Dangerous Play: More Kids Ingesting Magnets, Rushed To ER

Years ago, a relaxing family vacation with friends in the Berkshires was cut short by a medical emergency involving the host's 6-year-old son and a couple of powerful magnets.  The problem? The kid blithely placed a magnet in each nostril and couldn't remove them. A bloody nose, forceps and a frantic trip to the local emergency room followed.

The child, it turns out, is far from unique.

According to a new study, the number of children ingesting magnets, or stuffing them up their nasal passages (possibly a thwarted attempt to emulate nose-piercing) has soared: cases, amazingly, quintupled between 2002 and 2011. Not only that, this spike in magnet-related accidents is leading to more serious injuries that are more likely to involve emergency surgery, according to the report, just published online in the Annals of Emergency Medicine.

Researchers propose two possible theories driving the rapid rise in cases:

1. Smaller, stronger magnets have become more widely available (and not only in kids' toys; it's also those addictive Buckyballs, marketed for grownups).
2. Powerful and cool-looking magnets are being used, mostly by older children to "imitate nose, tongue, lip, or cheek piercings," the study says.

To find out more, I contacted one of the study authors, Dr. Julie C. Brown, with the department of pediatrics at the University of Washington in Seattle. Here, lightly edited is her very thorough response via email:

Q: What might be driving the increase in these pediatric magnet emergencies?

A: Small, powerful magnets are increasingly ubiquitous, in numerous household objects. Rare earth magnets have only been widely available and affordable since a little after 2000, and have had increasing use since. Many companies marketed rod and ball construction sets to children around 2005, and there were a number of ingestions related to a flawed Magnetix product around that time, including a Kirkland boy who died in 2005. There have been other flawed toys around that time as well. In recent years, however, it appears that the increase is due more to products not marketed as toys. They are sold with metallic bulletin boards, as fridge magnets, as jewelry, as novelty items.

Most notably, a number of companies, Buckyballs the leader amongst them, marketed sets of spherical magnet balls as executive desktop toys for adults. Although Buckyballs recently liquidated, hundreds of millions of these balls are in the community (about 3 million sets of 216 balls sold), and they are still being sold by two companies in the U.S. and by other companies on the internet (you can get them mailed to you with Buckyballs packaging from Canada, or from other companies directly from China). We have a second study based on our local population that is better able to inform us at to the source of the magnets, and in that study, these magnet balls appear to explain all of the increase in magnet ingestions between 20010-2012. We don’t have similar granularity in the Annals study to know the source of these magnets, especially as brand names are removed from the database.

Q: What age child is most vulnerable?

A: Toddlers are most at risk for all types of foreign body ingestions, and magnets are no exception. With magnets, however, we are seeing more preteens and teens than is typical. This is likely because Buckyball-type magnets are often used by these older children to imitate tongue, lip or cheek piercings, and then they swallow them. Other histories include things like sticking them to braces, or in front of and behind teeth. We know of at least a few cases where a child brought a set to school and shared them with friends, who all imitated piercings together.

Q: Do you have any advice for parents?

A: Parents should:
·Take stock of magnets in the home and make sure they are out of reach or safely contained safely in products.
·Keep small magnets away from young children and older children with developmental disabilities, pica or autism.
·Teach kids not to put magnets in or near their mouths.
·Counsel teens about the hazards of using magnets to imitate piercings.

[Here are more details on the study, for readers who are particularly curious about this phenomenon]:

Q: What was the magnitude of the increase in magnet incidents?

A: To answer this question, we used a Consumer Products Safety Commision (CPSC) database that contains information from a nationally representative sample of 100 emergency departments (ED) visits around the country, for the years 2002 through 2011. We found an increase in magnet injuries involving children who ingested or inserted magnets in their mouth, nose, ears or other orifices. In particular, the incidence of magnet ingestions increased from 0.6 cases per 100,000 children per year in 2002-2003 to 3.1 cases per 100,000 children per year in 2010-2011. In our study of 56 patients visiting the Seattle Children’s ED from 2002 to 2012, who had x-rays obtained as part of their evaluation for magnet ingestions, we similarly noted an increase in ingestions over time. Magnet ingestions were nearly twice as common in 2010-2012 compared with 2007-2009.
Q: What type of magnet-related injuries did you see?
A: In the CPSC study, magnets were ingested in 74% of the cases we investigated, and children inserted magnets through their noses in 21% of the cases.

Q: How do children with magnet ingestions typically present?
A: In the Seattle children’s study, 32% complained of abdominal pain, 11% presented after a choking event, and 57% were asymptomatic. Three quarters of children presenting with magnet ingestions have another medical diagnosis that may have predisposed them to the event, such as autism, attention deficit disorder, developmental disability, behavioral issues, or a history of pica.

Q: Were there changes in the types of injuries seen over time?
A: Multiple magnet ingestions increased over time in both studies, with the highest incidence 2010 though 2012 – exactly when desktop toys like “Buckyballs” were the most widely available. In the Seattle Children’s study, these small, spherical balls were sufficiently common to account for all of the increase in ingestions between 2010 through 2012, relative to 2007 through 2009. In both studies, there were smaller increases in ingestions 2006-2007, which corresponds to a period time where there were injuries and a well-publicized death of a child from a flawed Magnetix magnet construction set.

Q: What are the risks of swallowing a single magnet:
A: In general, a single magnet is low-risk. The risk is in making sure that only one magnet has been ingested, which means obtaining at least two x-ray images to view the ingested object in two planes. It is helpful to image a non-ingested object next to the patient whenever possible, in order to compare dimensions. Occasionally a large, single magnet will get stuck in the esophagus or in the stomach, and will require removal. Finally, with magnets getting stronger and stronger, there is increasing concern that even a single magnet might do harm if a child continues to wear metallic clothing, which might cause the magnet to get stuck in a loop of bowel, and begin to erode.

Q: Are risks different when children ingest multiple magnets?
A: Children who swallow more than one magnet, or a magnet along with another metallic object, are at risk of bowel injury and perforation. Two magnets, ingested at even slightly different times, can travel through the digestive system separately and then attract together across loops of bowel. Even magnets swallowed simulateously can cause harm.When a patient swallows three or more magnets together, they can later click into a loop that can snap around a mucosal surface, such as esophagus or bowel wall. They can then cause erosion through this mucosa, potentially leading to serious injury. There is insufficient evidence to know whether or not two small magnets, swallowed together, are likely to cause harm. In any case, the history is rarely sufficiently clear to be sure these patients are without risk, and they merit close monitoring.

Q: How often do children need surgery?
A: Based on our SCH study, more than half of the 32 children with multiple magnet ingestions required a procedure: 25% required endoscopy, and 31% required surgery. There were increasing numbers of multiple magnet ingestions in the last 3 years of study (2010-2012), corresponding with an increase in procedures. This could be explained by an increase in ingestions of small, spherical magnets, which were typically swallowed in groups of two or more.

Q: Do you manage children with abdominal complaints differently now?

A: We see many patients with abdominal pain without fever or other signs of viral illness. In well-appearing kids without tender bellies on examination, our most common diagnoses, previously and now, are problems that require little investigation, such as constipation, gas or muscle strain. I typically recommend treatment of constipation, or waiting to see how they progress, with follow-up. These days, however, I make sure I ask numerous questions about things the child might have swallowed, and I have a lower threshold for obtaining x-rays if the story is concerning, the pain has lasted more than a few days, or the child has had multiple care visits. There is much to lose if we don’t identify the child with magnet ingestion early on, before they become seriously ill.

Q: What should physicians do if they suspect magnet ingestion?
A: There’s a great algorithm about this in a recent paper, Management of Ingested Magnets in Children, in the Journal of Pediatric Gastroenterology. In addition, providers should be aware than the balls in ball-and-rod construction set toys are not magnets. Parents often mistakenly believe these are magnetic, but the magnets are contained in the rods of these toys. If uncertain, the parents can test remaining balls by touching them together to test for magnetism. Children who swallow the rods, however, merit investigation.

Brown adds that better regulation is needed regarding the sale of small magnets. She says parents of toddlers need to magnet-proof their houses and parents of tweens and teens need to discuss with their children that magnets don't belong in mouths.

Finally, she writes: "Metal detectors do a great job of detecting ingested coins, but miss most magnets. I would not want to convey the message to providers that a metal detector can save them from getting an xray, when magnet ingestion is suspected. This would be a dangerous practice."

Everything turned out fine with my friends' son. But, readers, have you ever rushed to the ER with a pediatric magnet emergency? Are there Buckyballs all over your house? Tell us your story and how it was (hopefully) resolved.