Alimentary tract foreign body ingestion is common in pediatrics, especially in neonates and toddlers [5]. While among them, more than 80% need no intervention and the foreign body will pass out uneventfully, only 20% call for further attention, and less than 1% required surgery [6]. Treatments are different towards different categories of foreign bodies, wait-and-see strategy could be used in the ordinary foreign body, such as coins, jewelries, and small toys; however 20% of patients who had fish bones, jujube pits, batteries, or magnets ingestions call for much more positive interventions. Different from other foreign bodies, ingested magnets will attract each other across bowel loops, and cause gastrointestinal wall ischemia, pressure necrosis or perforation, especially when swallowed separately [7-8]. Other studies also described intestinal obstruction from internal hernia and volvulus of intestine, fistula formation [9], and hemorrhage when the mesenteric was involved [9]. Midget J reported a twenty-month old boy who had such magnets ingested, causing intestinal necrosis and abdominal sepsis, which led to tragedy death [10-11]. Besides, Waters AM [12] reported another death case due to the hemorrhage from an esophago-aortic fistula induced by magnets ingestion. So the risk of magnets ingestion was higher than the ordinary foreign bodies.
Rare-earth magnet, made from NdFeB (neodymium iron boron)-a newly developed magnetic material, has a maximum magnetic energy product 5 to10 times than the ordinary ferrite [11, 13-14], which means that the tiny rare-earth magnet could produce huge magnetic force. It was primarily developed for industrial manufacture such as electrical machinery, medical apparatus and instruments, in order to decrease the volume of production and enlarge the properties. However, in recent years, it was largely used in toy production. Buckyball, which is made of this kind of magnet and mostly consists 216 magnets with the same size of 5 mm, is colorful in appearance and cheap to afford. It could not only motivate the intelligence and creativity, but also ease the time mentally and physically through making wonderful creatures, both planar and triaxial, statically and dynamically (Fig 4 A-B). But, it was developed only for the crowd elder than 14 yeas of age for entertainment and stress release (Fig 4 C-D). However, because of toy abuse, it is brought to children of all ages.
Early study revealed that from the year 2003 to 2009, 38 cases of magnetic foreign body ingestion were identified, and 8 cases were multiple magnets ingestion, and the number was still growing [15]. Another investigation in 2013 reported that during 2002 and 2011, there had been more than 22,000 pediatric magnetic foreign body ingestion cases in America, and it showed a 5 folds increase comparing the first and the last 2 years [3]. In the year 2014, Buckballs and high-powered magnets were mandatory recalled by the consumer product safety commission in the United States, and since the recall, a significant decrease was reported in multiple mini-magnet ingestion [4]. However, unlike the United States, our results (Fig 2C) reveal the truth that alimentary tract Buckyball injuries are still increasing sharply in China year by year, with no trend to decline.
Our investigation showed the peak age of the ingested children was between one and three years old, and from six to eleven years old (Fig 1 B), consistent with De Roo AC’s study in 2013 [16]. It may be explained by the fact that toddlers explore the world with their mouths and may accidentally swallow the balls, and the school age children prove their braveness through the swallowing, as one case in this study. However 71 of the 74 patients were accidental, just consistent with the reports from De Roo AC [16] and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) [5]. Other special reasons such as psychological disorders or allotriophagia [14, 15] were not fond in this study. The ingestion displayed an obvious male predominance at any age period (Fig 1 A), which was in accordance with other reports [17]. This may attribute to the naughty and brave character, and the explorative spirit of boys.
Beyond the rising popularity of Buckball, severe injuries occurred. Since it was first introduced to the market in 2009 [13, 18], the irreversible injuries increase than the past because of the powerful magnetic force [19]. Unlike ordinary magnets, Buckyballs could attract each other even through six layers of intestinal walls [20], within an average distance of 3.5cm [21], and strengthen will increase with multiple balls ingested [21]. Symptoms were not specific, and were decided by the time and location, but more than a half of the patients (40/74) showed abdominal pain. Richard Sola Jr concluded that abdominal pain was one risk factor for emergency surgery [22]. Other complications, such as ischemia and necrosis, gastrointestinal perforation (Fig 3 A), abscess, ileus, fistula (Fig 3 B-C) also turned to be critical. Diagnosis and treatment algorithm were published by the NASPGHAN in 2012 [23], and patients in this study was managed following the algorithm with satisfied results.
Treatment are of great significance, while prevention is much more important. It is the time to take measures for the prevention, and some suggestions should be followed. Firstly, on the national administration level, the Buckyballs as well as other high-powered magnetic toys’ production and trade should be stopped [14]; and the publicity of serious complications should be reinforced by all means of medias. Secondly, on the producer level, especially for the pediatric toy producers, national policy should be followed; the magnetic toy size should be enlarged; the material should be changed back to ordinary object that has low magnetic energy product [24], or magnetic force lowered to a flux index of 50kG2 [11]; and the warning labels should be much more striking. Thirdly, on the consumer level, parents and caregivers should be realized about the potential risk of the toy [10, 18, 24]; and make children younger than 14 years old or have psychological disorders and allotriophagia away from it; strengthen the nursing; and educate children to well managed their toys before and after playing [3, 25]. Besides, children should be taught stop instigating others to swallow as well. When evaluating the complaints of unexplained abdominal pain, specifically inquire about the ingestions should be took [14].