BBs can also cause severe or life-threatening esophageal injuries, especially for children aged <1 year.14,17 The electrical current generated by the BB in contact with tissue leads to rapid hydrolysis of water into hydroxide ions (highly alkaline pH) and resultant liquefactive necrosis. Unfortunately, liquefactive necrosis can progress even after the BB is removed, leading to delayed complications.18 Nasal BB insertion can also cause complications including nasal septal perforation and periorbital cellulitis, and ear canal insertion can lead to tympanic membrane perforation, hearing loss, and facial nerve paralysis.10
In the United States, batteries are among the most common sources of FBI that result in children presenting to emergency departments (EDs), with BBs being the most frequently implicated battery type.5,10,12,15,19–23 Children aged ≤5 years are at greatest risk, with a peak incidence among 1- and 2-year-olds.10,12,15,19,24,25 A 2012 study by Sharpe et al reported a statistically significant increase in both the number and rate of battery-related ED visits among children aged <18 years from 1990 to 2009, particularly during the last 8 years of the study. Three-fourths of injuries resulted from battery ingestion, and the remainder from ear, mouth, and nasal insertion. BBs were implicated in 84% of cases where battery type was known.12 The objectives of the current study were to:
describe the epidemiology of battery-related ED visits among children aged <18 years from 2010 to 2019 and the extent to which ingestions were involved; and
compare the results to those previously found by Sharpe et al.
Methods
Data Source
Data on battery-related ED visits among children aged <18 years occurring from January 1, 2010, to December 31, 2019, were obtained from the National Electronic Injury Surveillance System (NEISS).26 Operated by the US Consumer Product Safety Commission (CPSC), NEISS is a sentinel surveillance system that uses a stratified probability-based sample of ∼100 US hospitals. Statistical weights are applied to produce national estimates of consumer product-related injuries presenting to EDs. The NEISS includes data on patients’ demographics, injury diagnoses, affected body parts, disposition, and consumer products involved. A brief narrative field is included, providing further circumstantial information for each case.
Variables and Case Selection
ED visits involving battery exposures were identified using the NEISS product code 884 (batteries).27 Cases were categorized into ≤5 years and 6 to 17 years of age. Patient disposition codes were dichotomized as hospitalized (admitted and treated and transferred) and not hospitalized (treated and released, held for observation, or left without being seen). Case narratives were reviewed to categorize 3 battery types:
cylindrical (included those described as “cylindrical,” “AA,” and “AAA”);
BB (included those described as “button,” “disc,” “flat,” “round,” and “circular”); and
unknown (not documented or insufficient detail).
Body part and diagnosis codes were used in conjunction with case narratives to categorize 4 exposure routes: (1) ingestion, (2) mouth exposure, (3) nasal insertion, and (4) ear insertion. Cases not involving exposure to internal areas of the body were excluded. Further, because of small sample size, national estimates for 12 cases involving insertion into the vagina or rectum could not be calculated and were therefore excluded from the study. Mouth exposures were limited to cases in which the battery resulted in chemical burns in the mouth. Ingestions were limited to cases in which the battery was swallowed intact. Cases categorized as ingestion were further subcategorized as “suspected ingestion” or “confirmed ingestion.”
There were 2868 unweighted cases identified for the study period. Excluded from the study were cases where the battery was not swallowed intact (n = 47) and cases where the battery was in the mouth but did not result in chemical burns (n = 36), resulting in a final sample of 2785 unweighted cases.
Statistical Analysis
Data were analyzed by using Stata 14.2 statistical software. National estimates were calculated using CPSC-provided statistical weights. The CPSC considers a national estimate to be unstable and potentially unreliable when: (a) the estimate is <1200, (b) the unweighted number of cases is <20, or (c) the coefficient of variation exceeds 33%. Estimates not meeting these stability requirements were noted as such in results tables. Data from the US Census Bureau were used to calculate population-based rates.28 Statistical analyses included the calculation of relative risks with 95% confidence intervals (CIs). Simple or piecewise linear regression was performed, as appropriate, to evaluate the statistical significance of secular trends using α = 0.05. This study was determined exempt from review by the institutional review board at Children’s National Hospital.
Results
There were 70 322 battery-related ED visits among children aged <18 years from 2010 to 2019, for an annual average of 7032 per year, or 9.5 visits per 100 000 children (Table 1). The ED visit rate was highest among children aged ≤5 years compared with children aged 6 to 17 years (24.5 and 2.2 per 100 000, respectively [mean age: 3.2 years, 95% CI: 2.93–3.42, median: 2 years]). Most patients (n = 59 218, 84.2%) were aged ≤5 years and more than half (n = 40 311, 57.4%) were male. One-year-olds had the greatest number of battery-related ED visits of any other single year of age (n = 19 226, 27.3%) (Fig 1).
Estimated number of battery-related ED visits among children aged <18 years by age, United States, 2010–2019.
Estimated number of battery-related ED visits among children aged <18 years by age, United States, 2010–2019.
Demographic Characteristics of Children <18 Years Presenting to US Emergency Departments for Battery-Related Exposures, Present Study Period (2010–2019) and Previous Study Period (1990–2009)
| Present Study (2010–2019) | Sharpe et al Study (1990–2009)12 | |||||
|---|---|---|---|---|---|---|
| Characteristic | Actual Sample | National Estimate (%)a | Estimated 95% CI | Rate per 100 000 Children | National Estimate (%) | Rate per 100 000 Children |
| Total | 2785 | 70 322 (100.0) | 51 275–89 369 | 9.5 | 65 788 (100.0) | 4.6 |
| Age, y | ||||||
| ≤5 | 2322 | 59 218 (84.2) | 42 657–75 779 | 24.5 | 51 618 (78.5) | 10.8 |
| 6–17 | 463 | 11 104 (15.8) | 8080–14 127 | 2.2 | 14 170 (21.5) | 1.5 |
| Sex | ||||||
| Male | 1633 | 40 331 (57.4) | 29 200–51 462 | 10.7 | 39 517 (60.2) | 5.4 |
| Female | 1152 | 29 991 (42.7) | 21 641–38 341 | 8.3 | 26 156 (39.8) | 3.8 |
| Present Study (2010–2019) | Sharpe et al Study (1990–2009)12 | |||||
|---|---|---|---|---|---|---|
| Characteristic | Actual Sample | National Estimate (%)a | Estimated 95% CI | Rate per 100 000 Children | National Estimate (%) | Rate per 100 000 Children |
| Total | 2785 | 70 322 (100.0) | 51 275–89 369 | 9.5 | 65 788 (100.0) | 4.6 |
| Age, y | ||||||
| ≤5 | 2322 | 59 218 (84.2) | 42 657–75 779 | 24.5 | 51 618 (78.5) | 10.8 |
| 6–17 | 463 | 11 104 (15.8) | 8080–14 127 | 2.2 | 14 170 (21.5) | 1.5 |
| Sex | ||||||
| Male | 1633 | 40 331 (57.4) | 29 200–51 462 | 10.7 | 39 517 (60.2) | 5.4 |
| Female | 1152 | 29 991 (42.7) | 21 641–38 341 | 8.3 | 26 156 (39.8) | 3.8 |
Column percentages may not sum to 100.0% due to rounding.
From 2010 to 2017, the rate of battery-related ED visits per 100 000 children increased significantly among both those aged <18 years (7.0–14.3, respectively; P = .03) and ≤5 years (16.8–38.4, respectively; P = .03), followed by a nonsignificant decrease among both age groups from 2017 to 2019 (14.3–8.7, P = .28, and 38.4–22.8, P = .27, respectively) (Fig 2). There was also a nonsignificant decrease among both age groups from 2013 to 2015 (9.7–6.9, P = .31, and 25.7–17.4, P = .31, respectively). The rate among children aged 6 to 17 years remained relatively unchanged during the study period and was the same in 2010 as in 2019 (2.0 per 100 000 children).
Annual rate of battery-related ED visits among children aged <18 years old by age group and year, United States, 2010–2019.
Annual rate of battery-related ED visits among children aged <18 years old by age group and year, United States, 2010–2019.
Among all patients, 12.0% (n = 8410) were hospitalized (Table 2). Patients aged 6 to 17 years were 1.65 times (95% CI: 1.58–1.73) more likely to be hospitalized than patients aged ≤5 years. Of cases where battery type was described (n = 48 642, 69.2% of cases), most involved BBs (n = 41 175, 84.7%). Of cases where the battery’s intended use was described (n = 25 880, 36.8% of cases), the most frequently were watches (n = 7696, 29.7%) and toys/games (n = 7458, 28.8%), followed by hearing aids (n = 2679, 10.4%), remote controls (n = 2524, 9.8%), flashlights (n = 1653, 6.4%), and all other product types (n = 3870, 14.9%).
Disposition, Battery Exposure Route, and Battery Type Involved Among Children <18 Years of Age Presenting to US Emergency Departments for Battery-Related Exposures, Comparing 2010–2019 and 1990–2009
| Characteristic | Actual Sample 2010–2019 | National Estimate 2010–2019 | Estimated 95% CI 2010–2019 | % National Estimatea | National Estimate Percentage Point Change 1990–200912 to 2010–2019 | |
|---|---|---|---|---|---|---|
| 2010–2019 | 1990–200912 | |||||
| Dispositionb | ||||||
| Not hospitalized | 2394 | 61 911 | 45 113–78 710 | 88.0 | 92.6 | −4.6 |
| Hospitalized | 391 | 8410 | 5725–11 095 | 12.0 | 7.3 | 4.7 |
| Exposure route | ||||||
| Ingestion | 2482 | 63 281 | 45 916–80 646 | 90.0 | 76.6 | 13.4 |
| Nasal insertion | 185 | 4006 | 2741–5272 | 5.7 | 10.2 | −4.5 |
| Ear insertion | 82 | 1738 | 1078–2398 | 2.5 | 5.7 | −3.2 |
| Mouth exposure | 36 | 1297 | 453–2141 | 1.8 | 7.5 | −5.7 |
| Battery typec | ||||||
| Button | 1714 | 41 175 | 27 864–54 486 | 84.7 | 83.8 | 0.9 |
| Cylindrical | 283 | 7467 | 5340–9594 | 15.4 | 16.2 | −0.8 |
| Characteristic | Actual Sample 2010–2019 | National Estimate 2010–2019 | Estimated 95% CI 2010–2019 | % National Estimatea | National Estimate Percentage Point Change 1990–200912 to 2010–2019 | |
|---|---|---|---|---|---|---|
| 2010–2019 | 1990–200912 | |||||
| Dispositionb | ||||||
| Not hospitalized | 2394 | 61 911 | 45 113–78 710 | 88.0 | 92.6 | −4.6 |
| Hospitalized | 391 | 8410 | 5725–11 095 | 12.0 | 7.3 | 4.7 |
| Exposure route | ||||||
| Ingestion | 2482 | 63 281 | 45 916–80 646 | 90.0 | 76.6 | 13.4 |
| Nasal insertion | 185 | 4006 | 2741–5272 | 5.7 | 10.2 | −4.5 |
| Ear insertion | 82 | 1738 | 1078–2398 | 2.5 | 5.7 | −3.2 |
| Mouth exposure | 36 | 1297 | 453–2141 | 1.8 | 7.5 | −5.7 |
| Battery typec | ||||||
| Button | 1714 | 41 175 | 27 864–54 486 | 84.7 | 83.8 | 0.9 |
| Cylindrical | 283 | 7467 | 5340–9594 | 15.4 | 16.2 | −0.8 |
Column percentages may not sum to 100.0% due to rounding.
For comparison purposes, “admitted” and “transferred to another hospital” disposition categories reported by Sharpe et al were grouped in the current study as “hospitalized,” and “treated and released,” and “other” were grouped as “not hospitalized.”
Battery type could not be determined for 30.8% (n = 21 680) of estimated cases in the current study and 35.2% (n = 23 133) of estimated cases in Sharpe et al.
Exposure Routes
Among all patients, ingestions were the most frequent exposure route (n = 63 281, 90.0% [mean age: 3.0, 95% CI: 2.8–3.2; median: 2]), followed by nasal insertion (n = 4006, 5.7% [mean age: 3.5, 95% CI: 3.1–3.9, median: 3]), ear insertion (n = 1738, 2.5% [mean age: 7.2, 95% CI: 6.1–8.2, median: 6]), and mouth exposure (n = 1297, 1.8% [mean age: 5.2, 95% CI: 3.7–6.7, median: 4]). Ear insertion was the only exposure route for which patients aged 6 to 17 years predominated (n = 1118, 64.3% of ear insertions), and this age group was 9.62 times (95% CI: 8.74–10.59) more likely to present with an ear insertion than patients aged ≤5 years.
Table 3 displays the characteristics of ingestion cases compared with all other exposure routes combined. Patients in both the ingestion and noningestion groups were predominately aged ≤5 years (n = 53 800, 85.0%, and n = 5418, 77.0%, respectively) and male (n = 36 003, 56.9%, and n = 4328, 61.5%, respectively). There was no change in the proportion of patients who were hospitalized when comparing ingestion to noningestion cases.
Demographic Characteristics, Treatment Disposition, and Battery Type Involved Among Children <18 Years of Age Presenting to US Emergency Departments for Battery-Related Exposures, Ingestion Versus All Other Exposure Routes, 2010–2019
| Ingestion | All Other Exposure Routes | |||||
|---|---|---|---|---|---|---|
| Characteristic | Actual Sample | National Estimate (%) | Estimated 95% CI | Actual Sample | National Estimate (%) | Estimated 95% CI |
| Total | 2482 | 63 281 (100.0) | 45 916–80 646 | 303 | 7041 (100.0) | 4947–9134 |
| Age, y | ||||||
| ≤5 | 2082 | 53 800 (85.0) | 38 530–69 070 | 240 | 5418 (77.0) | 3775–7061 |
| 6–17 | 400 | 9481 (15.0) | 6919–12 043 | 63 | 1623 (23.0) | 890–2355 |
| Sex | ||||||
| Male | 1438 | 36 003 (56.9) | 25 696–46310 | 195 | 4328 (61.5) | 3005–5651 |
| Female | 1044 | 27 278 (43.1) | 19 717–34 840 | 108 | 2713 (38.5) | 1657–3768 |
| Disposition | ||||||
| Not hospitalized | 2132 | 55 724 (88.0) | 40 435–71 014 | 262 | 6187 (88.0) | 4247–8128 |
| Hospitalized | 350 | 7557 (12.0) | 4998–10 115 | 41 | 854a (12.0) | 472–1235 |
| Battery typeb | ||||||
| Button | 1532 | 37 109 (84.5) | 24 759–49 459 | 182 | 4066 (86.4) | 2725–5408 |
| Cylindrical | 261 | 6828 (15.5) | 4787–8868 | 22 | 639a (13.6) | 140–1139 |
| Ingestion | All Other Exposure Routes | |||||
|---|---|---|---|---|---|---|
| Characteristic | Actual Sample | National Estimate (%) | Estimated 95% CI | Actual Sample | National Estimate (%) | Estimated 95% CI |
| Total | 2482 | 63 281 (100.0) | 45 916–80 646 | 303 | 7041 (100.0) | 4947–9134 |
| Age, y | ||||||
| ≤5 | 2082 | 53 800 (85.0) | 38 530–69 070 | 240 | 5418 (77.0) | 3775–7061 |
| 6–17 | 400 | 9481 (15.0) | 6919–12 043 | 63 | 1623 (23.0) | 890–2355 |
| Sex | ||||||
| Male | 1438 | 36 003 (56.9) | 25 696–46310 | 195 | 4328 (61.5) | 3005–5651 |
| Female | 1044 | 27 278 (43.1) | 19 717–34 840 | 108 | 2713 (38.5) | 1657–3768 |
| Disposition | ||||||
| Not hospitalized | 2132 | 55 724 (88.0) | 40 435–71 014 | 262 | 6187 (88.0) | 4247–8128 |
| Hospitalized | 350 | 7557 (12.0) | 4998–10 115 | 41 | 854a (12.0) | 472–1235 |
| Battery typeb | ||||||
| Button | 1532 | 37 109 (84.5) | 24 759–49 459 | 182 | 4066 (86.4) | 2725–5408 |
| Cylindrical | 261 | 6828 (15.5) | 4787–8868 | 22 | 639a (13.6) | 140–1139 |
National estimate is potentially unstable because the national estimate is <1200 or the coefficient of variation is >33%.
Battery type could not be determined for 30.6% (n = 19 345) of estimated ingestion cases and 33.2% (n = 2335) of estimated cases with other exposure routes.
Two-thirds (n = 43 415, 68.6%) of ingestion cases were confirmed ingestions. Patients with confirmed battery ingestion were 1.98 times (95% CI: 1.87–2.08) more likely to be hospitalized than those with suspected ingestions. Where battery type was described for ingestion (n = 43 937, 69.4%) and noningestion (n = 4705, 66.8%) cases, BBs were most frequent (n = 37 109, 84.5%, and n = 4066, 86.4%, respectively). Among all cases, BB ingestions were 2.1 times (95% CI: 1.92–2.30) more likely to result in hospitalization than cylindrical battery ingestions. The likelihood of BBs being the ingested battery type was about the same among patients aged ≤5 years compared with patients aged 6 to 17 years (relative risk: 1.03; 95% CI: 1.02–1.04).
When the trend in ED visits for battery ingestions alone is considered, there was a significant increase among both children aged <18 years (5.6–13.5, respectively; P = .02) and children aged ≤5 years (12.6–36.4, respectively; P = .02) from 2010 to 2017, followed by a nonsignificant decrease among both age groups from 2017 to 2019 (13.5–8.2, P = .303, and 36.4–21.9, P = .296, respectively). For BB ingestions alone, the ED visit rate per 100 000 children increased significantly from 2010 to 2017, both among children aged <18 years (2.6–7.1, respectively; P = .02) and children aged ≤5 years (6.1–19.3, respectively; P = .03), followed by a nonstatistically significant decrease among both groups from 2017 to 2019. Similar to the overall trend, there was, again, a nonsignificant decrease from 2013 to 2015 among both children aged <18 years and children aged ≤5 years in the rates of overall battery ingestions (8.6–6.1, P = .29, and 22.9–15.8, P = .19, respectively) and BB ingestions alone (5.6–3.8, P = .08, and 14.4–9.4, P = .09, respectively).
Discussion
The battery-related ED visit rate per 100 000 children has continued to rise in the last decade and was 2.1 times higher during 2010 to 2019 compared with 1990 to 2009 (9.5 and 4.6 per year, respectively).12 There was an average of 1 battery-related ED visit every 1.25 hours among children aged <18 years during 2010 to 2019 compared with 1 battery-related ED visit every 2.66 hours during 1990 to 2009.12
The significant increase in battery-related ED visits among children aged <18 years observed from 2010 to 2017 appears to have been primarily driven by a 2.3-fold increase in the rate among the ≤5-year-old age group between the 2 study periods. Although a nonsignificant decrease in rates was observed from 2013 to 2015, the reason for this is unknown.
In alignment with Sharpe et al,12 ingestions were the most common exposure route, with children aged ≤5 years accounting for 85% (n = 53 800) of ingestion cases. Previous research has similarly found that a smaller proportion of battery ingestion cases involve older children, although those cases tend to have less severe outcomes.5,11,12 This may be partly due to younger children having a smaller esophagus and thus being predisposed to esophageal foreign body impaction. Furthermore, parents and caregivers may be unaware that a young child has ingested a battery until significant and often life-threatening symptoms develop. In the current study, battery-related ED visits were more frequent among 1-year-olds than any other single year of age, and the mean patient age between the 2 study periods decreased from 3.9 years to 3.2 years,12 indicating that children presenting at EDs may be getting younger.
Where battery type was known, BBs accounted for similar proportions of ingestions among children aged <18 years for both study periods (84.5% during 2010–2019 and 83.8% during 1990–2009).12 The significant increase in BB ingestions among children aged <18 years found by Sharpe et al12 also continued during the first 8 years of the current study period, driven by increases among the ≤5-year-old age group. This increase may reflect an increase in BB-powered products in the home, leading to increased exposure.8,16,29
Although the NEISS does not provide detailed information regarding outcomes after patient discharge from the ED, the rise in the proportion of battery-related hospitalizations between the 1990–2009 and 2010–2019 study periods may indicate that injuries are increasing in severity. Other reports have confirmed increasing incidence of injury severity and death after BB ingestions that has paralleled the introduction and increased use of larger (≥20 mm diameter), 3-voltage lithium BBs in the home.10,15,25,30,31 Litovitz et al reported a 6.7-fold increase in the proportion of BB ingestions resulting in major or fatal outcomes from 1985 to 2009, with outcomes being significantly worse for ingestions of ≥20 mm lithium-powered BBs and children aged <4 years.15 Further, 12.6% of children aged <6 years who ingested a ≥20 mm BB suffered a major effect such as tracheoesophageal fistula, esophageal perforation, fistulization into major vessels, esophageal strictures, spondylodiscitis, or vocal cord paralysis.15 A mechanism for improved reporting directly by medical professionals who manage these cases may allow for more detailed reporting and understanding of BB ingestion treatment and outcomes. One example is the recently developed GIRC app (Google Play and App Store, www.globalirc.org), a free, Health Insurance Portability and Accountability Act- compliant smartphone application for clinicians to anonymously report pertinent injury details, including up to 3 photographs of the BB or other object removed, symptom severity, removal techniques, complications, treatment provided, and clinical outcomes, to a centralized, global database.32
When intended battery use was described, toys/games, watches, and hearing aids predominated; however, the proportion of batteries intended for watches increased from 13.7% during 1990 to 200912 to 29.7% during 2010 to 2019. The leading products identified during both study periods align with previous analyses of calls to poison centers for the management of battery exposures in the United States and Australia.7,13 Litovitz et al reported that, in 61.8% of calls to the National Battery Ingestion Hotline in the US, children had obtained the battery themselves directly from the product.13
Although the decreases in rates of overall battery- and BB-related ED visits from 2017 to 2019 did not reach statistical significance, they may signal the beginning of a downward trend attributable to multisectoral prevention initiatives in recent years. Prevention efforts initially focused only on preventing exposure to BBs and educating parents and other caregivers about the hazards BBs present. For example, in 2011, Safe Kids Worldwide and Energizer partnered to launch the “Battery Controlled” campaign, which used media and community outreach to spread public awareness of the risks of BB ingestion.33 In 2012, the National Button Battery Task Force was formed by the American Academy of Pediatrics and American Broncho-Esophagological Association as a multidisciplinary effort of representatives from relevant organizations in industry, government, poison control, clinical medicine, and public health to develop, coordinate, and implement strategies to reduce the incidence of BB injuries in children.10 Although the National Button Battery Task Force also supports education of parents and caregivers, they recognized that education alone is not enough and have advocated for voluntary standards addressing product design and packaging.17 Standards such as UL60065 and UL4200A require that lithium battery compartments require 2 or more independent movements or the use of a tool to open them. In 2017, the CPSC updated ASTM F963–17 to require that BB-powered toys intended for children aged <14 years include warning labels and instructions to inform consumers of BB risks. Although these standards are an improvement, they have yet to be expanded to include all BB-containing household items commonly associated with child exposure. In August 2022, “Reese’s Law” was passed by the US Congress with bipartisan support and signed into law. This new law will require the CPSC to develop child-resistant testing standards for BB packaging and BB-powered device battery compartments, and that BB-powered devices include labeling clearly identifying ingestion risk and instructing consumers to keep such products out of reach of young children.30
BB manufacturers have also introduced features to prevent ingestions, including child-resistant packaging and hazard warning labels.14 In 2020, Duracell released a BB option with a nontoxic bitter coating to try to discourage ingestions; however, use of bitterants has not prevented ingestion of other hazards, so the efficacy of this approach with BBs has yet to be established.34–36 Other industry efforts are targeted toward reducing injury severity in the event of BB ingestion. For example, Landsdowne Laboratories has designed an innovative technology (ChildLok), which aims to reduce liquefactive tissue necrosis when a BB becomes lodged in the esophagus.37 If proven effective, such safety technologies should immediately be widely adopted by battery manufacturers.
Another issue is safe disposal of BBs. BBs no longer powering a device may still have enough residual charge to cause injury when lodged inside the body, yet current packaging does not clearly define safe disposal after removal from a device. A recent study involving wrapping BBs bidirectionally in common household tapes found no further drop in voltage, no change in esophageal tissue pH, and no visible tissue injury in esophageal tissue models, suggesting a safer disposal solution. However, the authors caution that taped BBs should still be removed emergently if swallowed.
Finally, novel clinical mitigation strategies for reducing the rate of injury pre- and post-removal have been developed for esophageal BB impactions and incorporated into the National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline.14,15,18,38 Although not a substitute for emergent BB removal from the esophagus, these strategies can be considered to help slow the rate of injury during emergency transportation.
Limitations
This study has several limitations. The study sample is limited to battery-related exposures that resulted in an ED visit and, thus, likely underestimates the actual number of battery-related exposures among children given it does not include patients treated in non-ED health care settings. Battery type, intended use, and exposure routes were ascertained using the NEISS narratives, which are often limited and inconsistent in level of detail, which could lead to misclassification in the current study. In addition, specific battery size and chemical composition are typically not noted in the NEISS narratives, limiting the identification of specific battery types. Unfortunately, the NEISS does not provide information on treatment details, complications, or longer-term outcomes.
Finally, data on battery exposure are not available, so population estimates were used to calculate rates. As a result, it is unknown whether changes in rates are attributable to increased exposure, increased severity, changes in health-seeking behaviors of parents and caregivers, or changes in treatment protocols for battery-related ingestions resulting from increased education and awareness-raising efforts.
Despite these limitations, the major strength of the NEISS is that it is the only nationally representative sample of battery-related injuries treated in US EDs. As such, the NEISS allows for the evaluation of incident trends over time, which is critical for informing a public health response, including evaluation of the effectiveness of current safety standards and public education efforts.
Conclusions
Using a nationally representative sample, this study found that previously reported significant increases in battery-related ED visits among children aged <18 years in the United States during 1990 to 2009 continued through 2017, after which there was a nonsignificant decrease until 2019. Ingestion was the most common route of exposure and children aged ≤5 years had the highest ED visit rate. Unfortunately, despite all existing injury prevention efforts, battery-related ED visits remain too frequent. Regulatory efforts and adoption of safer BB designs by industry to reduce or eliminate ingestion injuries in children are critically needed.
Mr Chandler conducted all stages of data analysis, interpretation, and drafting of the preliminary and final manuscript, and coordinated and implemented coauthor contributions; Ms Ilyas assisted with the initial descriptive analysis and drafted the initial results; Drs Smith and McKenzie critically reviewed the manuscript for intellectual content and interpretation of data; Dr Jatana critically reviewed the manuscript for intellectual content, interpretation of data, and contributed to portions of manuscript text; Ms MacKay provided study oversight, supervised data analysis, critically reviewed the manuscript for intellectual content and interpretation of data, and contributed portions of manuscript text; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: Dr Jatana has a patent-pending coin/battery metal detector device under development and receives royalties for a patented, commercially available medical device, not related to nor discussed in this article, from Marpac Inc; is a shareholder in Zotarix LLC, Landsdowne Laboratories LLC, and Tivic Health Systems; serves in a leadership position on the National Button Battery Task Force; and serves on the medical advisory board of the Global Injury Research Collaborative, which is a US Internal Revenue Service-designated, 501(c)(3) nonprofit organization. The other authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
COMPANION PAPER: A Companion to this article can be found online at http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-057477.
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