See “Magnet Ingestion in Children” by Sahn and Mamula on page 1.
When ≥2 magnets or a magnet and metallic object attract across tissues in the body, the pressure of the 2 objects on the tissue in between can result in tissue ischemia, necrosis, and perforation (1–3). When this occurs across multiple loops of bowel, fistula formation (4–6) and bowel perforation (3,7–14) can cause significant injury (15) and even death (6,16–20). The Consumer Product Safety Commission (CPSC) collaborated with the American Society for Testing and Materials (ASTM) on a campaign for toy safety and issued ASTM F963–11, which is a mandatory standard for toys intended for children younger than 14 years. No such mandatory standards exist for jewelry (21), refrigerator magnets, or toys with magnets targeted to adults. Adult magnetic toys were the focus of a 2008 lawsuit brought by CPSC after they were introduced to the consumer market that year. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) commended this act by the CPSC, calling it a “decisive action” (22).
There are limited data in the literature on the incidence of magnet-related injuries in children (1). The largest published series to date includes 38 cases of magnet-related injuries (6). NASPGHAN delivered a survey to 1747 of its members in August 2012 and received reports of magnet ingestions from 354 pediatric gastroenterologists (23). The survey shed light on the type of injuries; of the children requiring surgical intervention in that survey response, in almost all of the cases, sedation and either single or multiple x-rays were required. Of the cases requiring surgical intervention, 16% resulted in bowel resection, and 62% of the interventions were for repair of perforation or fistula.
This survey likely underestimates the rate of overall magnet-related injuries. Some cases are rushed directly to the operating room for magnet removal and tissue repair, and others involve aspiration or necrosis of the nasal septum; these cases may not involve a gastroenterology evaluation. We sought to assess the rate of emergency department (ED) visits for magnet-related injuries over time to inform and evaluate standards and legislation.
We performed a retrospective study of all ED visits between 1995 and 2012, to a single urban tertiary care pediatric ED with an annual volume of 60,000 visits. Our hospital serves as a referral center for all of the pediatric subspecialties in the region, including gastroenterology, and some of the cases included were referrals from community hospitals. In addition, we are the local pediatric hospital for children living in the surrounding urban neighborhoods.
We identified cases using a text-search tool application and screened the potential cases using manual chart review (C.A., T.K.). We included patients who underwent evaluation for magnet ingestion or magnet foreign body impaction in the ears, nose, vagina, or rectum. We included children evaluated for magnet ingestion who underwent imaging and inspection of the nose, vagina, or rectum, regardless of whether a magnet was identified. Our rationale for including these cases was that just the presence of small magnets in the household can lead to the similar “morbidity” of unplanned visits, imaging, and inspection, which would be identical to those children in whom a single magnet was identified. Variables extracted included patient demographics, the source and number of magnets, imaging results, specialist consult, interventions, patient disposition, length of hospital stay, and future unplanned visits related to the injury (eg, small bowel obstruction, surgical wound infections). Two reviewers reviewed every chart and only variables with high interrater agreement (K > 0.6) were included in the analysis.
To test for a linear trend in the rate of ED visits for magnet ingestions over time, we estimated a Poisson regression model with the annual number of magnet ingestions as the dependent variable and calendar year as the independent variable. We used the annual number of ED encounters to generate incident rates. We also compared rates between 2 time periods: 1998–2006 (premandatory toys standard) and 2007–2012 (poststandard implementation).
Rates of Injuries and the Effect of ASTM F963–11 Standard for Toys
From 1995 to 2012, 112 cases met study criteria. The descriptive variables are presented in Table 1. We identified a significant increase in the number of cases during the study period (incidence rate ratio [IRR] 1.19 (1.14–1.25) (Fig. 1). When comparing magnet-related injuries in 2007–2012 with those before 2006, when the CPSC standard was issued, the IRR is 3.44 (95% confidence interval [CI] 2.3–5.11). For multiple magnets, the IRR is 7.54 (95% CI 3.51–16.19) (Table 2).
The median age of the injured patients increased over time (average 4.8% increase in age per year). Of the 21 children older than 9 years, 14 involved small office toy magnets not intended for children. Nine children accidentally swallowed magnets used as faux lip piercing.
We observed a >3-fold increase in the number of ED visits for magnet-related injuries between 1996 and 2012, with an even greater increase in cases in which multiple magnets were ingested. There were also more injuries in older children and adolescents using high-power magnets as faux jewelry. Toys remained the primary source of these magnet-related injuries, and despite the presence of a notice of proposed rule making for the prohibition of magnet sets (24), office toys (or toys not intended for children) caused an alarming number of these injuries. Magnet-related injuries in the United States are underreported: the CPSC reported a national rate of 14 cases in first 10 months of 2011 (25), whereas our study data include 18 cases from a single center for that same time period.
There are newly engineered magnets containing iron, boron, and neodymium that are 5 to 10 times stronger than plain iron magnets. This allows the practice of faux lip piercing that is seen among teenagers, but if these magnets are swallowed, they can be attracted to each other across multiple bowel loops. As a result, a more proactive invasive approach is required to retrieve any ingested magnets. Special algorithms for the management of magnet ingestion cases (26,27) and early surgical intervention (19) should be considered.
The ASTM F963–11 mandatory toy standard addresses only toys intended for children younger than 14 years and it seemed to have no effect on the rate of injuries from toy magnets. A case series of magnet-related ingestions between 2003 and 2009 actually demonstrated a higher occurrence after 2006. Our data reinforce this finding that the rate of magnet-related injuries was increasing both before and after the introduction of ASTM F963–11. The children in our study were younger than 14 years, and toys accounted for the majority of the magnet-related injuries, regardless of whether these were intended for children or not. It is possible that without ASTM F963–11 the rates of magnet-related injuries may have been even higher. We conclude that even if ASTM F963–11 mitigated this surge in magnet-related injuries, this stand-alone safety standard will not suffice in the prevention of all magnet-related injuries because some of these injuries involve toys designed for populations older than 14 years (eg, office desktop toys), and others may involve other sources of magnets that do not involve toys (eg, jewelry).
We acknowledge that parental supervision is a key element for any kind of injury prevention, yet the growing population of adolescents and teenagers using office toy magnets is challenging to supervise. Furthermore, parents may not realize office toys marketed toward adults could be appealing to children and a potential source of injury. This trend demonstrates a need for newer standards (24) and the improved enforcement of existing ones.
Our study has several limitations. It is a case series from a single hospital and the results should be replicated in a larger multicenter study. This was a retrospective chart review, which is limited by the quality of documentation for these injuries. As a result, we may have missed cases that fit our inclusion criteria. In addition, magnet-related injuries have received substantial media coverage, which may account for more awareness and a lower threshold to seek medical care, resulting in an increase in cases during the last 2 years. Finally, as a tertiary care referral center, patients with magnet-related injuries requiring intervention will often be sent from other hospitals, thereby increasing our observed rate of injury; however, the overall trend is not likely to be affected because our referral rate has not changed significantly during this period.
Rates of pediatric magnet-related injuries have increased at our institution during the last 12 years. The ingestion of multiple magnets simultaneously, increases in the age of the child over time with these injuries, and the presence of adult magnetic office toys as the injurious agent were some of the key features identified. If these data are replicated among other centers, improved enforcement of existing standards and the institution of legislation will be important in decreasing these serious injuries.
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