A curious young girl was playing with rare earth magnets and wondered what they would taste like.
She has had no abdominal pain or vomiting, and her observations were normal.
Imaging confirmed two spherical magnets stuck together in the stomach.
When you review her later in the week, they appear to have moved...
You transfer her to the local tertiary centre.
She was asymptomatic, but lack of progression on serial X-rays raises the possibility that the two magnets have fistulated.
At laparotomy, the magnets had not progressed. One magnet was found in the jejunum, and the other was in the ileum. They were stuck to each other with bowel wall in between. There was one perforation, which was repaired. She spent around five days as an inpatient post-operatively. She tolerated eating and drinking normally. No long-term complications are expected.
Most toys have warnings, reminding us to keep magnets and small parts away from children and infants. Despite this, children are inquisitive and remain vulnerable to foreign body ingestion and inhalation. Sometimes, these magnets can pose a risk to life. It is important to know the time, place and number of magnets ingested to aid diagnosis and management by a paediatric gastroenterologist or paediatric surgeon.
What are rare earth magnets?
Unlike traditional magnets, the powerful rare magnets are made of neodymium, iron and boron.
They are 5-10 times stronger than traditional magnets.
Powerful rare earth magnets are often found in:
- cordless tools
- hybrid electric cars
- cell phones
- MRI machines
- hard drives, and speakers
Does the number of magnets ingested matter?
After ingesting a single rare earth magnet, we expect intestinal peristalsis to push it through the GI system and out into the world. However, things become more serious when more than one magnet has been ingested or swallowed with another metal object. They attract each other across the loop of the intestine, causing serious complications such as perforation, intestinal fistula and possible death.
Even with early endoscopic removal, ulceration and indentation of the gastric mucosa may occur in less than eight hours.
The challenge of rare earth magnet ingestion
These magnets are small and easy to swallow. Common symptoms associated with foreign body ingestion, like gaging, drooling or choking, may be absent.
Parents should seek urgent medical advice if they witness the ingestion. Having obtained the history, the clinician can order an x-ray and liaise with the paediatric surgery team. The huge challenge is making the diagnosis if it is unwitnessed. Children may present in many ways, from symptomatic subtle symptoms to symptoms that mimic gastrointestinal symptoms.
Investigations
Plain X-ray remains the gold standard to find the magnet and follow its progress. Multiple views are required to clarify whether it is single or multiple. Many magnets may attract each other and appear like a single magnet in a single view.
Management of rare earth magnet ingestion
Taking a detailed history is the first step in management. Ingestion time: was it witnessed? How many magnets have been ingested? Any symptoms of abdominal pain or vomiting?
Examination – Does the child appear to be in pain or not? Does the abdominal examination favour of acute abdomen presentation like tenderness and guarding?
What does the observations chart show? Is the child tachycardic? Tachycardia could be a sign of intestinal perforation.
Plain X-ray – AP and lateral view. Taking two views is recommended as multiple magnets could get stuck together and appear like a single magnet, which leads to missing the proper management.
Early liaise with the paediatric surgery team or gastroenterology depending on the position of magnets and timing of ingestion. Transfer to a tertiary centre with paediatric surgery or gastroenterology facilities for potential removal.
Using laxatives to expedite movement is controversial. Despite the absence of published data to support this practice, clinicians still do it. Polyethylene glycol is used for colonoscopy preparation if magnets are lodged in the distal intestine.
Before discharge
- Advise the parents/carers to keep powerful rare-earth magnets away from children at home.
- Parents/carers should be made aware of information sharing for safeguarding.
The following algorithm has been taken from the Algorithm made by the North American Society for Paediatric Gastroenterology, Hepatology & Nutrition. (NASPGHAN)
Paediatric and Emergency doctors must be more vigilant about the seriousness of rare earth magnets. An informal survey of North American Society of Paediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) members in Spring 2012 identified significant morbidity in >80 magnet ingestions, which resulted in 39 endoscopies, 26 surgeries, 26 bowel perforations, and three bowel resections.
Learning points
Magnet ingestion is an emergency.
The number of ingested magnets or single magnets with other metal objects does matter. A single magnet ingestion can be treated conservatively; however, more than one magnet should be taken seriously.
Plain X-ray is the investigation of choice. It specifies the location and the progress of the ingested magnet. Take multiple views. If it is a case of more than one magnet ingestion, they could be stuck together, which could be interpreted wrongly as one magnet.
Liaise with paediatric surgery and paediatric gastroenterology early. Subsequent decisions could be made according to location and progress.
Complications are serious, including fistulae and intestinal perforations, and in the worst-case scenario, children can die.
Safeguarding: Parents should be made aware about sharing information with the safeguarding team.
Conclusion
Commercial magnet production has led to increased foreign body ingestion in children. The strong, attractive power of rare earth magnets can result in serious health complications. Ingesting a single magnet, multiple magnets or a single magnet with another metallic object can lead to life-threating complications that may jeopardize the patient’s long-term health or even cause death.
Increasing awareness among healthcare professionals and the public about the risks associated with magnets and powerful rare earth magnets is crucial. Particular emphasis on the danger of multiple ingestion.
Acknowledgements
We thank our patient’s family for consenting us to write about this case to help save other children and increase awareness among medical professionals and the public.
References
Hussain SZ, Bousvaros A, Gilger M, Mamula P, Gupta S, Kramer R, Noel RA. Management of ingested magnets in children. Journal of pediatric gastroenterology and nutrition. 2012 Sep 1;55(3):239-42.
Silverman JA, Brown JC, Willis MM, Ebel BE. Increase in pediatric magnet-related foreign bodies requiring emergency care. Annals of emergency medicine. 2013 Dec 1;62(6):604-8.
