Journal of Pediatric Gastroenterology & Nutrition:
Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA.
Address correspondence and reprint requests to Petar Mamula, MD, The Children's Hospital of Philadelphia, Philadelphia, PA 19104 (e-mail: email@example.com).
Received 18 April, 2013
Accepted 18 April, 2013
The authors report no conflicts of interest.
See “Magnet Ingestions in Children Presenting to US Emergency Departments, 2002–2011” by Abbas et al on page 18, and “Magnet-Related Injury Rates in Children: A Single Hospital Experience” by Agbo et al on page 14.
Escalating exposure to and injury from powerful magnet-based toys and related products has led to a series of exchanges between North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the US Consumer Product Safety Commission (CPSC) to limit the accessibility of these magnets by children; however, manufacturers argue that the published literature does not support the claims of rising morbidity and mortality from ingestion of these magnets. Recently released data from the 2012 NASPGHAN survey of society members highlight the scope of this problem: at least 480 known cases of high-powered magnet ingestion were documented, 204 of which were reported in 2011; 80% required endoscopic or surgical management; and 51% were in children younger than 6 years. Further documentation is reported in this issue of the Journal of Pediatric Gastroenterology and Nutrition. Abbas et al (1) present a comprehensive look at the growing trend of magnet ingestion–related emergency department (ED) visits across the United States using CPSC database resources that permit national estimates to be calculated from a geographically diverse group of medical centers. Remarkably, they detected a 75% annual increase in these encounters during a 10-year span. Complementary to this report, Agbo et al (2) detail the experience of a single tertiary care ED with injuries related to magnet ingestion and impaction during the last 18 years, with 112 newly reported injuries in children, 86% caused by ingestion. This report far surpasses the volume of any single center's case series to date. Both studies corroborate the ominous increasing incidence in ED encounters related to magnet ingestion during the last decade.
In 2002, the first alarming report on the hazard of magnet ingestion in children appeared as a case series of 24 injured children in the United Kingdom (3). In 2006, following the voluntary recall of 2 magnet-containing toy-building sets, the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report summarized 20 known cases in the United States including 1 death and a CPSC warning to child caregivers of small magnet perils (4). A rare earth magnet product marketed as an adult desk toy was released on the market in 2008, and sales rapidly rose in 2009. In early 2010, the CPSC received the first incident reports of bowel injury following ingestion of rare earth magnets and began issuing notices of noncompliance to manufacturers for sale to children younger than 14 years. In 2011, an agreement between the American Society for Testing and Materials International and the CPSC (American Society for Testing and Materials F963-11) redefined what constitutes a “hazardous magnet” and established new limits for magnet attraction strength allowable for products sold to the public. The 2012 NASPGHAN survey mentioned above detailed the rise of magnet ingestion morbidity, propelling NASPGHAN advocacy efforts in the CPSC decision to halt the production of the popular rare earth magnet sets. A follow-up survey to update these trends is in progress.
Given the momentum of the recent events in Washington DC, the 2 articles within this issue represent a giant leap forward in the epidemiological information available to policy makers and physicians. Abbas et al identify important limitations of analyzing information from the available national database, including the inability to discriminate between possible and actual ingestions and the reality that ED data are insufficient to detail outcomes such as endoscopy or surgery once the child leaves the ED. Agbo et al have similar lack of available outcome data, with the added potential influence of referral bias inherent to a single large referral center. These realities make the reliance on ED data inherently insufficient to capture the full scope of the problem for both health care leaders and policy makers. Therefore, a new national registry is clearly needed to accurately document the number of cases of confirmed magnet ingestion and the details surrounding their presentations, including short- and long-term outcomes. Outcome data would allow us to draw evidence-based conclusions to optimize management strategies for these patients. In September 2012, a proposed management algorithm for pediatric magnet ingestion, based largely on expert opinion, was published in JPGN, accounting for anatomic location of the magnet(s), number of magnets ingested, and timing of ingestion. A registry and new dataset would likely help establish patient characteristics and factors that could be reliable predictors of poor outcomes, so that we could proceed with conservative or more urgent endoscopic or surgical interventions. Some magnet ingestions are managed by our surgical colleagues alone. Therefore, to be able to identify all cases, to understand differences in clinical practice, and to develop management algorithms, we must engage other pediatric medical and surgical societies including those for emergency medicine, otolaryngology, and general surgery, as well as the American Academy of Pediatrics. The registry would provide a foundation for prospective epidemiological research on follow-up magnet ingestion incidence trends, subsequent to the NASPHGAN survey results and governmental action. Additionally, the registry could serve as a model for other registries detailing the cases of other critical ingestions, such as disk button batteries and certain sharp objects, ultimately leading to further treatment algorithms based on best pediatric evidence not presently available.
The evolving abundance of available epidemiological data, combined with the present political climate of alertness and interest in the potential dangers that powerful magnets pose to the health of children, signifies the perfect marriage of means and opportunity for substantial change and to curb the unsettling trends reported in the 2 studies mentioned above.
1. Abbas M, Oliva-Hemker M, Choi J, et al. Magnet ingestions in children presenting to US emergency departments, 2002–2011. J Pediatr Gastroenterol Nutr
2. Agbo C, Lee L, Chiang V, et al. Magnet-related injury rates in children: a single hospital experience. J Pediatr Gastroenterol Nutr
3. McCormick S, Brennan P, Yassa J, et al. Children and mini-magnets: an almost fatal attraction. Emerg Med J
4. Centers for Disease Control and PreventionGastrointestinal injuries from magnet ingestion in children—United States, 2003–2006. MMWR Morb Mortal Wkly Rep