Downloaded from http://adc.bmj.com/ on October 24, 2015 - Published by group.bmj.com
Case report
How dangerous a toy can be? The magnetic effect Mohamed Sameh Shalaby1,2 1
Department of Paediatric Surgery, Bristol Royal Children’s Hospital, Bristol, UK 2 Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt Correspondence to Mohamed Sameh Shalaby, Department of Paediatric Surgery, Bristol Royal Children’s Hospital, Upper Maudlin Street, Bristol BS2 8BJ, UK; [email protected] Received 20 October 2014 Revised 4 March 2015 Accepted 10 March 2015 Published Online First 31 March 2015
ABSTRACT During the last decade, there has been a significant increase in the number of magnetic toys available for children. Two or more magnets separate from each other along the gastrointestinal course can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation. This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. We report the ingestion of a large number of magnets from one toy (>60 pieces). Our patient presented with generalised peritonitis and shock. During emergency laparotomy, she was found to have gross abdominal contamination with multiple bowel perforations and fistulae. This report emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from ‘unsupervised’ ingestion of these ‘nice-looking’ toys. CASE HISTORY
▸ http://dx.doi.org/10.1136/ archdischild-2015-308313
To cite: Shalaby MS. Arch Dis Child 2015;100: 1049–1050.
A 12-year-old girl presented to the District General Hospital with abdominal pain and green vomiting. Urgent abdominal CT showed multiple foreign bodies (FBs). She was transferred to our centre for definitive management. On arrival, she was tachycardiac, confused with generalised abdominal tenderness. Plain X-ray (figure 1) revealed multiple (>60) pieces of magnets in her upper abdomen and right iliac fossa. She was taken to theatre for emergency laparotomy that revealed gross abdominal contamination with multiple small pieces of magnets attached to each other and occupying her distal stomach and proximal duodenum. There were also two mid-small bowel perforations with magnets protruding extra-luminal (figure 2). In addition, there were three separate holes in her right colon with additional magnets in her caecum. Her gastric and duodenal magnets were removed through an anterior gastrotomy. Some of the gastric magnets were used to attract the duodenal magnets that allowed their extraction through the same gastrotomy. The anterior gastrotomy was then closed in two layers. Her perforated mid-small bowel was resected with primary anastomosis. Finally, right hemi-colectomy was performed to deal with her colonic perforations with formation of ileostomy and mucous fistula. Intraoperative fluoroscopy was helpful to confirm removal of all the magnets. Her postoperative course was complicated with wound infection and superficial dehiscence that was managed with vacuum dressing. Postoperatively, she confirmed swallowing the magnets a month ago from her ‘nice-looking’ magnetic toy over a week period because she was ‘bored’. This was one toy that consists of more than 70 pieces of small magnets of different sizes, shapes and colours (figure 3). She had an extensive input from the
social services, child protection team, psychologists, dieticians and stoma nurse specialist. The conclusion of their input was that she does not have any feeding, social or psychological condition that prompted this behaviour and this was a ‘one-off ’ behaviour. She remained an in-patient for around a month then discharged with plans for elective stoma reversal in 6-month time.
BRIEF DESCRIPTION OF THE CONDITION Most of the ingested FBs will pass uneventfully once they reach the stomach. During the last decade, there has been a significant increase in the number of magnetic toys available for children.1 Two or more magnets can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation.1 This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. This is the first report describing the ingestion of such a large number of magnets from one toy. It emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from the ‘unsupervised’ ingestion of these ‘nice-looking’ toys.
How common is it? In one study, the prevalence of magnetic FB ingestions reported to the total number of FB ingestions was 1.97% with 79% of them being a single magnet.1 It has been well documented that the incidence of magnet ingestions among children has been dramatically rising in the past year.2 3
Why is it missed? ‘Although the US Consumer Product Safety Commission had mandated magnet toys to be marketed as “adult toys” and not to be sold to children under the age of 14 years, yet thousands of sets were in houses across the US. Many of these are high-powered magnets. Consequently, these magnets are easily and unknowingly ingested by toddlers and children2’. These magnets are ‘nice-looking’, small and colourful with a quite innocent-appearance that most of the parents will not consider them as dangerous toys that they should particularly supervise their children when they are playing with them. Most of the physicians are aware of the benign natural course following ingestion of blunt FBs. The presence of large number of colourful magnets in the children’s toys has only started to appear commercially in the recent years and its damaging serious effect is not yet appreciated.
Why does it matter? Multiple magnet ingestion can cause bowel perforations, intestinal fistulae, obstruction and death.1–5 Cox et al6 have reproduced this effect by placing
Shalaby MS. Arch Dis Child 2015;100:1049–1050. doi:10.1136/archdischild-2014-307756
1049
Downloaded from http://adc.bmj.com/ on October 24, 2015 - Published by group.bmj.com
Case report
Figure 3
Some of the removed magnets.
Figure 1 Preoperative X-ray showing multiple magnets in the upper abdomen and right iliac fossa.
HOW IS IT MANAGED? magnetic toy beads within a porcine bowel and demonstrated that perforation from magnet appeared ‘extremely rapidly’. Hence, a child with suspected ingestion of a magnetic object should be referred immediately to a gastroenterologist/surgeon so that it can be removed before bowel injury.4 5
HOW IS IT DIAGNOSED? Clinical Diagnosis is based on a high index of suspicion. Patients may be completely asymptomatic; however, if intestinal complications have occurred (usually between 1 and 7 days after ingestion7), they may suffer from abdominal pain, green vomiting, haematemesis, peritonitis or even shock as in our case.
Investigations Plain X-ray of the abdomen can be enough to confirm the diagnosis. In some cases, two views might be required to ascertain the number of magnets.
Authors universally recommend removal of multiple magnetic FBs before symptoms occur.1 For ingestions of single magnetic FBs, recommendations include close observation, repeat abdominal radiographs within a few hours to assure advancement of the FB and if it remains in the same position, the magnetic FB may be entrapping bowel, and surgical intervention is required.1 It is important that the significant morbidity associated with magnet ingestion is appreciated and prompt intervention is carried out to avoid serious complications.
HOW CAN THIS REPORT CONTRIBUTE TO PREVENTING MISSED CASES? The NASPGHAN published their guidelines2 that involved: 1. Educating physicians and the public about the management of this new hazard. 2. Liaise with government leaders for the removal of these hazardous toys from the shelves of retailers, and possibly for a ban. The aim of this work is to further emphasis the need for strong actions to protect our children from these dangerous toys and improve the public and physicians awareness of the need for seeking immediate surgical/gastroenterological advice to prevent the serious and potentially fatal outcome of ingesting these ‘nice-looking’ toys. Contributors MSS is the first and only author and acts as guarantor. MSS reviewed the literature, drafted and critically revised the submitted manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2
3 4 5 6
Figure 2 Two mid-small bowel perforations with magnets protruding extra-luminal. 1050
7
Tavarez MM, Saladino RA, Gaines BA, et al. Prevalence, clinical features and management of pediatric magnetic foreign body ingestions. J Emerg Med 2013;44:261–8. Bousvaros A, Bonta C, Gilger M, et al. Advocating for child health: how the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition took action against high-powered magnets. J Pediatr 2014;164:4–5. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg 2014;207:754–9. Pryor H, Lange PA, Bader A, et al. Multiple magnetic foreign body ingestion: a surgical problem. J Am Coll Surg 2007;205:182–6. Schierling S, Snyder SK, Custer M, et al. Magnet ingestion. J Pediatr 2008;152:294. Cox S, Brown R, Millar A, et al. The risks of gastrointestinal injury due to ingested magnetic beads. S Afr Med J 2014;104:277–8. Kim Y, Hong J, Moona S. Ingestion of multiple magnets: the count does matter. J Ped Surg Case Reports 2014;2:130–2.
Shalaby MS. Arch Dis Child 2015;100:1049–1050. doi:10.1136/archdischild-2014-307756
Downloaded from http://adc.bmj.com/ on October 24, 2015 - Published by group.bmj.com
How dangerous a toy can be? The magnetic effect Mohamed Sameh Shalaby Arch Dis Child 2015 100: 1049-1050 originally published online March 31, 2015
doi: 10.1136/archdischild-2014-307756 Updated information and services can be found at: http://adc.bmj.com/content/100/11/1049
These include:
References Email alerting service
This article cites 7 articles, 0 of which you can access for free at: http://adc.bmj.com/content/100/11/1049#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Case report
How dangerous a toy can be? The magnetic effect Mohamed Sameh Shalaby1,2 1
Department of Paediatric Surgery, Bristol Royal Children’s Hospital, Bristol, UK 2 Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt Correspondence to Mohamed Sameh Shalaby, Department of Paediatric Surgery, Bristol Royal Children’s Hospital, Upper Maudlin Street, Bristol BS2 8BJ, UK; [email protected] Received 20 October 2014 Revised 4 March 2015 Accepted 10 March 2015 Published Online First 31 March 2015
ABSTRACT During the last decade, there has been a significant increase in the number of magnetic toys available for children. Two or more magnets separate from each other along the gastrointestinal course can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation. This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. We report the ingestion of a large number of magnets from one toy (>60 pieces). Our patient presented with generalised peritonitis and shock. During emergency laparotomy, she was found to have gross abdominal contamination with multiple bowel perforations and fistulae. This report emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from ‘unsupervised’ ingestion of these ‘nice-looking’ toys. CASE HISTORY
▸ http://dx.doi.org/10.1136/ archdischild-2015-308313
To cite: Shalaby MS. Arch Dis Child 2015;100: 1049–1050.
A 12-year-old girl presented to the District General Hospital with abdominal pain and green vomiting. Urgent abdominal CT showed multiple foreign bodies (FBs). She was transferred to our centre for definitive management. On arrival, she was tachycardiac, confused with generalised abdominal tenderness. Plain X-ray (figure 1) revealed multiple (>60) pieces of magnets in her upper abdomen and right iliac fossa. She was taken to theatre for emergency laparotomy that revealed gross abdominal contamination with multiple small pieces of magnets attached to each other and occupying her distal stomach and proximal duodenum. There were also two mid-small bowel perforations with magnets protruding extra-luminal (figure 2). In addition, there were three separate holes in her right colon with additional magnets in her caecum. Her gastric and duodenal magnets were removed through an anterior gastrotomy. Some of the gastric magnets were used to attract the duodenal magnets that allowed their extraction through the same gastrotomy. The anterior gastrotomy was then closed in two layers. Her perforated mid-small bowel was resected with primary anastomosis. Finally, right hemi-colectomy was performed to deal with her colonic perforations with formation of ileostomy and mucous fistula. Intraoperative fluoroscopy was helpful to confirm removal of all the magnets. Her postoperative course was complicated with wound infection and superficial dehiscence that was managed with vacuum dressing. Postoperatively, she confirmed swallowing the magnets a month ago from her ‘nice-looking’ magnetic toy over a week period because she was ‘bored’. This was one toy that consists of more than 70 pieces of small magnets of different sizes, shapes and colours (figure 3). She had an extensive input from the
social services, child protection team, psychologists, dieticians and stoma nurse specialist. The conclusion of their input was that she does not have any feeding, social or psychological condition that prompted this behaviour and this was a ‘one-off ’ behaviour. She remained an in-patient for around a month then discharged with plans for elective stoma reversal in 6-month time.
BRIEF DESCRIPTION OF THE CONDITION Most of the ingested FBs will pass uneventfully once they reach the stomach. During the last decade, there has been a significant increase in the number of magnetic toys available for children.1 Two or more magnets can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation.1 This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. This is the first report describing the ingestion of such a large number of magnets from one toy. It emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from the ‘unsupervised’ ingestion of these ‘nice-looking’ toys.
How common is it? In one study, the prevalence of magnetic FB ingestions reported to the total number of FB ingestions was 1.97% with 79% of them being a single magnet.1 It has been well documented that the incidence of magnet ingestions among children has been dramatically rising in the past year.2 3
Why is it missed? ‘Although the US Consumer Product Safety Commission had mandated magnet toys to be marketed as “adult toys” and not to be sold to children under the age of 14 years, yet thousands of sets were in houses across the US. Many of these are high-powered magnets. Consequently, these magnets are easily and unknowingly ingested by toddlers and children2’. These magnets are ‘nice-looking’, small and colourful with a quite innocent-appearance that most of the parents will not consider them as dangerous toys that they should particularly supervise their children when they are playing with them. Most of the physicians are aware of the benign natural course following ingestion of blunt FBs. The presence of large number of colourful magnets in the children’s toys has only started to appear commercially in the recent years and its damaging serious effect is not yet appreciated.
Why does it matter? Multiple magnet ingestion can cause bowel perforations, intestinal fistulae, obstruction and death.1–5 Cox et al6 have reproduced this effect by placing
Shalaby MS. Arch Dis Child 2015;100:1049–1050. doi:10.1136/archdischild-2014-307756
1049
Downloaded from http://adc.bmj.com/ on October 24, 2015 - Published by group.bmj.com
Case report
Figure 3
Some of the removed magnets.
Figure 1 Preoperative X-ray showing multiple magnets in the upper abdomen and right iliac fossa.
HOW IS IT MANAGED? magnetic toy beads within a porcine bowel and demonstrated that perforation from magnet appeared ‘extremely rapidly’. Hence, a child with suspected ingestion of a magnetic object should be referred immediately to a gastroenterologist/surgeon so that it can be removed before bowel injury.4 5
HOW IS IT DIAGNOSED? Clinical Diagnosis is based on a high index of suspicion. Patients may be completely asymptomatic; however, if intestinal complications have occurred (usually between 1 and 7 days after ingestion7), they may suffer from abdominal pain, green vomiting, haematemesis, peritonitis or even shock as in our case.
Investigations Plain X-ray of the abdomen can be enough to confirm the diagnosis. In some cases, two views might be required to ascertain the number of magnets.
Authors universally recommend removal of multiple magnetic FBs before symptoms occur.1 For ingestions of single magnetic FBs, recommendations include close observation, repeat abdominal radiographs within a few hours to assure advancement of the FB and if it remains in the same position, the magnetic FB may be entrapping bowel, and surgical intervention is required.1 It is important that the significant morbidity associated with magnet ingestion is appreciated and prompt intervention is carried out to avoid serious complications.
HOW CAN THIS REPORT CONTRIBUTE TO PREVENTING MISSED CASES? The NASPGHAN published their guidelines2 that involved: 1. Educating physicians and the public about the management of this new hazard. 2. Liaise with government leaders for the removal of these hazardous toys from the shelves of retailers, and possibly for a ban. The aim of this work is to further emphasis the need for strong actions to protect our children from these dangerous toys and improve the public and physicians awareness of the need for seeking immediate surgical/gastroenterological advice to prevent the serious and potentially fatal outcome of ingesting these ‘nice-looking’ toys. Contributors MSS is the first and only author and acts as guarantor. MSS reviewed the literature, drafted and critically revised the submitted manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2
3 4 5 6
Figure 2 Two mid-small bowel perforations with magnets protruding extra-luminal. 1050
7
Tavarez MM, Saladino RA, Gaines BA, et al. Prevalence, clinical features and management of pediatric magnetic foreign body ingestions. J Emerg Med 2013;44:261–8. Bousvaros A, Bonta C, Gilger M, et al. Advocating for child health: how the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition took action against high-powered magnets. J Pediatr 2014;164:4–5. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg 2014;207:754–9. Pryor H, Lange PA, Bader A, et al. Multiple magnetic foreign body ingestion: a surgical problem. J Am Coll Surg 2007;205:182–6. Schierling S, Snyder SK, Custer M, et al. Magnet ingestion. J Pediatr 2008;152:294. Cox S, Brown R, Millar A, et al. The risks of gastrointestinal injury due to ingested magnetic beads. S Afr Med J 2014;104:277–8. Kim Y, Hong J, Moona S. Ingestion of multiple magnets: the count does matter. J Ped Surg Case Reports 2014;2:130–2.
Shalaby MS. Arch Dis Child 2015;100:1049–1050. doi:10.1136/archdischild-2014-307756
Downloaded from http://adc.bmj.com/ on October 24, 2015 - Published by group.bmj.com
How dangerous a toy can be? The magnetic effect Mohamed Sameh Shalaby Arch Dis Child 2015 100: 1049-1050 originally published online March 31, 2015
doi: 10.1136/archdischild-2014-307756 Updated information and services can be found at: http://adc.bmj.com/content/100/11/1049
These include:
References Email alerting service
This article cites 7 articles, 0 of which you can access for free at: http://adc.bmj.com/content/100/11/1049#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
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