Liam Howard's 6-year-old sister Grace saved his life.
Twelve months old and curious, Liam had found a way to pop the shiny, coin-shaped battery out of Grace's handheld digital toy and had swallowed it.
"I had no idea what he was choking on," said his mother, Susan Howard, 40, of Leesburg, Virginia. Liam was retching and grabbing at his throat, so Susan scooped up the children and was on the way out the door to the hospital when Grace noticed that her toy wasn't working. She asked her mother if Liam might be choking on the battery.
Sure enough, an X-ray at the hospital showed a flat disc lodged in Liam's esophagus, the passage that connects the mouth to the stomach.
Three hours later, the battery had been removed, but the damage had been done: Liam had third-degree burns to his esophagus and the wall of his windpipe.
Liam stayed in the hospital for a month. He needed a breathing tube for a week, a feeding tube for three weeks, and several follow-up procedures to widen his scarred esophagus.
"We're still dealing with it," said his mother. "He vomited 3 or 4 times a day for at least 18 months. He lost his teeth from the stomach acid. He now has a lot of breathing issues."
But overall, she considers her family lucky. Now 4, Liam is doing great.
For a curious toddler, the home is full of exciting potential toys to explore -- from light-up sneakers and jewelry to singing greeting cards, remote controls and electric toothbrushes. But these devices, as well as numerous other powered items found in nearly every home, have a hidden danger in the form of flat, round batteries known as button batteries.
A pair of studies published in Monday's issue of the journal Pediatrics reports an alarming rise in the number of battery ingestions that can be serious or even fatal. The studies make strong recommendations for ways that product designers, parents and physicians can work to keep children safer.
The rate at which people accidentally swallow batteries each year has remained more or less constant over the past 25 years, bouncing between 6.3 and 15.1 per million. However, the percentage of those ingestions that end up being serious or fatal increased 6.7-fold over the time period studied. These numbers came from the National Battery Ingestion Hotline (NBIH), a service that provides guidance to families and health professionals after battery ingestions.
Dr. Toby Litovitz, an emergency medicine physician and medical toxicologist in Washington, D.C., founded the center in 1982 when she realized that guidelines for families and physicians on how to deal with battery ingestions were scarce.
"For many years, most of the cases were benign," she said. Kids would swallow batteries, the batteries would pass through the stomach and not need to be retrieved, and the kids would do fine.
"In the last five years or so, things have changed," she said, "and we've done an about-face because of the emergence of the 20-millimeter lithium cell as a very popular cell for consumer electronics."
This coin-shaped battery, which is frequently used in remote controls and other household devices, is larger than most older "button batteries," so it more frequently becomes lodged in the esophagus.
This is particularly dangerous, Litovitz said, because the prolonged contact of the battery surface with the tissues of the esophagus creates an external current. The battery then can burn through the wall of the esophagus into whatever structure is next to it. The results can include damage to the windpipe or the aorta, which is the main blood vessel carrying blood from the heart to the rest of the body.
"Kids can bleed out," Litovitz said.
For this reason, it's important for doctors to identify the problem and, if one of these large button batteries is lodged in the esophagus, retrieve it quickly with endoscopy, a procedure using a lighted, flexible instrument.
The study authors recommend a goal of having the battery removed from the esophagus within two hours of ingestion. This can be tricky, especially if no one actually witnessed the child swallowing a battery. The symptoms of battery ingestion are not very specific, and they are often the same symptoms seen with potentially less serious ailments like croup or a stomach virus.
The study found that 61.8 percent of children younger than 6 who ingested the 20-millimeter lithium batteries got them directly from a product, like a remote control, toy, hearing aid, or personal digital assistant. In other cases, children picked up batteries lying loose or got them out of their original packaging. Of children younger than 6 who ingested large button batteries, 12.6 percent experienced serious problems or death.
"There are children that have died from this," said Susan Howard, "and I just can't even imagine our life without [Liam], and to think, a battery, really?"
The study's authors recommend several ways to prevent button battery ingestion in children. For one, they call on manufacturers of household devices to make battery compartments more secure.
"The little latches that are on remote controls now are really not adequate," Litovitz said. "Kids are defeating them all the time."
Dr. Mark Meredith, a pediatric emergency physician at the Monroe Carell Jr. Children's Hospital at Vanderbilt University, agreed. "There have been many different ways to try and secure these batteries in different devices over the years. If the manufacturers would treat all of these compartments like a child's toy that requires batteries and secure the compartment with a screw, I am willing to bet that the number of ingestions would decrease."
Another important piece of prevention, the study's authors say, is that parents must keep track of batteries and not leave them loose.
Dr. Dale Tylor, a pediatric ear, nose, and throat surgeon at Vanderbilt, has seen countless children with injuries to the inside of the nose from children putting batteries up a nostril.
She says that a big problem "is hearing aids, sometimes the child's own, sometimes an elderly family member's. Parents don't even think about it because nobody knows they're dangerous." Just as in the esophagus, a battery can burn a hole through the tissues of the nose.
The authors also recommend that battery manufacturers make packaging child resistant.
For physicians, the authors hope to get the word out that timely removal of batteries lodged in the esophagus is more important than ever.
"I'm hoping we can let physicians know they've only got two hours," Litovitz said. "By the time the parent gets to the [emergency department], they do the X-ray, they find a pediatric gastroenteroenterologist... they need to move quickly."
And because the diagnosis is easy to miss if the parent didn't witness the ingestion, physicians need to be vigilant about the possibility of a foreign body ingestion in young children.
Some things parents can do to help prevent battery ingestions include:
Storing batteries out of sight and out of reach of children. Don't let them play with batteries or with objects/devices whose batteries they might get into.
Trying to only buy products that have a child-resistant battery compartment, or ones that require a special tool like a screwdriver to open.
When that's not possible, being sure batteries in household devices are secure -- for example, you can cover the battery compartment on the remote control with strong tape.
Being particularly vigilant about hearing aids; family members with hearing aids will often remove the batteries when they take off the aids.
If your child does swallow a battery, Do not try to induce vomiting.
Call the National Battery Ingestion Hotline at 202-625-3333 (or your local poison center at 1-800-222-1222) immediately. You may be asked to provide the identification number from the battery package or a matching battery.
Go to nearest emergency department (and use caution getting there) -- bringing the battery packaging with you if it's available. Your child will need an X-ray to make sure the battery isn't lodged in the esophagus.
Don't let your child eat or drink anything until the X-ray is completed and the doctor says it's okay.
If the battery is in the ear or nose, your child will also need to go to the Emergency Department. Do not use eardrops or nose drops until the child has been seen by a doctor.
More tips and information can be found at www.poison.org/battery.