Pediatric Radiology

, 39:142

Worldwide survey of damage from swallowing multiple magnets

Authors

    • Radiology Department 5031Cincinnati Children’s Hospital Medical Center
Original Article

DOI: 10.1007/s00247-008-1059-7

Cite this article as:
Oestreich, A.E. Pediatr Radiol (2009) 39: 142. doi:10.1007/s00247-008-1059-7

Abstract

Background

It is increasingly recognized that in children swallowed multiple magnets cause considerable damage to the gastrointestinal tract.

Objective

To emphasize that complications from swallowed magnets are extensive worldwide and throughout childhood.

Materials and methods

The author surveyed radiologists and researched cases of magnet swallowing in the literature and documented age and gender, numbers of magnets, nature of the magnets, reasons for swallowing, and clinical course.

Results

A total of 128 instances of magnet swallowing were identified, one fatal. Cases from 21 countries were found. Magnet swallowing occurred throughout childhood, with most children older than 3 years of age. Numbers of swallowed magnets ranged up to 100. Twelve children were known to be autistic. Many reasons were given for swallowing magnets, and a wide range of gastrointestinal damage was encountered. Considerable delay before seeking medical assistance was frequent, as was delay before obtaining radiographs or US imaging.

Conclusion

Damage from swallowing multiple magnets is a considerable worldwide problem. More educational and preventative measures are needed.

Keywords

Magnet ingestionFistulaPerforationGastrointestinal damageAutismPostgastric magnetopathy

Introduction

Magnets in the gastrointestinal tract, usually beyond the stomach, attract one another across bowel wall, and often result in severe damage. In order to emphasize the extent of the problem, I conducted a survey and extensive literature search and present the outcomes of 128 incidents worldwide.

Materials and methods

For a minisymposium on the topic presented in Edinburgh, Scotland, at the European Society of Paediatric Radiology annual meeting in June 2008, I prepared a survey form that was sent to the annual meeting registrants and to members of the European Society and the Society for Pediatric Radiology, as well as to former trainees at my institution and to selected members and corresponding members of the Radiology Society of North America. The medical literature was also examined. In order to avoid any patient being included more than once, the age, gender, and city of origin were checked whenever possible. This study was deemed exempt from review by our hospital’s Institutional Review Board.

Results

Published cases [152] and personal responses to the survey came from Australia, Austria, Canada, Chile, Denmark, Finland, France, Germany, Iceland, India, Ireland, Italy, Japan, Poland, South Korea, Spain, Sweden, Switzerland, Turkey, United Kingdom, USA, and the U.S. Virgin Islands. Thus, 21 countries and one territory were included. Table 1 summarizes the origin of the cases.
Table 1

Summary of geographic locations of cases (three cases from Turkey included with Europe)

Geographic region

No. of cases

USA

71

Europe

32

Asia

15

Canada

5

South America

3

Australia

1

Caribbean

1

Of those cases in which gender was noted, 92 were boys and 25 girls, a ratio of 3.7 to 1. Only one child, a 20-month-old boy, is known to have died from the consequences of swallowing multiple magnets [24], from overwhelming sepsis related to perforations. The age distribution is given in Table 2 for patients whose age was known. Only three were younger than 1 year, nine were 1 year old, and all but 21 were 3 years old or older. One patient was 18 years old, and two were adults.
Table 2

Ages of patients with damage from swallowing multiple magnets

Reported age of patients (years)

No. of patients

<1

3

1

9

2

9

3

13

4

15

5

11

6

8

7

6

8

11

9

5

10

4

11

9

12

13

13

6

18

1

32

1

48

1

Unknown

3

The number of magnets swallowed, when known, is given in Table 3. In four children, only one magnet was swallowed, with other metal objects in addition. The most frequent numbers were two in 32 patients and three in 22. One child in Iceland swallowed approximately 100.
Table 3

Stated numbers of magnets swallowed

Number of magnets swallowed

No. of patients

1 plus other metal

4

2

32

3

22

4

9

5

7

6

4

7

2

8

5

9

3

10

3

11

3

12

2

13

3

14

1

15

2

16

2

17

2

18

2

19

2

21

1

24

1

26

1

34

1

37

1

40

1

Approx 100

1

Because a minority of patients were infants and toddlers, the question of why the objects were swallowed was of interest. One factor is the medical or psychological status of the child. Autism as a known condition was reported in 12 children (9.4% of the entire series; 16.2% of children 4 years old and older). One girl and 11 boys were in this group. Other listed descriptions or diagnoses of possible predisposing conditions included developmental delay, history of pica, schizoid characteristics, attention-deficit/hyperactivity disorder, Angelman syndrome, repeated inappropriate swallowing of objects, psychiatric history of compulsive chewing, behavioral problems, Beckwith-Wiedemann syndrome with developmental delay, neurosis (in home for psychiatrically disturbed), 4p-syndrome, congenital hydrocephalus with “vacuum cleaner” ingestion of many objects, mental retardation, reactive attachment, and anxiety. Quite a variety of explanations were given by the children involved (Table 4).
Table 4

Some of the explanations for and specific circumstances of the magnet swallowing

Swallowing as a dare or bet

“Thought it was humorous”

Magnets had been placed between lips so hands were free to perform a task (affixing clothes to a doll; playing football with no pockets)

To hide earrings from mother

Toy was a gift in a bag of crisps

“To neutralize electromagnetic forces implanted into body” (48-year-old)

To retain coins longer in stomach (32-year-old)

“Boredom”

Considered to be candy (2½-year-old)

Was using teeth to separate magnetic pieces from building set

Mock tongue-piercing

“As an experiment”

Angry at sibling

Liked flavor of toy magnets in mouth

To see how many toys could be swallowed because “it would be fun”

Some toddlers found magnet toys left by older siblings on the floor

The majority of swallowed magnetic objects were components of toy sets, including many well-known brands. Other objects included magnets used for muscle stiffness, a chain necklace with a magnetic component, magnet-backed earrings, magnets to attach metal marks onto a cap, another to attach to a metal board, small industrial magnets, magnets intended to imitate cicadas, magnets from a tic-tac-toe game, shiny magnet mineral stones, magnets from an office organizer, toy alphabet pieces for refrigerators, magnets from an interactive reading book, magnetic bracelet pieces, and magnets from educational instruments.

In almost all cases, the magnets were first visualized on plain abdominal radiographs; see, for example, Fig. 1. In a few cases US or CT was the first imaging on which the objects were seen. Sometimes a CT scan was performed because of uncertainty from the plain radiographs. No MRI was performed (which could have happened for abdominal symptoms in the absence of pertinent history, leading to untoward consequences). Table 5 shows imaging findings.
https://static-content.springer.com/image/art%3A10.1007%2Fs00247-008-1059-7/MediaObjects/247_2008_1059_Fig1_HTML.jpg
Fig. 1

Six magnetic toy pieces, plus one button battery, swallowed by a 21-month-old girl. Dilated gas fluid levels are seen on this horizontal beam lateral decubitus image. These parts of a construction toy set were brought home from school by an older sibling

Table 5

Imaging findings in 91 cases that included some imaging information

Imaging modality

Imaging finding

No. of cases

Plain radiography, or occasionally CT

Metallic foreign bodies on plain images

86

Dilated bowel loops

25

Gas fluid levelsa

20

Free gas

8

No free gas

45

US

Peritoneal fluid

4

Bowel loops clustered around foreign body

2

Intussusception containing foreign body

1

“Acute appendicitis” pattern

1

Foreign body surrounded by inflammation

1

Segmented foreign body

1

Intestinal obstruction

1

aMany cases had no horizontal beam.

The original symptoms were often mild, resembling ’flu-like illness, nausea, vomiting, cramps, or abdominal pain. Delay between onset of symptoms and going for health-care assistance was hours to weeks; many of the most recent cases were more quickly brought for assistance. The delay between seeking medical assistance and the making of the diagnosis also ranged from minutes (if radiography was done) to weeks.

Some radiographs showed free peritoneal gas, but that was a minority. Bowel loops were sometimes distended.

As mentioned above, one child died of sepsis before any surgery or endoscopy could be performed. Findings at surgery, and occasionally at endoscopy, included magnets stuck to each other across bowel (or stomach and bowel) wall, often with at least superficial erosions, along with perforations, intussusception, ulceration, magnets free in peritoneum, mesentery compressed between magnets, peritonitis, adhesions, obstruction, fistulas, volvulus, local necrosis, internal hernia, abscesses, long-term lack of progression of magnets, and various combinations of the above involving colon, appendix, ileum, jejunum, duodenum, stomach, and rarely esophagus. In all but seven cases, at least one of the magnets had passed beyond the stomach. Often some bowel had to be resected, fistulas were repaired, magnets removed, and abscesses drained at initial surgery or later.

This survey did not include cases of multiple magnet ingestion in which the magnets passed safely through the gastrointestinal tract without any known damage. In my experience, in two of nine children with multiple magnet ingestion, the magnets passed uneventfully and in one the magnets remained in the right lower quadrant unchanged on radiographs for several days and at endoscopic removal no damage was reported. I also was consulted by a mother whose autistic child had swallowed 25 magnets that apparently all passed after several days of the child being kept home from school. I have also been told of three other children with successful passage. Presumably, children with multiple ingestion are only reported when there is proven damage. Based on my experience, however, I believe a considerable majority of multiple swallowing events lead to damage (prospectively, in six of nine children).

Relatively few other articles document damage to nose, ears, and scrotum from multiple magnet attraction. A programmable shunt was rendered inoperative from interaction with magnets from toys [53].

Discussion

One general theme among these cases was the initial delay in seeking medical assistance, and in the medical setting, the delay in diagnosis and thus treatment. Symptoms were often relatively mild and a history of the ingestion was quite often lacking. A major problem is thus education of health-care and child-care workers, as well as parents and other supervisors of children. Newspaper articles, popular press articles, television programs, internet information, and word-of-mouth have helped. Adequate warnings and restrictions on magnet-containing toys have been slow to appear. The perception that the problem is restricted to toddlers was clearly disproved from this survey. The worldwide nature of the problem was also shown (no cases reported from the African continent as yet, however). The range of motivation for swallowing is documented. Patients with autism often have excessive hand-mouth behavior, which might explain the relatively high incidence among these children. Other behavioral and psychiatric disorders are also documented.

Almost certainly, the 128 cases reviewed here are not the totality of cases of gastrointestinal damage to date; the data are not all-inclusive nor was this study prospective. A prospective multiple-institution study might elucidate the proportion of cases with damage.

The question has arisen about the responsibility of the manufacturers and sellers of magnetic toys and other magnetic objects. The component parts, made with rare-earth metals, are far stronger than in past decades, when magnetic toys were considerably weaker. The comments by toy-makers and sellers to inquiring parents that the problem is highly infrequent cannot be supported or condoned. It is hoped they will take an active role in education and prevention, for the sake of their customers.

Although a single abdominal radiograph usually suffices to make the diagnosis of multiple ingested magnets, and it often reveals some complications, a second image such as a horizontal X-ray beam to look for gas fluid levels or free gas, or a lateral image to reveal more magnets if some were superimposed, is advisable. If US is the first imaging method to reveal suspicious foreign objects, then plain radiography should follow for better definition. One tool to improve the diagnosis of the multiplicity of magnets on radiographs is to enlarge the pertinent portion of the image, so that notches between individual pieces are more easily perceived [54].

Our choice of the term postgastric magnetopathy [54] to describe the condition described in this paper is supported in that only seven children had magnets only in the esophagus or stomach.

Institutional and personal efforts are to be encouraged to get the word out about the dangers of swallowing multiple magnets and the deceptively mild symptoms encountered. The message has appeared in several hospital internal and community publications, as well as in major newspapers and on television stations, and it has been included in a pediatric grand rounds program. Many radiologists regularly talk to parents about the problems and prevention, as well as the need to seek prompt medical assistance if a question arises.

Conclusion

Postgastric magnetopathy and in general damage to the gastrointestinal tract from swallowing magnets occurs quite often, over a broad range of ages in childhood, with a wide range of numbers of magnets involved. Predisposing conditions, such as autism, are varied, as are the reasons given by children for the swallowing.

Many forms of gastrointestinal damage occur. Symptoms are often mild, delaying parents from seeking medical assistance and also delaying diagnostic imaging. My institution recommends a plain radiograph of the abdomen when a child with autism or other developmental issues presents with vague abdominal complaints.

Magnets from toys are the most frequent type of magnet swallowed, but other kinds of magnets should also be considered. There should be increased publicity about this health problem, including warnings, and with attempts at prevention. Manufacturers, in particular, should make warnings about the dangers and symptoms of magnet ingestion more frequently and more dramatically evident. Further efforts by professional health-care organizations to emphasize the dangers of magnet ingestion would also be helpful.

Acknowledgements

I thank all colleagues, both medical and in other professions (such as reporters, lawyers, and government workers), who contributed material to this survey.

Copyright information

© Springer-Verlag 2008