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Don’t Forget the Orbeez!

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Orbeez, those colourful, water-absorbent polymer beads, have become increasingly popular among children for play and craft activities. However, their small size and appealing appearance can pose significant health risks to young children.

What are Orbeez made of?

Orbeez are made from a superabsorbent polymer (SAP), primarily composed of cross-linked polyacrylate. This polyacrylate is formed from acrylate compounds, long-chain molecules consisting of repeating units known as monomers. In Orbeez, these monomers are typically derivatives of acrylic acid, giving the beads their unique absorbent properties.

The cross-linking process in the production of Orbeez is crucial. It involves linking the chains of polymers together to create a three-dimensional network. This network enables Orbeez to retain their structure and not dissolve in water, yet allows them to swell. The amount of cross-linking directly affects the Orbeez’s capacity to absorb water.

After Meshram et al, 2020

When Orbeez are exposed to water, the water molecules diffuse into the polymer network through osmosis. This absorption is driven by the hydrophilic groups in the acrylic acid components of the polymer. These groups have a strong affinity for water due to their ability to form hydrogen bonds with water molecules, pulling them into the polymer network.

As the water molecules continue to enter, they cause the Orbeez to swell. Despite absorbing a large amount of water, the cross-linked nature of the polymer ensures that the beads maintain their structural integrity. This unique feature allows them to expand to many times their original size without dissolving.

Interestingly, Orbeez can reverse this swelling process and shrink to their original size under certain conditions, such as exposure to a high ionic strength solution. The presence of ions in such solutions interferes with the polymer’s capacity to retain water, demonstrating the dynamic nature of these beads.

Photos: Scott Meadows/Consumer Reports

What are water beads used for?

Because of their absorbent properties, long before they were marketed as a child’s plaything, they were used as water absorbers in diapers, menstrual pads and incontinence garments.

Photos: Scott Meadows/Consumer Reports

In Korea, they are known as gaegulial (frog eggs) and are popular toys for children with sensory processing disorders.

What are the risks of water beads?

Although the beads themselves are non-toxic, they can still cause significant morbidity and mortality.

Curious Ken is brought into your emergency department. His older brother, Roy, had found him playing with his toys, and an argument ensued. Roy was less than impressed when young Kendall tried to eat his Orbeez.

Their parents are worried about what might happen to their toddler.

Inhalation

There are surprisingly few case reports in the literature surrounding inhalation or aspiration of water beads.

Alharbi and Dabbour report a similar case to our fictitious one. Here, a water bead had been aspirated. Once it nestled in the moist environment of the respiratory tract, it began to expand. Over time, it caused a localized fibrotic foreign body reaction, leading to focal bronchiectasis and recurrent chest infections in the left lower lobe. Remarkably, it took a full two years from the time of the bead’s probable inhalation for doctors to reach a diagnosis,

Ingestion

Ken looks pretty chipper when he comes into the cubicle, and given that he spat out a water bead, you decide to send him home with some good safety netting advice.

The next day, one of your colleagues pulls you aside and utters those dressed words…

“Do you remember that kid you sent home yesterday?




By 2 AM, he had begun to vomit, and his parents, remembering your advice, brought him straight back. He had vomited up one water bead and it was considerably bigger than when it went in.


His abdominal X-ray looked a lot like this.

Image adapted from Mullens et al., 2021

A plain abdominal X-ray shows multiple dilated loops of bowel.

Here at DFTB, we know a thing or two about swallowing things we shouldn’t. Children will swallow almost anything. Why should Orbeez be an exception? Forrester reported data from the Texas Poison Centers surrounding 110 cases of superabsorbent polymer bead ingestions between 2011 and 2016. A quarter of all cases occurred in December, with 15% taking place in the week between Christmas and New Year. The vast majority were managed at home, with no adverse events reported.

Closer to home, the New South Wales Poisons Information Centre (NSWPIC) reported 129 incidents involving water-absorbing beads since 2004. Again, the majority were managed at home. Most foreign bodies, even bits of Lego, will pass through without incident.

A wonderful experiment by Darracq suggested that water beads won’t cause harm. The experimenters soaked beads in a variety of liquids – room temperature tap water, whole milk, simulated gastric fluid, and GoLytely – to see what would happen. The liquids were chosen to “approximate a pediatric digestive environment.” (Ed. – Very few three-year-olds drink 210mls of vodka in one sitting).

After Darracq et al., 2015

But we all know that what happens in the lab does not always mirror what happens in real life.

A recent literature review by Caré et al. explored 43 cases of bowel obstruction caused by super-absorbent polymer ingestion. These cases involved young children, with ages ranging from just six months to 3 years. The timeline between ingestion and the onset of symptoms was notably short. In the few reports where this data was available, the median delay was just one day, with symptoms appearing as quickly as 15 hours and up to two days after ingestion. Zamora et al., point out that the SAPs are small enough to pass through the pylorus initially, so symptoms don;t start to develop until they reach maximal size around the mid to distal small bowel.

Persistent vomiting affected all 43 cases. Other symptoms, such as constipation, abdominal pain and dehydration, were also be seen.

Imaging

Diagnostic imaging presented its own set of challenges. Abdominal radiography, performed in 31 of the 43 patients, failed to show any evidence of foreign body ingestion. Abdominal computed tomography scans were more revealing, visualizing an intraluminal mass in half of the 10 cases where it was performed.

Abdominal ultrasound, used in 34 cases, was able to visualize a rounded intraluminal image corresponding to a bead in 28 patients. Point-of-care ultrasound may show well-demarcated, round, and hypoechoic material in the stomach and first part of the duodenum, though it can underestimate the number of beads present.

From Mullens et al., 2021

These beads, once hydrated inside the body, reached considerable sizes. The median diameter of the beads at the time of diagnosis was 30 mm, with a range from 25 to a staggering 65 mm. The average intraluminal diameter of the small intestine is just 30mm.

Around 80% of those reported pass spontaneously, with another 10-20% requiring endoscopic removal and only 1% requiring surgical intervention. Mirza and Sheikh reported perhaps the first unfortunate case in 2012. A six-month-old infant presented with sub-acute obstruction and needed an enterostomy. Unfortunately, the anastomosis broke down. They passed away a few days after a second operation.

Insertion

It’s not just fingers that children like to stick in their noses or ears. It’s beads, too!

As the SAPs expand, they may cause nasal congestion, rhinorrhea and swelling. The big challenge is getting them out. Try the Mother’s Kiss before you insert anything into the nose. The beads are brittle and often break into pieces rather than come out whole, making them prone to aspiration. If that’s the case, then a wide-bore suction catheter may be able to grab them when forceps can’t.

And what about if they put one in their ears?

It should go without saying that trying to flush it out with water is not the right move. It’s just going to get bigger and more stuck. Instead, try and scoop it out with a wax curette.

If they’ve been in there for a long time, they can press against the tympanic membrane, leading to perforation, potential ossicular chain erosion and labyrinthitis ossificans with subsequent hearing loss. If you can;t get it out, the patient should be referred to your friendly ENT surgeon.

Injury

The Orbeez Challenge, a popular TikTok trend, involves using air guns to shoot Orbeez water beads and gel pellets at often innocent victims. While this might seem like harmless fun, there have been instances where this activity led to unintended consequences.

There have been reports of the Orbeez Challenge leading to serious outcomes. In New York, Raymond Chaluisant, 18, was shot and killed by an off-duty corrections officer after he allegedly performed a drive-by shooting with a bead blaster.

Even when they don’t result in retaliatory shootings, the small beads are perfectly sized to do some serious damage if they hit you in the right place. The eye, for instance. Krisch et al. reported a number of Orbeez-relate eye injuries, including corneal abrasions, hyphema, commotio retinae, intraretinal haemorrhage, pre-retinal haemorrhage, vitreous haemorrhage, and one case of retinal tear in a 13 month period.

In 2012, one brand of SAP beads – Water Balz – was recalled by the U.S. Consumer Product Safety Commission due to their potential risk. Other brands are still available, although consumer agencies are advocating for their removal.

Although package inserts recommend that Orbeez (and other super absorbent polymers) are not suitable for young children, many of the case reports in the literature suggest that a younger sibling has found them.

References

Orbeez Challenge’ ends in MURDER after New Yorker, 18, is ‘shot and killed by off-duty cop’ | Daily Mail Online

Small and Deadly Danger, Water Bead Education, Water Beads – That Water Bead Lady – San Antonio, Texas

Water beads a safety risk for kids, warns ACCC | CHOICE

Water Beads | CPSC.gov

Age, B., Season, B., Metro, D.C., Ingestions, C.B.B., Fast, A., Pill, I.D. and Cases, F., Are Water Beads Toxic?.

Alharbi, N. and Dabbour, M., 2020. Aspiration of superabsorbent polymer beads resulting in focal lung damage: a case report. BMC Pediatrics20, pp.1-5.

Al-Saied G, Al-Malki T, Ayoub M, et al. Unusual cause of small-bowel obstructions in infants: a warning letter to the parents. J Pediatr Surg Case Rep. 2016;11:39-43.

Cairns, R., Brown, J.A. and Buckley, N.A., 2016. Dangerous toys: the expanding problem of water-absorbing beads. The Medical Journal of Australia205(11), p.528.

Darracq, M.A., Cullen, J., Rentmeester, L., Cantrell, F.L. and Ly, B.T., 2015. Orbeez: the magic water absorbing bead—risk of pediatric bowel obstruction? Pediatric Emergency Care31(6), pp.416-418.

Forrester, M.B., 2019. Pediatric Orbeez ingestions reported to Texas poison centers. Pediatric Emergency Care35(6), pp.426-427.

Fuger M, Desmoulins C, Dunlop NK, Gobbo F, Blakime P, Cheron G. Bowel obstruction due to ingestion of a water-absorbing bead. Arch Pediatr. 2018;25(2):136–8.

Gardner, J.R., Navuluri, S., Small, M. and Richter, G.T., 2021. Superabsorbent Gel Polymer Aspiration and Erosion Into Mediastinum. OTO open5(2), p.2473974X211023020.

Han, S.H., Chen, Y.C., Xian, Z.X. and Teng, Y.S., 2021. Superabsorbent polymer balls as foreign bodies in the nasal cavities of children: our clinical experience. BMC Pediatrics21(1),

Jackson, J., Randell, K.A. and Knapp, J.F., 2015. Two year old with water bead ingestion. Pediatric Emergency Care, 31(8), pp.605-607.

Jung, E. and Lee, S.H., 2022. Hazard of Orbeez water-absorbent beads causing infantile small bowel obstruction: a report of two Korean cases. Journal of The Korean Society of Emergency Medicine33(1), pp.134-138.

Kim, H.B., Kim, Y.B., Ko, Y., Choi, Y.J., Lee, J. and Kim, J.H., 2020. A case of ingested water beads diagnosed with point-of-care ultrasound. Clinical and Experimental Emergency Medicine7(4), p.330.

Krisch, M., Ueberroth, J., Gupta, N., Merriam, S. and Breazzano, M.P., 2024. Characterization of ocular injuries caused by Orbeez hydrated gel pellet projectiles: clinical insights and implications. American Journal of Ophthalmology257, pp.212-217.

Meshram I, Kanade V, Nandanwar N, Ingle P. Super-absorbent polymer: a review on the characteristics and application. Int J Adv Res Chem Sci. 2020;7(5):8-21.

Michelakos, T., Tanaka, M., Patel, M.S. and Ryan, D.P., 2020. Orbezoar: a superabsorbent polymer causing small bowel obstruction in a toddler. Journal of Pediatric Gastroenterology and Nutrition70(2), p.e48.

Mirza B, Sheikh A. Mortality in a case of crystal gel ball ingestion: an alert for parents. APSP J Case Rep. 2012 Jan;3(1):6.

Moon JS, Bliss D, Hunter CJ. An unusual case of small bowel obstruction in a child caused by ingestion of water-storing gel beads. J Pediatr Surg. 2012;47(9):E19-E22.

Ramgopal, S., Ramprasad, V.H., Manole, M.D. and Maguire, R.C., 2019. Expansile superabsorbent polymer ball foreign body in the ear. The Journal of Emergency Medicine56(6), pp.e115-e117.

Sterling M, Murnick J, Mudd P. Destructive Otologic foreign body: dangers of the expanding bead. JAMA Otolaryngol Head Neck Surg. 2016;142(9):919–20

Zalzal, H.G., Ryan, M., Reilly, B. and Mudd, P., 2023. Managing the Destructive Foreign Body: Water Beads in the Ear (A Case Series) and Literature Review. Annals of Otology, Rhinology & Laryngology132(9), pp.1090-1095.

Zamora IJ, Vu LT, Larimer EL, et al. Water-absorbing balls: a “growing” problem. Pediatrics. 2012;130:e1011–e1014

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