While the ingestion of foreign bodies has been reported for children of all ages, younger children are generally at the highest risk of ingesting non-food items due to their tendency to explore objects in their environment with their mouths [10]. This type of ingestion is becoming increasingly common among children, and the ingestion of multiple magnetic beads can result in serious injuries, including intestinal perforation, bowel strangulation, and necrosis [11]. Several incidences have been reported in China-based studies [12–14], while the incidence of accidental foreign body ingestion was reported to be approximately 100,000 cases a year in the United States, with more than 80% of cases involving children aged under the age of five years. A single foreign body can pass spontaneously and uneventfully through the digestive tract; however, the ingestion of multiple magnetic objects can result in serious issues due to aggregation through mutual attraction throughout the intestinal wall [15].
Over the past decade, many cases involving serious complications caused by the ingestion of multiple rare-earth magnets have been reported in numerous countries [16–18], with the phenomenon closely related to the widespread use of such magnets in products, including children's toys. This applies to both prosperous cities and rural areas [3], with the present study finding no difference in the number and frequency of the accidental ingestion of magnetic beads between children living in rural environments and those living in urban areas.
Magnetic-type foreign bodies are of particular concern because they can cause severe injuries to the gastrointestinal tract, which can be life-threatening. As noted, when swallowed alone, they tend to pass through the gastrointestinal tract uneventfully; however, if multiple magnetic foreign bodies are swallowed, they can aggregate in various layers of the intestines, potentially causing ischemia, pressure necrosis, or perforation or volvulus of the intestines, ultimately resulting in a severe situation [19]. The magnetic balls noted above primarily comprise neodymium–iron–boron (NdFeB) magnets, a type of artificial magnet with a substantially strong magnetic force that can attract weights of up to 640 times that of their own weight. Tsai et al. [20] revealed that when NdFeB magnets are in close proximity (3.5–4.6 cm) they will start attracting one another. Hence, when several such magnets enter the abdominal cavity, they can aggregate through this mutual attraction across the intestinal wall. Cox [21] found that once these magnets began attracting one another, the intestinal tissues could become sandwiched in the middle; the magnets would then be unable to separate by themselves, which could lead to rapid intestinal tract necrosis and perforation.
Early symptoms of the accidental ingestion of magnetic beads are mostly atypical. Furthermore, since the expressive ability of children is often limited, accurately defining their state of health can be difficult, making an early diagnosis problematic. The rare-earth magnets used in toys are generally small and, accordingly, the perforation caused by their ingestion will be correspondingly small. In some cases, due to wrapping of the omentum following perforation or the direct formation of an internal fistula, the clinical symptoms tend to be mild, and the findings obtained via imaging tend to be atypical [22].
In the present study, the clinical symptoms of the sample group were as follows: 16 cases involved abdominal pain, 8 involved vomiting, 5 involved fever, and 28 involved abdominal pain with vomiting and abdominal distension; in 15 cases, the patients exhibited no symptoms. The main symptoms were abdominal pain, vomiting and abdominal distension, followed by asymptomatic presentation; these findings were similar to those reported in existing studies [23–25]. The current study found that the risk of perforation due to symptoms 2( vomiting) and 3 (abdominal pain with vomiting and abdominal distension) was 13.844 and 12.703 times higher than in cases involving asymptomatic presentation (risk value = 1). Therefore, the risk of gastrointestinal perforation can be preliminarily determined according to the symptoms detected in clinical trials.
Clinicians must be fully aware of the dangers of ingesting magnet-type foreign bodies, obtain an accurate medical history, carefully examine the patient, and perform parallel abdominal positive and lateral radiographs to determine the number and location of the magnetic beads [3]. In the present study, the accuracy of detecting gastrointestinal perforation, based on a preoperative B-scan ultrasound examination, was 71%, while the accuracy of detecting gastrointestinal perforation, based on the presence of free gas under the diaphragm, was only 46%. A total of 246 magnetic beads were identified in our sample group; the main locations were the jejunum and the ileum (accounting for 56%), locations that are prone to perforation.
Many professional health organizations have recognized the risk of magnet ingestion and recommend immediate medical consultation in such cases [26]. Various management options have been reported but there is no current consensus on the ideal management approach [27]. Based on previously formulated guidelines and algorithms, as well as the Shanghai Children’s Hospital magnet-type foreign body treatment process, the National Children’s Hospital Science Center and Beijing Children’s Hospital (affiliated with Capital Medical University) developed diagnosis and treatment processes for the ingestion of magnetic beads [3, 28, 20, 29].
In cases where the number of magnets ingested is uncertain, it is important to assume that multiple magnets may have been swallowed, while multi-position photography can help to determine the exact number. Meanwhile, for patients reporting that a single magnet was ingested, follow-up observation is also necessary. If the magnet position is found to be fixed, the necessary intervention should be performed [10]. If the ingestion of multiple magnets is confirmed, early consultation with a gastroenterologist and/or surgeon is recommended. Treatment options for the investigation and removal of ingested magnets include the following: no treatment (if a single magnet is ingested and is expected to pass without complications), the use of motility agents, upper or lower endoscopy, laparotomy, gastrotomy, small bowel enterotomy, and removal of the magnets through the appendiceal stump [6]. While endoscopic removal using a net retrieval device, snares, basket retrieval devices, or multiprong forceps is common, the magnetic force may be too strong to allow for the removal of magnets that are attracted to one another through the bowel wall, and open surgery may be required.
In numerous cases of multiple magnet ingestion, bowel resection and/or perforation and fistula repair have been performed [10]. In the present study, 40 patients underwent an exploratory laparotomy, 22 underwent intestinal perforation repair, 4 underwent gastric wall perforation repair, 7 underwent intestinal adhesion release, 6 underwent gastroscopic removal, 3 underwent combined gastroscopic removal, 8 underwent gastroscopy alone, and 27 underwent laparoscopic exploration. Laparotomy, intestinal perforation repair, and laparoscopic exploration were the main surgical approaches that were adopted. The ingestion of this type of object can cause serious gastrointestinal injury, even if removed quickly. Furthermore, children may be reluctant to admit ingestion or may be too young to describe the history; nonetheless, any delay in diagnosis can lead to severe or even potentially fatal results. As such, the surgeon must look for multiple magnets and if identified, every effort should be made to remove the objects, either endoscopically or surgically.
The surgery method can include performing a laparotomy or laparoscopic exploration. If the child's condition is critical or abdominal distension is obvious, a laparotomy is a preferable option, while laparoscopic exploration can be considered if the conditions permit its use. Whether laparotomy or laparoscopy is selected, the general position of the magnetic bead can be identified using a preoperative B-scan ultrasound and abdominal standing and lying-down film techniques. During the procedure, forceps (hemostatic/operating forceps) can be used to approach the magnetic bead, and the bead can be seized and removed through the perforated intestinal tube (Fig. 5: e) [29]. The entire digestive tract (the stomach to the rectum) must be explored during the operation to ensure that no incidence of perforation is missed. Before the abdomen is closed, intraoperative radiographs must be taken to ensure that all foreign bodies have been removed [3]. If the ingestion was witnessed or if magnetic beads were observed in the abdominal X-ray scans, and of the child is symptomatic, a decision must be made for immediate removal via endoscopy. A surgical consultation is warranted in cases where endoscopic removal cannot be achieved or if a complication occurs during retrieval. Surgical removal can be performed either via laparotomy or laparoscopy, depending on the facility and the surgeon’s level of experience. Laparoscopic removal can be challenging due to the adherence of the magnets to surgical instruments. In the present study, an exploratory laparotomy (34%), perforation repair (53%), and laparoscopic exploration (23%) were performed. All the patients recovered successfully following the surgical treatment and were discharged from the hospital; no clear complications were subsequently observed during the follow-up period.
Compared with the non-surgical group, the peripheral WBC count (P = 0.048) and the CRP level (P = 0.033) were both higher in the surgical group. A high WBC count and/or CRP level suggest a high possibility of perforation, and surgical treatment is required as soon as possible in such cases [22]. However, there were no significant differences between the perforated and the non-perforated group in terms of mean age, gender, medical history, and the number of magnetic beads ingested (P > > 0.05). These findings were similar to those obtained by Zheng et al[22].
Many accidental ingestion incidents have caused serious harm to children, and numerous products have been banned via legislation in several countries as a result. Nonetheless, several such products can still be easily purchased in stores or online in China. A large number of cases of magnet ingestion had been reported in Saudi Arabia until magnet sets were banned from the market by the Defective Products Recall Center in February 2020 (recall reference number: 20020–20023), with the number of cases subsequently decreasing dramatically at both the local and national levels. However, a year after this ban, the number of cases steadily increased, which may be explained by the unrecorded reselling of the magnets [27]. Elsewhere, Julie C et al [30] reported that since 2009, the severity of injury caused by magnet intake has increased, with increasing cases requiring emergency surgery or hospitalization.
Supervision by parents and caregivers is a key factor in injury prevention. This study found a statistical correlation between the number of ingested magnetic beads and the educational level of children’s caregivers (primary school and below, middle school, and college/university) (P = 0.018), where the number of incidences was 14.062 times higher when the educational level reflected primary school and below. This indicated that caregivers with a high level of education had a better understanding of the potential harm magnetic beads pose. However, there was no difference between the number of cases of accidental ingestion of magnetic beads among rural and urban residents.
Rosenfield D [31] reported that a re-examination of the cases of multiple magnet ingestion in large pediatric hospitals found that the ingestion of multiple mini-magnets had been significantly reduced following a mandatory product recall, which indicated that the recall of such products could help reduce the number of injuries they caused. The results of a survey conducted by the American Academy of Pediatric Surgeons, as reported by Alicia M [32], indicated that despite recent efforts to remove these items from the market, magnetic beads remain a serious health hazard to children, particularly at a young age. A total of 5,738 cases of magnet ingestion were identified, with a 33% decrease in cases (from 418 annually in 2008–2011 to 281 annually in 2012–2017) after various high-powered magnet sets were removed from the market; however, this subsequently increased by 444% to 1,249 yearly (2018–2019) after these products re-entered the market. The number of cases in 2018 and 2019 increased across all age groups and account, and cases involving the ingestion of magnets accounted for 39% of those reported since 2008 [26].
In addition to restricting the manufacturing of rare-earth-magnet-based toys, parents and families should be educated via educational school programs, social media, and public media channels about the unique risks posed by the ingestion of such magnets [27].