Research Article
Incidental Ingestion of Rare-Earth Magnet Toys: A Disappearing Complication
Behrouz Banieghbal and Natasha Fourie*
Department of Pediatric Surgery, Tygerberg Hospital, University of Stellenbosch, South Africa
*Corresponding author: Natasha Fourie, Department of Pediatric Surgery, Tygerberg Hospital, University of Stellenbosch, PO Box 241, Cape Town 8000, South Africa
Published: 02 Nov, 2017
Cite this article as: Banieghbal B, Fourie N. Incidental
Ingestion of Rare-Earth Magnet Toys: A
Disappearing Complication. Clin Surg.
2017; 2: 1706.
Abstract
Purpose: Newly released toys made of small but powerful magnets, made of Rare-Earth Magnets
(REM), could easily be obtained in South Africa. This is done through online internet shops as well
as a number of retail shops. There is a small-print warning about ingestion hazards. However, in
practice, accidental ingestion of multiple magnets can result in significant gut injuries.
Material: Over a 6 years period (July 2009- August 2015), 8 children with REM ingestions were
seen. Seven requiring operative intervention.
Result: Laparotomy in all cases required disconnection and over-sewing of intra-luminal intestinal
fistulae/perforations. No morbidity or mortality was noted in this cohort. One patient who ingested
a single magnet was treated non-operatively.
Conclusion: Ingestion of more than one REM-made toy is dangerous and there is increasing
regulation to ban these new magnetic toys.
Keywords: Magnets; Intestinal fistula; Rare-Earth Alloys; Bowel obstruction; Laparoscopy
Introduction
Foreign body (FB) ingestion is undoubtedly common in children and in a recent survey, more
than 125,000 ingestion of FB in children were reported to American Poison Centre. Most ingested
foreign objects readily pass through the GIT and FB ingestion is not commonly considered on the
differential diagnosis of acute abdominal pain.
In a recent cross-sectional survey of parents of more than 1500 children, 4% of the children had
swallowed a coin. Almost no material causes complications once they have pass the oesophagus, the
exception is wooden tooth picks [1].
In the past 20 years a new FB has been found as an ingested, Rare-Earth Magnets (REM) is
recently discovered alloys. They are magnetized and have a powerful magnetic field many times
stronger, unlike older iron based magnets. The most widely available type is Neodymium-Iron-
Boron alloy which is commercially manufactured and used mostly in electronics industry.
They also became commonly available in the open market due to its low cost and marketed as
puzzle-like toys in 1990’s.
Because many look similar to silver or color cake ball decoration, they are mistakenly ingested
by young children. Accidental ingestion of REMs is reported to be hazardous in a large international
review, which did not include Africa [2]. This is the first large cases report which high lights
implication of REMs ingestion in Africa.
Patients and Methods
In a retrospective review over a 6-year period (July 2009- August 2015), eight children with
ingestion of toy REMs were treated by the author in Johannesburg, South Africa. There were 7 males
and 1 female. Seven required operative intervention due to signs and symptoms of peritonitis. Age
range of patients was from 2 to 11 years.
Three parents obtained the magnets from car dealerships as gifts and the remaining 5 bought
them from online toy-companies, music stores and curiosity shops.
Five children were seen by doctors in emergency rooms and they were treated conservatively as
any other benign foreign body in the gastro-intestinal tract. Repeat X-rays a week later confirmed non-passage and referral to pediatric surgeons.
Because of this delay surgical intervention was delayed 4 -12 days
post-ingestion of REMs.
Written parental consents were obtained for ethics requirement.
Figure 1
Figure 2
Figure3
Figure 4
Results and Discussion
In all but one patient worsening abdominal pain and clinical signs
of peritonism necessitated surgical intervention. Symptoms appear to
occur within 3-4 days after ingestion in 4 patients who could verbalize
adequately; they confirmed that they ingested REMs one at a time
over period of minutes to hours apart.
In 2 cases, abdominal X-ray was suggestive of REMs within the
stomach (Figure 1). These patients underwent endoscopic attempt
at extraction but it was only partially successful by removing a few
magnets (Figure 2a,2b). In one other, patient laparoscopic evaluation
confirmed the presence of an entero-colic fistula but repair and
extraction of the magnets deemed too complicated and the procedure
was converted to open laparotomy.
Irrespective of the REM configuration on X-ray, significant gut
injuries were caused.
Ingested REMs produced “pinching-type” injuries, in all 7 cases,
resulting in intra-luminal intestinal fistulae with minor collection of
pus around them (Figure 3a,3b). This was entero-enteric in 4 cases,
gastro-duodenal in 2 and entero-colic in 1 case.
In one patient; ingestion of 2 REMs was enough to cause an
entero-colic fistula. In the remainder cases, 4 to 20 magnets were
ingested. These either remained more or less in a straight line (5
cases) (Figure 4, and 1) or produced a ring (2 cases).
In one case, a single magnet was incidentally noted in the sigmoid
colon during follow-up angiography in a patient with a cardiac lesion.
This ingested magnet passed the next day per rectum facilitated by
usage of rectal enema.
There were no peri-operative or post-operative complications
in operative cases. Patients were discharged home day 5-8 post
operatively. No surgical complications were noted at 6-week followup.
Conclusion
REMs are strong permanent magnets made from alloys of rare
earth elements. They are the strongest type of permanent magnets
made, producing significantly stronger magnetic fields than other
types such as ferrite or alnico magnets. The magnetic field produced
by rare-earth magnets can be in excess of 1.5 teslas, whereas ferrite or
ceramic magnets typically exhibit fields of 0.2 to 0.5 tesla [3].
There are hundreds of types of REMs manufactured in the past
4 decades; the first was described in 1966 by an American scientist,
Dr. K. Strnat of the U.S. Air Force as an alloy of Samarium-Cobalt
(SmCo5) compound, but it was not immediately used in industry due
to its high manufacturing cost.
In 1983, a new REM was described when General Motors,
Sumitomo Special Metals and the Chinese Academy of Sciences,
independently, developed a high energy product from Neodymium-
Iron-Boron (Nd2Fe14B) compound.
This new alloy is extensively used in many electrical and electronic
devices such as hard drives and cordless tools. After the lapse of patent
in 2002, many non-industrial usages of REM commenced. Its usage
in children’s toys became a common commercial success since (e.g.
Buckyballs®, Maxfield & Oberton Holdings LLC, New York, N.Y). At
about the same time, the first report of bowel injuries surfaced [3] and
first fatality in 2005 was recorded [4]. Since then there has been a total
of 12 anecdotal reports in the medical literature [5,6] and many more
in various lay-press news outlets.
Symptoms in our patients appear to occur within a few days after
ingestion of REMs which is similar to reports from at least one other
center [7].
The mechanism of injury is assumed to be pressure necrosis due
to pinching of bowel by ingestion of these powerful magnets [4],
which is swallowed by a child at different times. In two cases with ring
effect, REMs were probably ingested minutes apart, causing pressure
necrosis in stomach/duodenal area rather than in small bowel when
ingestion was hours apart.
Ingestion of a single magnet and possibly a group of magnets
attached together does not cause injury, as was noted in one of our
cases.
In a number of developed countries, REMs toy manufacturers and
suppliers of these magnets are either banned completely or required
to place extensive and large print warnings about this danger on their
website and on the packages.
Likewise, South African Consumer Protection Act has strict
measures with regard to false advertising but only for print media [5].
However, due to relatively lax online advertising laws in South Africa,
these warnings are rarely adhered to. There are at least 2 online
companies and 1 retail music store which sell REMs with minimal
warning about dangers to children. The packaging suggests in smallprint
that “in case of ingestion, medical attention must be sought”.
This warning is woefully insufficient and does not signify potentially
fatal consequence of REMs ingestion to the parents. This is relative
to more stringent warning label recommended in more developed
countries [6].
This report confirms that REMs ingestion is not easily recognized
by many doctors due to its novelty and rarity but ingestion of even
2 REMs can result in intra-luminal fistula. Rapid ingestion of high
number of REMs causes gastro-duodenal injury and/or fistula due
to ring effect.
Endoscopic or laparoscopic removal appears to be futile; once a
ring is formed in upper gastro-intestinal (GI) tract or if it has passed
through the duodenum because of the complexity of the fistulae
formed.
This is a different outcome to those made by other authors, where
an early recognition and immediate attempt at upper GI endoscopic
removal of REMs was possible in a minority of cases [2,8].
REM toys are dangerous and even fatal if ingested. By definition,
toys are ultimately designed for children’s use and virtually no adults
will play with magnetic toys. Therefore, it is recommended that these
dangerous toys are banned irrespective of warning labels. Social and
published media have had positive impact and most companies no
longer advertise or sell these products.
References
- Budnick LD. Toothpick-related injuries in the United States, 1979-82. JAMA.1984;252(6):796-7.
- Oestreich AE. Worldwide survey of damage from swallowing multiple magnets. Pediatr Radiol. 2009;39(2):142-7.
- Cullity BD, Graham CD. Introduction to Magnetic Material. J. Wiley &Sons. NJ, USA. 2008;489-96.
- Cox S, Brown R, Millar A, Numanoglu A, Alexander A, Theron A. The risks of gastrointestinal injury due to ingested magnetic beads. S Afr Med J. 2014;104(4):277-8.
- Consumer Product Safety Commission. Release 06-127. Washington, DC: Consumer Product Safety Commission; March 31, 2006.
- Centers for Disease Control and Prevention (CDC). Gastrointestinal injuries from magnet ingestion in children--United States, 2003-2006. MMWR Morb Mortal Wkly Rep. 2006;55(48):1296-300.
- Cauchi JA, Shawis RN. Multiple magnet ingestion and gastrointestinal morbidity. Arch Dis Child. 2002;87(6):539-40.
- South African Consumer Protection Act.