Dr. Ballard is an associate emergency physician at Kaiser-Permanente in San Rafael, CA, and the chair of the CREST ED Research Network. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly-medical column for the Marin Independent Journal, which he posts on his blog: http://incisionanddrainage.blogspot.com.
A grade-schooler amazed his classmates with a remarkable feat of attraction. He suspended a spoon from his navel, held as if floating by an invisible attachment. An American preteen was the envy of her BFFs because of her shiny tongue bolt, achieved without the pain of piercing. How did they do it? Gorilla Glue? Superhuman powers?
Neither actually, but rather a stalwart force present all around us but not usually within us. Fans of AMC's Breaking Bad will recognize this force as the same one that Walter White utilized to destroy the evidence police had linking him to methamphetamine production. More mundanely, most of us will recognize it as the molecular reaction that secures photos and to-do lists to our refrigerators. Magnetism.
Magnets are part of our daily lives, but they are not always harmless. In fact, they can exert powerful and destructive forces on the human body. You may not have heard about it yet, but a mini-magnet problem is occurring around the globe. You might even call it an epidemic here in the United States, with reports of magnet ingestions in children increasing approximately tenfold over the past 10 years and resulting in hundreds of injuries and at least one known death.
The sticky issue is the remarkable force with which some magnets are attracted to one another, a force that can push right through gastrointestinal tissue. Recently, a clinical report in The Lancet described two children (one 18 months and the other 8 years old) with toy magnet ingestions. (Lancet 2012;379:2341.) Both required laparotomies and partial bowel resections for injuries caused by the magnets' compressive “pull” forces, which can be up to 1300 Gauss. A typical refrigerator magnet by comparison exerts only 50 Gauss on the gut wall.
A few months ago, a 10-year-old girl ingested two toy magnets she had used to make her own tongue piercing. She avoided the pain of a real tongue piercing, but she ended up short her appendix in the process. A 3-year-old nearly died in Portland this past March after swallowing 37 magnets. Inside her abdomen, the balls snapped together to form a ring and tore at least four holes in her gastrointestinal tract.
The common and concerning characteristic was the ingestion of multiple neodymium (“rare earth”) magnets. These neodymium magnets are a relatively new product — they were invented by General Motors in 1982 — and are five to 10 times more powerful than traditional magnets. Still, solitary magnets, even of the neodymium variety, tend to pass through the gut without major incident. But multiple magnets, or magnets paired with other metal objects in the bowel, pose a unique problem because they have an insatiable desire to find and press against each other. Some describe such magnets as “kissing magnets.” And like lovestruck fools, kissing magnets will do anything to stay together, even, for example, pushing right through the linings of internal organs, causing fistulas or perforations in the process.
Pediatricians and consumer product safety groups have been warning about the dangers of kissing magnets for some time. In fact, the Consumer Product Safety Commission issued new standards for children's products and toys containing magnets in 2008. The standards require that the magnets be secured so that they will not fall out of the toy or become unattached.
Despite this, we're hearing about more and more kids swallowing magnets, especially neodymium magnets used as “stress relief” desk toys for adults. You may have already seen Buckyballs at your local store; the magnets are sold in groups of 100 to 1000, and are replete with enticing shapes and colors. The products are labeled and designed for adults and contain prominent safety warnings, but they can easily find their way into the hands and mouths of children. Youngsters with developmental delay are known to be at higher risk for ingesting objects, and many kissing magnet reports have occurred in developmentally normal children. That led the Consumer Product Safety Commission to file suit recently to prevent their sale.
Whether such products stay on the market, ED providers need to be aware of the risk and the recommended management. Hussain et al recently published a management algorithm from by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. (J Pediatr Gastroenterol Nutr 2012;55:239.)
They recommend that all children with known magnet ingestion as well as those with GI symptoms and possible exposure to neodymium magnets in their environment receive a plain film of the abdomen with a lateral view for patients with evidence of a foreign body. Management is usually conservative for patients with solitary magnet ingestion; use serial exams, x-rays, and close parental instruction to avoid any additional metal ingestion. Cases with delayed passage may require laxatives (PEG-3350 solution), but removal is necessary, either by endoscopy or surgery, for those who ingested multiple magnets or magnets and another metallic object. Asymptomatic patients may be safe for endoscopic (or colonscopic) removal, but any patient with symptoms is at high risk for fistula formation, and will need surgical management.
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