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research-article2013
CPJXXX10.1177/0009922813507129Clinical PediatricsRoo et al
Article
Rare-Earth Magnet Ingestion–Related Injuries Among Children, 2000-2012
Clinical Pediatrics 52(11) 1006–1013 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813507129 cpj.sagepub.com
Ana C. De Roo, BA1,2, Meghan C. Thompson, BA1,2, Thiphalak Chounthirath, MS1, Huiyun Xiang, MD, PhD, MPH1,2, Nancy A. Cowles3, Liliya Shmuylovskaya, MA3, and Gary A. Smith, MD, DrPH1,2,4
Abstract This study describes the epidemiology of rare-earth magnet ingestion by children by retrospectively analyzing 72 cases of magnet ingestion collected from Saferproducts.gov and the US Consumer Product Safety Commission from 2000 through 2012. The mean child age was 6.4 years. Patients ingested between 1 and 40 magnets, most often 1 to 4 magnets. Unique circumstances of ingestion included faux piercing (19.4%) and mistaking magnets for candy (6.9%). Surgery was required in 69.7% of cases where treatment was reported. Fifty-three patients were hospitalized (73.6%), and the length of hospital stay was reported in 58.5% of those cases, ranging from 1 to 54 days. Approximately half (50.7%) of the magnets causing injury were products intended for use by adults. Study findings demonstrate that pediatric ingestion of rare-earth magnets can cause serious gastrointestinal injury. Establishing a performance standard that limits the attraction force of these magnets offers the best prevention solution to this important pediatric public health problem. Keywords magnet, ingestion, injury, foreign body, pediatric, children
Introduction Children commonly ingest foreign bodies, which usually pass through the gastrointestinal tract with a benign outcome. However, in rare cases, such as when a child swallows multiple powerful magnets, life-threatening internal injuries are possible. A solitary ingested magnet is similar to other foreign bodies, but dangerous situations arise once a subsequent magnet or metal object is ingested. Powerful rare-earth magnets, commonly consisting of alloys of neodymium iron boron or samarium cobalt,1 are popular as desk toys for adults and were previously found in construction toys for children. These 3 to 6 millimeter diameter magnets2 are capable of attracting each other through up to 6 layers of bowel wall3 and are strong enough to reposition the intestines in order to meet. On joining through bowel wall, the magnets can produce pressure ulcers, ischemic injury, obstructions, fistulae, necrosis, and perforations.4-8 Treatment may be as simple as waiting for the magnet to pass through the digestive tract naturally, but can be as serious as bowel resection surgery.9 In one reported case, a 2-year-old died of sepsis before rare-earth magnet ingestion was discovered and treated.10 Following this fatality, the US Consumer Product Safety Commission (CPSC) issued
multiple voluntary recalls of toys containing these strong magnets,11-13 but other products containing rareearth magnets remain on the market and continue to cause injury among children. Previous studies have found the majority of patients to be younger than 7 years of age and note a preponderance of males, ranging from 55% to 72%.5,14 Many studies note the number of magnets ingested, most often ranging from 2 to 5 magnets.14 Some studies suggest a correlation with autism and other psychological conditions.14,15 The American Academy of Pediatrics; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; and the 1
Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA 2 The Ohio State University College of Medicine, Columbus, OH, USA 3 Kids in Danger, Chicago, IL, USA 4 Child Injury Prevention Alliance, Columbus, OH, USA Corresponding Author: Gary A. Smith, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. Email: [email protected]
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Roo et al Centers for Disease Control and Prevention have highlighted the danger of rare-earth magnet ingestion in their publications.16,17 Media reports, case reports in the medical literature, comprehensive literature reviews, and small surveys in the medical field have drawn attention to pediatric injuries resulting from swallowing magnets. This study includes up-to-date information on pediatric rare-earth magnet ingestion and adds previously unreported information about these ingestions, including delays in treatment, reasons for delay, treatment details, mechanism of ingestion, length of hospital stay, whether the ingestion was witnessed, and owner of the magnets. This article aims to increase physician and public awareness about rare-earth magnet ingestion by children as a serious public health problem.
Methods Data regarding children 15 years of age or younger with a magnet-associated injury from 2000 through August 2012 were obtained from 2 CPSC databases, the “Injury or Potential Injury Incident Database” and the “In-Depth Investigation Database.” The former database collects product-related incidents reported by consumers and makes this information available on the website, Saferproducts.gov. The latter database consists of injury incidents reported to the CPSC, which were selected for an in-depth investigation (IDI) by CPSC staff based on various factors, including injury severity. IDIs provide detailed information about these selected injury incidents. Reports from both databases include city, state, age and gender of the injured person, medical disposition, injury diagnosis, and body parts involved. Accompanying each case is a narrative describing the injury, or a full report for the IDI cases, which was used to create additional variables. Mechanism of injury was specified as follows: (a) magnet used as faux piercing, (b) magnet mistaken for candy, (c) magnet ingestion, not otherwise specified, and (d) magnet swallowed when using teeth or mouth to separate or carry magnets. Each case was limited to a single clinical outcome from the following possibilities: (a) no adverse effects, (b) magnet lodged in bowel, (c) bowel obstruction, (d) volvulus, (e) ulcer, (f) single perforation, (g) fistula, (h) multiple perforations and necrosis, and (i) unspecified damage. The decision rule used to assign clinical outcome when more than one outcome was listed was based on severity of injury: multiple perforations and necrosis took precedence over a fistula, which took precedence over a single perforation, which took precedence over ulcers. Bowel obstruction was a commonly documented outcome; 2 cases noted bowel obstruction
as the only outcome and these were coded as such. In all other cases of bowel obstruction, a second, more specific injury that likely preceded the obstruction in clinical course was recorded and coded instead. The detailed case reports provided information regarding the duration of delay in treatment and the reasons for these delays, which included the following: (a) ambiguous symptoms, (b) incorrect diagnosis/discharged, (c) patient did not report ingesting magnets, and (d) scheduled appointment for later date. The owner of the magnet was categorized as follows: (a) patient, (b) sibling, young relative, friend or classmate, (c) childcare or school, and (d) parent or adult relative. Using the narratives, we also identified the occurrence of long-term sequelae, the number of magnets ingested, the number of days spent in the hospital, any concurrent ingestion of metal, whether or not the event was witnessed, whether the toy was meant for adults or children, and whether imaging technology was used. Duplicate cases and nonmagnet ingestions were excluded. A case involving multiple intravesicular magnets and a case involving magnet-related lip injury were also excluded. Data were analyzed using SPSS 19.0 (SPSS Inc, Chicago, IL) and SAS Version 9.3 (SAS Institute, Inc, Cary, NC) statistical software.
Results Demographics From 2000 through August 2012, there were 72 case reports of children injured by rare-earth magnet ingestion, of which 72.2% (52/72) included an in-depth investigation report. Those injured ranged from 9 months to 15 years of age. The mean age of those injured was 6.4 years, with a median age of 6.5 years, and a mode of 8 years (8-year-olds represented 15.3% [11/72] of cases; Figure 1). Males comprised 54.2% (39/72) of the study sample. All injured children 12 years or older were female (9 cases), and males represented 61.9% (39/63) of injured children younger than 12 years of age.
Number of Magnets Swallowed and Mechanism of Ingestion The number of magnets ingested ranged from 1 to 40, and multiple magnet ingestion without a specified number was reported in 12.5% (9/72) of cases (Figure 2). Ingestion of 2 to 4 magnets comprised 44.4% (32/72) of cases. Eleven percent of cases (8/72) involved concurrent metal and magnet ingestion, of which 87.5% (7/8) involved more than 1 magnet. Females swallowed
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Figure 1. Number of children injured by ingesting magnets by age and gender, 2000-2012.
Figure 2. Number of magnets ingested with or without concurrent metal ingestion by gender, 2000-2012. *More than 1 magnet ingested, but exact number is unspecified.
magnets when using them as faux tongue or lip piercings in 13.9% (10/72) of cases, more than double the number for males (5.6%; 4/72; Table 1). Children 10 to 15 years old accounted for 71.4% (10/14) of ingestions involving fake piercing. When used as a fake piercing, 21.4% (3/14) of the children stated that the 2 magnets “snapped
together” and rolled to the back of the throat, causing them to unintentionally swallow the magnets. Mistaking magnets for candy was noted specifically in 6.9% (5/72) of cases. Using teeth to separate 2 magnets or carrying magnets in the mouth were implicated in 4.2% (3/72) of cases.
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Roo et al Table 1. Circumstances of Magnet Ingestion by Gender.a Mechanism of Ingestion
Male, n (%)
Female, n (%)
Total, n (%)
Faux piercing Mistaken for candy Ingestion, not otherwise specified Using teeth/mouth to carry/separate
4 (5.6) 3 (4.2) 31 (43.1) 1 (1.4)
10 (13.9) 2 (2.8) 19 (26.4) 2 (2.8)
14 (19.4) 5 (6.9) 50 (69.4) 3 (4.2)
Total
39 (54.2)
33 (45.8)
72 (100.0)
a
All percentages are expressed as a percentage of 72 total cases. Some percentages may not sum to the column totals because of rounding error.
Table 2. Clinical Outcome of Magnet Ingestion by Gender.a Outcome
Male, n (%)
Female, n (%)
Total, n (%)
No adverse effects Fistula Volvulus Ulcer Perforation Bowel obstruction Magnet lodged in bowel Multiple perforations and necrosis Unspecified damage
8 (11.9) 2 (3.0) 1 (1.5) 1 (1.5) 3 (4.5) 1 (1.5) 2 (3.0) 15 (22.4) 3 (4.5)
14 (20.9) — — 2 (3.0) 1 (1.5) 1 (1.5) 2 (3.0) 8 (11.9) 3 (4.5)
22 (32.8) 2 (3.0) 1 (1.5) 3 (4.5) 4 (6.0) 2 (3.0) 4 (6.0) 23 (34.3) 6 (9.0)
Total
36 (53.8)
31 (46.3)
67 (100.0)
a
Five of 72 cases (6.9%) had missing data. All percentages are expressed as a percentage of 67 total cases. The percentages in the Total column do not sum to 100.0% because of rounding error.
Outcome Clinical outcomes were specified in 93.1% (67/72) of cases; of those, 32.8% (22/67) noted no adverse effects, the majority of which involved females (Table 2). Multiple perforations and necrosis occurred in 34.3% (23/67) of cases where outcome was specified, with nearly twice as many of these cases occurring among males.
Treatment The medical treatment of the patient was reported in 91.7% (66/72) of cases. Surgical intervention was required in 69.7% (46/66) of children where treatment was reported (Table 3). Excision of at least one section of intestine was required in 16.7% (11/66) of cases, and 4.5% (3/66) of cases required multiple surgeries. Removal of magnets via endoscope or colonoscope was possible in 7.6% (5/66) of the reported cases, and for 21.2% (14/66) of the patients, the magnets passed naturally.
Table 3. Treatment and Outcome of Children Injured by Ingesting Magnets. Treatment/outcome
Number (%)
Surgery (all) Surgery Excision of intestinal segments Multiple surgeries Magnets passed naturally Endoscopic or colonoscopic removal Death
46 (69.7) 32 (48.5) 11 (16.7) 3 (4.5) 14 (21.2) 5 (7.6) 1 (1.5)
Total
66 (100.0)
days spent in the hospital was documented for 58.5% (31/53) of those hospitalized (Figure 3), ranging from 1 to 54 days. A hospital stay of “several” days, but no exact count, was noted for 9.4% (5/53) of cases.
Other Descriptive Details
Hospitalization Admission to the hospital was a consequence of magnet ingestion for 73.6% (53/72) of patients. The number of
Descriptive information about the magnetic product causing injury was recorded in 95.8% (69/72) of cases; using that information, the intended age group for use of
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Figure 3. Number of days of hospitalization for children injured by ingesting magnets, 2000-2012. Data were available for 58.5% (31/53) of the children who were hospitalized.
the magnetic product could be identified. Among those cases, 49.3% (34/69) of magnets were intended for use by children (eg, construction toys) and the remaining 50.7% (35/69) were intended for use by adults (eg, desk toys). Among 10- to 15-year-olds, 88.9% (16/18) of magnet ingestions were products intended for use by adults. The owner of the magnets was noted in 70.8% (51/72) of cases. The ingested magnets belonged to the patient in 47.1% (24/51) of the cases in which the owner was noted. A parent or adult relative owned the magnets in 7.8% (4/51) of cases, and the magnets belonged to another child, such as a sibling, young relative, classmate, or friend, in 37.3% (19/51) of cases. In 7.8% (4/51) of cases, the magnets were owned by a school or childcare facility. Ingestion was directly witnessed in only a single case, although nearly two thirds (63.9%; 46/72) of cases noted whether or not the ingestion was witnessed or the patient admitted to the ingestion. Of those cases, patients admitted to swallowing magnets 54.3% (25/46) of the time, and in one case, a 12-year-old girl only reported the ingestion after a classmate was hospitalized with serious injuries following magnet ingestion. Of the 65.3% (47/72) of cases where medical imaging was performed, 91.5% (43/47) of children received x-rays and 8.5% (4/47) received computed tomography scans. The length of delay in treatment and reasons for the delay were noted in 45.8% (33/72) of cases. Treatment
delay ranged from 1 day to 2 months (Figure 4). Documented reasons for the delay were ambiguous symptoms (54.6%; 18/33), followed by incorrect diagnosis (21.2%; 7/33), the patient withholding information about the ingestion (21.2%; 7/32), and an upcoming scheduled appointment (3.0%; 1/33). Among the cases in which delay was noted, 63.6% (21/33) of patients suffered multiple intestinal perforations and necrosis; of those, 52.4% (11/21) had a delay time of less than 4 days. Long-term consequences were noted in 16.7% (12/72) of cases, including outcomes such as psychological distress and worsening autistic tendencies, intestinal scarring and adhesions, and an inevitable bowel transplant due to excision of all but 10 to 15 cm of small intestine. Attempts to prevent magnet ingestion were documented for 9.7% (7/72) of cases, including separating the patient from older siblings with the magnetic toy when the toy was in use, storing the magnetic toy out of reach of the child, and playing with the magnetic toy on a blanket so that there would not be “any small pieces lying around.”
Discussion Swallowing rare-earth magnets is not comparable to other foreign body ingestions among children. Previous studies note that foreign bodies pass spontaneously
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Figure 4. Number of children with selected outcomes by number of days of delay until treatment.
Delay until treatment was documented in 45.8% (33/72) of cases. The category “other outcomes” includes fistula, volvulus, ulcer, perforation, bowel obstruction, magnet lodged in bowel, and unspecified damage.
between 80% and 90% of the time, and less than 1% of foreign body ingestions require surgical intervention.16,17 In this study, among cases with documented medical treatment, almost 70% required surgical intervention and only slightly more than 20% passed spontaneously. Multiple case reports in the literature highlight the ambiguous clinical presentations of children who have swallowed rare-earth magnets; vomiting and “flu-like” symptoms may occur, with or without fever and dull abdominal pain.5,18 In one study, a patient experienced intermittent abdominal pain for 6 months before an x-ray was ordered and subsequent surgery removed 7 magnets and repaired 3 intestinal fistulas.6 In our study, delays up to 2 months were noted. A previous study estimates that foreign body ingestions are not witnessed in 40% of cases17; however, in this study, 98.6% (71/72) of cases were not witnessed. Identifying ingested magnets is possible with an x-ray or ultrasound, but the diagnosis may not be considered because of the rarity of witnessed ingestions. Many studies emphasize the need for early detection,5,19,20 and some studies advise radiography of children with abdominal pain coupled with unclear etiology.5,9 Delays in treatment can predispose children to more serious injury, including multiple perforations and bowel necrosis. In this study, among children with multiple intestinal perforations and necrosis, more than half had a treatment delay of 1 to 3 days.
Although the majority of foreign body ingestions typically occur among children younger than 3 years of age,16 ingestion of rare-earth magnets exhibits a different age distribution. There appears to be an approximately bimodal age distribution with peaks at 2 to 4 years and 8 to 10 years, with ingestions extending into the teenage years. Using magnets to mimic piercings predisposes teenagers to rare-earth magnet-related injury, especially teenage girls. In this study, 3 older patients (ages 10, 12, and 13) were caught by surprise when the magnets they were using as faux piercings unexpectedly “snapped together,” and were inadvertently swallowed. Children may not divulge magnet ingestion for fear of repercussions, putting them at risk for delay in treatment. In one case, a 12-year-old girl only disclosed that she had ingested multiple magnets after she heard of a classmate who had been hospitalized following ingestion of the same type of magnets. Because diagnosis is difficult without knowledge of the ingestion or an x-ray identifying the magnets, and because outcomes can be serious, especially when treatment is delayed, primary prevention of ingestion of these high-powered magnets is important. Clinicians, parents and other child caregivers should be alerted of the dangers of these magnets. However, despite product warning labels and public awareness efforts, these ingestions continue. In recent years, efforts to raise the awareness of the dangers of rare-earth magnets have increased. In 2006,
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the CPSC issued warnings about toys containing these strong magnets,13 and in 2010, after 2 reports of magnet ingestion by children, the CPSC evaluated the marketing of magnet sets to children younger than 14 years of age, because the small size and attraction strength of the magnets, and target age group violated ASTM Safety Specification F963. The CPSC issued Notices of Noncompliance to firms that did not adjust their marketing to ages 14 years and older.2 Following continuing reports of magnet-related injury to children, 11 of 13 importers of magnetic sets voluntarily withdrew their products from the market. In July and August 2012, the CPSC filed administrative complaints against the 2 manufacturers of magnetic sets that did not agree to halt sales, the first action of this type taken by the CPSC in 11 years.21-23 The American Academy of Pediatrics supported this action.24 One of the manufacturers subsequently discontinued sale of its magnetic sets in December 2012. In August 2012, the CPSC issued a notice of proposed rulemaking (NPR) that would prohibit magnet sets (defined as “any aggregation of separable, permanent magnetic objects that is a consumer product intended or marketed by the manufacturer primarily as a manipulative or construction desk toy for general entertainment”2) that contain more than 1 magnet that fits entirely within the CPSC’s small parts cylinder, unless the magnets in that set have a flux index of less than 50 kG2 mm2, as specified by the ASTM Safety Specification F963.25,26 The flux index correlates with the attraction force of the magnets, and most magnets involved in the injuries identified by the CPSC have had a flux index greater than 70 kG2 mm2. Imposing a magnet performance requirement of a flux index of less than 50 kG2 mm2 is tantamount to banning the product.26 Despite efforts to increase consumer awareness and product warning labels, it is important to note that approximately half of the ingested magnets in this study were products intended for use by adults. The CPSC has indicated that it is unlikely that additional warnings would decrease magnet-related injuries to children and that “designing out the hazard” would be more effective.2 Other countries have also taken actions in response to the dangers of rare-earth magnets. Australia proposed a permanent ban on the sale of small, separable, loose magnets with a magnetic flux greater than 50 kG2 mm2.27,28 Health Canada has also begun assessing the risk of small, powerful magnets subsequent to 2 incidents in Canada and the CPSC investigations in the United States.29 This study has several limitations. We could not comment on secular trends, because the 2 CPSC databases used in this study do not capture all magnet-related incidents. In addition, these databases are likely to include
more serious cases, and therefore, the cases in this study may not be representative of all rare-earth magnet ingestions. However, IDIs were available for almost three fourths of cases, which provided detailed information regarding magnet-related injury events and outcomes not previously reported.
Conclusions Pediatric ingestion of rare-earth magnets can cause serious gastrointestinal injury and lead to long-term morbidity and even fatality. This study provides previously unreported details about these ingestions, including information about delays in treatment, mechanism of ingestion, treatment received, length of hospital stay, whether the ingestion was witnessed, and owner of the magnets. Approximately half of the ingested magnets in this study were products intended for use by adults. Although efforts to raise public awareness and use of warning labels are important, establishing a performance standard that limits the attraction force of these magnets offers the best prevention solution to this important pediatric public health problem. Authors’ Note Opinions expressed in this article do not necessarily represent those of the funding organization.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors gratefully acknowledge support from a medical student research scholarship from The Ohio State University College of Medicine, which provided a student research stipend for author ACDR while she worked on this study. Opinions expressed in this article do not necessarily represent those of the funding organization.
References 1. Centers for Disease Control and Prevention; Midget J, Inkster S, Rauchschwalbe S, Gillice M, Gilchrist J. Gastrointestinal injuries from magnet ingestion in children—United States 2003-2006. MMWR Morb Mortal Wkly Rep. 2006;55(48):1296-1300. http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm5548a3.htm. Accessed October 21, 2012. 2. US Consumer Product Safety Commission. Safety Standard for Magnet Sets; Notice of Proposed Rulemaking. http://
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Roo et al www.cpsc.gov/library/foia/foia12/brief/magnetstd.pdf. Published August 8, 2012. Accessed October 21, 2012. 3. Wildhaber BE, Le Coultre C, Genin B. Ingestion of magnets: innocent in solitude, harmful in groups. J Pediatr Surg. 2005;40(10):E33-E35. 4. Berg DA, Tynan MG, Grewal H. Magnets in the stomach. J Pediatr Surg. 2006;41:1037-1039. 5. Gregori D, Morra B, Gulati A. Magnetic FB injuries: an old yet unresolved hazard. Int J Pediatr Otorhinolaryngol. 2012;76(suppl 1):S42-S48. 6. Chung JH, Kim JS, Song YT. Small bowel complication caused by magnetic foreign body ingestion of children: two case reports. J Pediatr Surg. 2003;38:1548-1550. 7. Hernández Anselmi E, Gutiérrez San Román C, Barrios Fontoba JE, et al. Intestinal perforation caused by magnetic toys. J Pediatr Surg. 2007;42(3):E13-E16. 8. Nui A, Hirama T, Katsuramaki T, et al. An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children. J Pediatr Surg. 2005;40(9):E9-E11. 9. Brown JC, Murray KF, Javid PJ. Hidden attraction: a menacing meal of magnets and batteries. J Emerg Med. 2012;43:266-269. 10. Family Voices: Kenny. Kids in Danger. http://www. kidsindanger.org/family-voices/kenny/. Published 2005. Accessed August 3, 2012. 11. US Consumer Product Safety Commission. Serious injuries prompt recall of Mattel’s Polly Pocket magnetic play sets. http://www.cpsc.gov/cpscpub/prerel/prhtml07/07039. html. Published 2006. Accessed August 18, 2012. 12. US Consumer Product Safety Commission. Serious intestinal injury prompts Kipp Brothers recall of Mag Stix magnetic building sets. http://www.cpsc.gov/cpscpub/ prerel/prhtml07/07231.html. Published 2007. Accessed August 18, 2012. 13. US Consumer Product Safety Commission. Child’s death prompts replacement program of magnetic building sets. http://www.cpsc.gov/cpscpub/prerel/prhtml06/06127. html. Published 2006. Accessed August 18, 2012. 14. Oestreich AE. Worldwide survey of damage from swallowing multiple magnets. Pediatr Radiol. 2009;39: 142-147. 15. Oestreich AE. Danger of multiple magnets beyond the stomach in children. J Natl Med Assoc. 2006;98:277-279. 16. Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep. 2005;7:212-218. 17. Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005;72:287-291.
18. Dutta S, Barzin A. Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med. 2008;162:123-125. 19. Naji H, Isacson D, Svensson JF, Wester T. Bowel injuries caused by ingestion of multiple magnets in children: a growing hazard. Pediatr Surg Int. 2012;28:367-374. 20. Fenton SJ, Torgenson M, Holsti M, Black RE. Magnetic attraction leading to a small bowel obstruction in a child. Pediatr Surg Int. 2007;23:1245-1247. 21. US Consumer Product Safety Commission. CPSC sues Maxfield & Oberton over hazardous Buckyballs and Buckycube desk toys. http://www.cpsc.gov/cpscpub/ prerel/prhtml12/12234.html. Published 2012. Accessed August 3, 2012. 22. Kids in Danger. CPSC takes strong action against dangerous magnetic toys. http://www.kidsindanger.org/2012/07/25/ cpsc-takes-strong-action-against-dangerous-magnetictoys/. Published July 25, 2012. Accessed August 3, 2012. 23. US Consumer Product Safety Commission. CPSC sues Zen Magnets over hazardous, high-powered magnetic balls. http://www.cpsc.gov/cpscpub/prerel/prhtml12/12243. html. Updated August 7, 2012. Accessed August 16, 2012. 24. American Association of Pediatrics. AAP commends CPSC action to ban magnetic desk toys from store shelves. http:// www.aap.org/en-us/about-the-aap/aap-press-room/pages/ AAPCommendsCPSCActiontoBanMagneticDeskToys. aspx. Published 2012. Accessed October 21, 2012. 25. ASTM International. F963-11 Standard Consumer Safety Specification for Toy Safety. West Conshohocken, PA: ASTM International; 2011. 26. CPSC staff presents NPR to “essentially” ban magnet sets. Product Safety Letter. 2012;41(33):2. http://www.productsafetyletter.com/Content/411.aspx. Accessed October 21, 2012. 27. US Consumer Product Safety Commission. Consumer Protection Notice No. 4 of 2012: Proposed Ban Notice: Permanent Ban on Small, High Powered Magnets. Bethesda, MD: US Consumer Product Safety Commission; 2012. 28. Australia moves to ban strong magnets. Product Safety Letter. 2012;41(34):1. http://www.productsafetyletter. com/Content/438.aspx. Accessed October 21, 2012. 29. Canada begins assessment of magnets. Product Safety Letter. 2012;41(34):1. http://www.productsafetyletter. com/Content/439.aspx. Accessed October 21, 2012.
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research-article2013
CPJXXX10.1177/0009922813507129Clinical PediatricsRoo et al
Article
Rare-Earth Magnet Ingestion–Related Injuries Among Children, 2000-2012
Clinical Pediatrics 52(11) 1006–1013 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813507129 cpj.sagepub.com
Ana C. De Roo, BA1,2, Meghan C. Thompson, BA1,2, Thiphalak Chounthirath, MS1, Huiyun Xiang, MD, PhD, MPH1,2, Nancy A. Cowles3, Liliya Shmuylovskaya, MA3, and Gary A. Smith, MD, DrPH1,2,4
Abstract This study describes the epidemiology of rare-earth magnet ingestion by children by retrospectively analyzing 72 cases of magnet ingestion collected from Saferproducts.gov and the US Consumer Product Safety Commission from 2000 through 2012. The mean child age was 6.4 years. Patients ingested between 1 and 40 magnets, most often 1 to 4 magnets. Unique circumstances of ingestion included faux piercing (19.4%) and mistaking magnets for candy (6.9%). Surgery was required in 69.7% of cases where treatment was reported. Fifty-three patients were hospitalized (73.6%), and the length of hospital stay was reported in 58.5% of those cases, ranging from 1 to 54 days. Approximately half (50.7%) of the magnets causing injury were products intended for use by adults. Study findings demonstrate that pediatric ingestion of rare-earth magnets can cause serious gastrointestinal injury. Establishing a performance standard that limits the attraction force of these magnets offers the best prevention solution to this important pediatric public health problem. Keywords magnet, ingestion, injury, foreign body, pediatric, children
Introduction Children commonly ingest foreign bodies, which usually pass through the gastrointestinal tract with a benign outcome. However, in rare cases, such as when a child swallows multiple powerful magnets, life-threatening internal injuries are possible. A solitary ingested magnet is similar to other foreign bodies, but dangerous situations arise once a subsequent magnet or metal object is ingested. Powerful rare-earth magnets, commonly consisting of alloys of neodymium iron boron or samarium cobalt,1 are popular as desk toys for adults and were previously found in construction toys for children. These 3 to 6 millimeter diameter magnets2 are capable of attracting each other through up to 6 layers of bowel wall3 and are strong enough to reposition the intestines in order to meet. On joining through bowel wall, the magnets can produce pressure ulcers, ischemic injury, obstructions, fistulae, necrosis, and perforations.4-8 Treatment may be as simple as waiting for the magnet to pass through the digestive tract naturally, but can be as serious as bowel resection surgery.9 In one reported case, a 2-year-old died of sepsis before rare-earth magnet ingestion was discovered and treated.10 Following this fatality, the US Consumer Product Safety Commission (CPSC) issued
multiple voluntary recalls of toys containing these strong magnets,11-13 but other products containing rareearth magnets remain on the market and continue to cause injury among children. Previous studies have found the majority of patients to be younger than 7 years of age and note a preponderance of males, ranging from 55% to 72%.5,14 Many studies note the number of magnets ingested, most often ranging from 2 to 5 magnets.14 Some studies suggest a correlation with autism and other psychological conditions.14,15 The American Academy of Pediatrics; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; and the 1
Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA 2 The Ohio State University College of Medicine, Columbus, OH, USA 3 Kids in Danger, Chicago, IL, USA 4 Child Injury Prevention Alliance, Columbus, OH, USA Corresponding Author: Gary A. Smith, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. Email: [email protected]
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Roo et al Centers for Disease Control and Prevention have highlighted the danger of rare-earth magnet ingestion in their publications.16,17 Media reports, case reports in the medical literature, comprehensive literature reviews, and small surveys in the medical field have drawn attention to pediatric injuries resulting from swallowing magnets. This study includes up-to-date information on pediatric rare-earth magnet ingestion and adds previously unreported information about these ingestions, including delays in treatment, reasons for delay, treatment details, mechanism of ingestion, length of hospital stay, whether the ingestion was witnessed, and owner of the magnets. This article aims to increase physician and public awareness about rare-earth magnet ingestion by children as a serious public health problem.
Methods Data regarding children 15 years of age or younger with a magnet-associated injury from 2000 through August 2012 were obtained from 2 CPSC databases, the “Injury or Potential Injury Incident Database” and the “In-Depth Investigation Database.” The former database collects product-related incidents reported by consumers and makes this information available on the website, Saferproducts.gov. The latter database consists of injury incidents reported to the CPSC, which were selected for an in-depth investigation (IDI) by CPSC staff based on various factors, including injury severity. IDIs provide detailed information about these selected injury incidents. Reports from both databases include city, state, age and gender of the injured person, medical disposition, injury diagnosis, and body parts involved. Accompanying each case is a narrative describing the injury, or a full report for the IDI cases, which was used to create additional variables. Mechanism of injury was specified as follows: (a) magnet used as faux piercing, (b) magnet mistaken for candy, (c) magnet ingestion, not otherwise specified, and (d) magnet swallowed when using teeth or mouth to separate or carry magnets. Each case was limited to a single clinical outcome from the following possibilities: (a) no adverse effects, (b) magnet lodged in bowel, (c) bowel obstruction, (d) volvulus, (e) ulcer, (f) single perforation, (g) fistula, (h) multiple perforations and necrosis, and (i) unspecified damage. The decision rule used to assign clinical outcome when more than one outcome was listed was based on severity of injury: multiple perforations and necrosis took precedence over a fistula, which took precedence over a single perforation, which took precedence over ulcers. Bowel obstruction was a commonly documented outcome; 2 cases noted bowel obstruction
as the only outcome and these were coded as such. In all other cases of bowel obstruction, a second, more specific injury that likely preceded the obstruction in clinical course was recorded and coded instead. The detailed case reports provided information regarding the duration of delay in treatment and the reasons for these delays, which included the following: (a) ambiguous symptoms, (b) incorrect diagnosis/discharged, (c) patient did not report ingesting magnets, and (d) scheduled appointment for later date. The owner of the magnet was categorized as follows: (a) patient, (b) sibling, young relative, friend or classmate, (c) childcare or school, and (d) parent or adult relative. Using the narratives, we also identified the occurrence of long-term sequelae, the number of magnets ingested, the number of days spent in the hospital, any concurrent ingestion of metal, whether or not the event was witnessed, whether the toy was meant for adults or children, and whether imaging technology was used. Duplicate cases and nonmagnet ingestions were excluded. A case involving multiple intravesicular magnets and a case involving magnet-related lip injury were also excluded. Data were analyzed using SPSS 19.0 (SPSS Inc, Chicago, IL) and SAS Version 9.3 (SAS Institute, Inc, Cary, NC) statistical software.
Results Demographics From 2000 through August 2012, there were 72 case reports of children injured by rare-earth magnet ingestion, of which 72.2% (52/72) included an in-depth investigation report. Those injured ranged from 9 months to 15 years of age. The mean age of those injured was 6.4 years, with a median age of 6.5 years, and a mode of 8 years (8-year-olds represented 15.3% [11/72] of cases; Figure 1). Males comprised 54.2% (39/72) of the study sample. All injured children 12 years or older were female (9 cases), and males represented 61.9% (39/63) of injured children younger than 12 years of age.
Number of Magnets Swallowed and Mechanism of Ingestion The number of magnets ingested ranged from 1 to 40, and multiple magnet ingestion without a specified number was reported in 12.5% (9/72) of cases (Figure 2). Ingestion of 2 to 4 magnets comprised 44.4% (32/72) of cases. Eleven percent of cases (8/72) involved concurrent metal and magnet ingestion, of which 87.5% (7/8) involved more than 1 magnet. Females swallowed
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Figure 1. Number of children injured by ingesting magnets by age and gender, 2000-2012.
Figure 2. Number of magnets ingested with or without concurrent metal ingestion by gender, 2000-2012. *More than 1 magnet ingested, but exact number is unspecified.
magnets when using them as faux tongue or lip piercings in 13.9% (10/72) of cases, more than double the number for males (5.6%; 4/72; Table 1). Children 10 to 15 years old accounted for 71.4% (10/14) of ingestions involving fake piercing. When used as a fake piercing, 21.4% (3/14) of the children stated that the 2 magnets “snapped
together” and rolled to the back of the throat, causing them to unintentionally swallow the magnets. Mistaking magnets for candy was noted specifically in 6.9% (5/72) of cases. Using teeth to separate 2 magnets or carrying magnets in the mouth were implicated in 4.2% (3/72) of cases.
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Roo et al Table 1. Circumstances of Magnet Ingestion by Gender.a Mechanism of Ingestion
Male, n (%)
Female, n (%)
Total, n (%)
Faux piercing Mistaken for candy Ingestion, not otherwise specified Using teeth/mouth to carry/separate
4 (5.6) 3 (4.2) 31 (43.1) 1 (1.4)
10 (13.9) 2 (2.8) 19 (26.4) 2 (2.8)
14 (19.4) 5 (6.9) 50 (69.4) 3 (4.2)
Total
39 (54.2)
33 (45.8)
72 (100.0)
a
All percentages are expressed as a percentage of 72 total cases. Some percentages may not sum to the column totals because of rounding error.
Table 2. Clinical Outcome of Magnet Ingestion by Gender.a Outcome
Male, n (%)
Female, n (%)
Total, n (%)
No adverse effects Fistula Volvulus Ulcer Perforation Bowel obstruction Magnet lodged in bowel Multiple perforations and necrosis Unspecified damage
8 (11.9) 2 (3.0) 1 (1.5) 1 (1.5) 3 (4.5) 1 (1.5) 2 (3.0) 15 (22.4) 3 (4.5)
14 (20.9) — — 2 (3.0) 1 (1.5) 1 (1.5) 2 (3.0) 8 (11.9) 3 (4.5)
22 (32.8) 2 (3.0) 1 (1.5) 3 (4.5) 4 (6.0) 2 (3.0) 4 (6.0) 23 (34.3) 6 (9.0)
Total
36 (53.8)
31 (46.3)
67 (100.0)
a
Five of 72 cases (6.9%) had missing data. All percentages are expressed as a percentage of 67 total cases. The percentages in the Total column do not sum to 100.0% because of rounding error.
Outcome Clinical outcomes were specified in 93.1% (67/72) of cases; of those, 32.8% (22/67) noted no adverse effects, the majority of which involved females (Table 2). Multiple perforations and necrosis occurred in 34.3% (23/67) of cases where outcome was specified, with nearly twice as many of these cases occurring among males.
Treatment The medical treatment of the patient was reported in 91.7% (66/72) of cases. Surgical intervention was required in 69.7% (46/66) of children where treatment was reported (Table 3). Excision of at least one section of intestine was required in 16.7% (11/66) of cases, and 4.5% (3/66) of cases required multiple surgeries. Removal of magnets via endoscope or colonoscope was possible in 7.6% (5/66) of the reported cases, and for 21.2% (14/66) of the patients, the magnets passed naturally.
Table 3. Treatment and Outcome of Children Injured by Ingesting Magnets. Treatment/outcome
Number (%)
Surgery (all) Surgery Excision of intestinal segments Multiple surgeries Magnets passed naturally Endoscopic or colonoscopic removal Death
46 (69.7) 32 (48.5) 11 (16.7) 3 (4.5) 14 (21.2) 5 (7.6) 1 (1.5)
Total
66 (100.0)
days spent in the hospital was documented for 58.5% (31/53) of those hospitalized (Figure 3), ranging from 1 to 54 days. A hospital stay of “several” days, but no exact count, was noted for 9.4% (5/53) of cases.
Other Descriptive Details
Hospitalization Admission to the hospital was a consequence of magnet ingestion for 73.6% (53/72) of patients. The number of
Descriptive information about the magnetic product causing injury was recorded in 95.8% (69/72) of cases; using that information, the intended age group for use of
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Figure 3. Number of days of hospitalization for children injured by ingesting magnets, 2000-2012. Data were available for 58.5% (31/53) of the children who were hospitalized.
the magnetic product could be identified. Among those cases, 49.3% (34/69) of magnets were intended for use by children (eg, construction toys) and the remaining 50.7% (35/69) were intended for use by adults (eg, desk toys). Among 10- to 15-year-olds, 88.9% (16/18) of magnet ingestions were products intended for use by adults. The owner of the magnets was noted in 70.8% (51/72) of cases. The ingested magnets belonged to the patient in 47.1% (24/51) of the cases in which the owner was noted. A parent or adult relative owned the magnets in 7.8% (4/51) of cases, and the magnets belonged to another child, such as a sibling, young relative, classmate, or friend, in 37.3% (19/51) of cases. In 7.8% (4/51) of cases, the magnets were owned by a school or childcare facility. Ingestion was directly witnessed in only a single case, although nearly two thirds (63.9%; 46/72) of cases noted whether or not the ingestion was witnessed or the patient admitted to the ingestion. Of those cases, patients admitted to swallowing magnets 54.3% (25/46) of the time, and in one case, a 12-year-old girl only reported the ingestion after a classmate was hospitalized with serious injuries following magnet ingestion. Of the 65.3% (47/72) of cases where medical imaging was performed, 91.5% (43/47) of children received x-rays and 8.5% (4/47) received computed tomography scans. The length of delay in treatment and reasons for the delay were noted in 45.8% (33/72) of cases. Treatment
delay ranged from 1 day to 2 months (Figure 4). Documented reasons for the delay were ambiguous symptoms (54.6%; 18/33), followed by incorrect diagnosis (21.2%; 7/33), the patient withholding information about the ingestion (21.2%; 7/32), and an upcoming scheduled appointment (3.0%; 1/33). Among the cases in which delay was noted, 63.6% (21/33) of patients suffered multiple intestinal perforations and necrosis; of those, 52.4% (11/21) had a delay time of less than 4 days. Long-term consequences were noted in 16.7% (12/72) of cases, including outcomes such as psychological distress and worsening autistic tendencies, intestinal scarring and adhesions, and an inevitable bowel transplant due to excision of all but 10 to 15 cm of small intestine. Attempts to prevent magnet ingestion were documented for 9.7% (7/72) of cases, including separating the patient from older siblings with the magnetic toy when the toy was in use, storing the magnetic toy out of reach of the child, and playing with the magnetic toy on a blanket so that there would not be “any small pieces lying around.”
Discussion Swallowing rare-earth magnets is not comparable to other foreign body ingestions among children. Previous studies note that foreign bodies pass spontaneously
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Figure 4. Number of children with selected outcomes by number of days of delay until treatment.
Delay until treatment was documented in 45.8% (33/72) of cases. The category “other outcomes” includes fistula, volvulus, ulcer, perforation, bowel obstruction, magnet lodged in bowel, and unspecified damage.
between 80% and 90% of the time, and less than 1% of foreign body ingestions require surgical intervention.16,17 In this study, among cases with documented medical treatment, almost 70% required surgical intervention and only slightly more than 20% passed spontaneously. Multiple case reports in the literature highlight the ambiguous clinical presentations of children who have swallowed rare-earth magnets; vomiting and “flu-like” symptoms may occur, with or without fever and dull abdominal pain.5,18 In one study, a patient experienced intermittent abdominal pain for 6 months before an x-ray was ordered and subsequent surgery removed 7 magnets and repaired 3 intestinal fistulas.6 In our study, delays up to 2 months were noted. A previous study estimates that foreign body ingestions are not witnessed in 40% of cases17; however, in this study, 98.6% (71/72) of cases were not witnessed. Identifying ingested magnets is possible with an x-ray or ultrasound, but the diagnosis may not be considered because of the rarity of witnessed ingestions. Many studies emphasize the need for early detection,5,19,20 and some studies advise radiography of children with abdominal pain coupled with unclear etiology.5,9 Delays in treatment can predispose children to more serious injury, including multiple perforations and bowel necrosis. In this study, among children with multiple intestinal perforations and necrosis, more than half had a treatment delay of 1 to 3 days.
Although the majority of foreign body ingestions typically occur among children younger than 3 years of age,16 ingestion of rare-earth magnets exhibits a different age distribution. There appears to be an approximately bimodal age distribution with peaks at 2 to 4 years and 8 to 10 years, with ingestions extending into the teenage years. Using magnets to mimic piercings predisposes teenagers to rare-earth magnet-related injury, especially teenage girls. In this study, 3 older patients (ages 10, 12, and 13) were caught by surprise when the magnets they were using as faux piercings unexpectedly “snapped together,” and were inadvertently swallowed. Children may not divulge magnet ingestion for fear of repercussions, putting them at risk for delay in treatment. In one case, a 12-year-old girl only disclosed that she had ingested multiple magnets after she heard of a classmate who had been hospitalized following ingestion of the same type of magnets. Because diagnosis is difficult without knowledge of the ingestion or an x-ray identifying the magnets, and because outcomes can be serious, especially when treatment is delayed, primary prevention of ingestion of these high-powered magnets is important. Clinicians, parents and other child caregivers should be alerted of the dangers of these magnets. However, despite product warning labels and public awareness efforts, these ingestions continue. In recent years, efforts to raise the awareness of the dangers of rare-earth magnets have increased. In 2006,
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the CPSC issued warnings about toys containing these strong magnets,13 and in 2010, after 2 reports of magnet ingestion by children, the CPSC evaluated the marketing of magnet sets to children younger than 14 years of age, because the small size and attraction strength of the magnets, and target age group violated ASTM Safety Specification F963. The CPSC issued Notices of Noncompliance to firms that did not adjust their marketing to ages 14 years and older.2 Following continuing reports of magnet-related injury to children, 11 of 13 importers of magnetic sets voluntarily withdrew their products from the market. In July and August 2012, the CPSC filed administrative complaints against the 2 manufacturers of magnetic sets that did not agree to halt sales, the first action of this type taken by the CPSC in 11 years.21-23 The American Academy of Pediatrics supported this action.24 One of the manufacturers subsequently discontinued sale of its magnetic sets in December 2012. In August 2012, the CPSC issued a notice of proposed rulemaking (NPR) that would prohibit magnet sets (defined as “any aggregation of separable, permanent magnetic objects that is a consumer product intended or marketed by the manufacturer primarily as a manipulative or construction desk toy for general entertainment”2) that contain more than 1 magnet that fits entirely within the CPSC’s small parts cylinder, unless the magnets in that set have a flux index of less than 50 kG2 mm2, as specified by the ASTM Safety Specification F963.25,26 The flux index correlates with the attraction force of the magnets, and most magnets involved in the injuries identified by the CPSC have had a flux index greater than 70 kG2 mm2. Imposing a magnet performance requirement of a flux index of less than 50 kG2 mm2 is tantamount to banning the product.26 Despite efforts to increase consumer awareness and product warning labels, it is important to note that approximately half of the ingested magnets in this study were products intended for use by adults. The CPSC has indicated that it is unlikely that additional warnings would decrease magnet-related injuries to children and that “designing out the hazard” would be more effective.2 Other countries have also taken actions in response to the dangers of rare-earth magnets. Australia proposed a permanent ban on the sale of small, separable, loose magnets with a magnetic flux greater than 50 kG2 mm2.27,28 Health Canada has also begun assessing the risk of small, powerful magnets subsequent to 2 incidents in Canada and the CPSC investigations in the United States.29 This study has several limitations. We could not comment on secular trends, because the 2 CPSC databases used in this study do not capture all magnet-related incidents. In addition, these databases are likely to include
more serious cases, and therefore, the cases in this study may not be representative of all rare-earth magnet ingestions. However, IDIs were available for almost three fourths of cases, which provided detailed information regarding magnet-related injury events and outcomes not previously reported.
Conclusions Pediatric ingestion of rare-earth magnets can cause serious gastrointestinal injury and lead to long-term morbidity and even fatality. This study provides previously unreported details about these ingestions, including information about delays in treatment, mechanism of ingestion, treatment received, length of hospital stay, whether the ingestion was witnessed, and owner of the magnets. Approximately half of the ingested magnets in this study were products intended for use by adults. Although efforts to raise public awareness and use of warning labels are important, establishing a performance standard that limits the attraction force of these magnets offers the best prevention solution to this important pediatric public health problem. Authors’ Note Opinions expressed in this article do not necessarily represent those of the funding organization.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors gratefully acknowledge support from a medical student research scholarship from The Ohio State University College of Medicine, which provided a student research stipend for author ACDR while she worked on this study. Opinions expressed in this article do not necessarily represent those of the funding organization.
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18. Dutta S, Barzin A. Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med. 2008;162:123-125. 19. Naji H, Isacson D, Svensson JF, Wester T. Bowel injuries caused by ingestion of multiple magnets in children: a growing hazard. Pediatr Surg Int. 2012;28:367-374. 20. Fenton SJ, Torgenson M, Holsti M, Black RE. Magnetic attraction leading to a small bowel obstruction in a child. Pediatr Surg Int. 2007;23:1245-1247. 21. US Consumer Product Safety Commission. CPSC sues Maxfield & Oberton over hazardous Buckyballs and Buckycube desk toys. http://www.cpsc.gov/cpscpub/ prerel/prhtml12/12234.html. Published 2012. Accessed August 3, 2012. 22. Kids in Danger. CPSC takes strong action against dangerous magnetic toys. http://www.kidsindanger.org/2012/07/25/ cpsc-takes-strong-action-against-dangerous-magnetictoys/. Published July 25, 2012. Accessed August 3, 2012. 23. US Consumer Product Safety Commission. CPSC sues Zen Magnets over hazardous, high-powered magnetic balls. http://www.cpsc.gov/cpscpub/prerel/prhtml12/12243. html. Updated August 7, 2012. Accessed August 16, 2012. 24. American Association of Pediatrics. AAP commends CPSC action to ban magnetic desk toys from store shelves. http:// www.aap.org/en-us/about-the-aap/aap-press-room/pages/ AAPCommendsCPSCActiontoBanMagneticDeskToys. aspx. Published 2012. Accessed October 21, 2012. 25. ASTM International. F963-11 Standard Consumer Safety Specification for Toy Safety. West Conshohocken, PA: ASTM International; 2011. 26. CPSC staff presents NPR to “essentially” ban magnet sets. Product Safety Letter. 2012;41(33):2. http://www.productsafetyletter.com/Content/411.aspx. Accessed October 21, 2012. 27. US Consumer Product Safety Commission. Consumer Protection Notice No. 4 of 2012: Proposed Ban Notice: Permanent Ban on Small, High Powered Magnets. Bethesda, MD: US Consumer Product Safety Commission; 2012. 28. Australia moves to ban strong magnets. Product Safety Letter. 2012;41(34):1. http://www.productsafetyletter. com/Content/438.aspx. Accessed October 21, 2012. 29. Canada begins assessment of magnets. Product Safety Letter. 2012;41(34):1. http://www.productsafetyletter. com/Content/439.aspx. Accessed October 21, 2012.
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