Ingestion of super strong Magnets in Children presenting to the Paediatric Emergency Department. - Management guideline

Publication: 27/09/2021  
Next review: 27/09/2024  
Clinical Guideline
CURRENT 
ID: 7181 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management Guideline for Ingestion of super strong Magnets in Children presenting to the Paediatric Emergency Department

This Guideline covers the initial investigation and management of children presenting to the Paediatric Emergency department following ingestion of magnets. It does not include the surgical management of these children or the ongoing follow up and management of these children after they have been referred to the paediatric surgical team.

Introduction

This Guideline relates specifically to the ingestion of super strong magnets in children and has been developed following a joint National Patient Safety Alert having been issued by the NHS England and NHS Improvement National Patient Safety Team and Royal College of Emergency Medicine on the need for urgent assessment/treatment following ingestion of ‘super strong’ magnets. These Neodymium magnets (also known as NdFeB, NIB, Neo magnet or Super Strong Rare-Earth Magnets) have become easy to purchase and are promoted as ‘adult desk toys’ or ‘stress relievers. They are inexpensive, easily available and are often brightly coloured and come in a variety of shapes. Ingestion has the potential to cause serious complications due to pressure necrosis, ulceration and ischemia. Evidence suggests that across the UK, the incidence of magnet ingestion is increasing, especially in older children who may have been attempting to mimic tongue and cheek piercings, as well as permanent dental work leading to accidental ingestion.

The guideline focuses specifically on the time critical nature of this emergency, management plan including follow up imaging and timing and criteria for referral and discharge. It has been developed following review of the latest best practice recommendations of the Royal College of Emergency Medicine and following discussion and agreement from Paediatric Surgery, Paediatric Medicine and Paediatric Radiology teams.

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Recommendations

  • Consider magnet ingestion in unwell children with gastrointestinal symptoms.
  • Do not use metal detectors for the assessment of children with suspected rare earth magnet ingestion.
  • All symptomatic rare earth magnet ingestion should be referred to paediatric surgical team.
  • The progression of the magnet/magnets through the gastrointestinal tract is crucial to determining whether surgical intervention is required.
  • Repeat abdominal X-rays should be performed after 6-12 hours in those children who are asymptomatic and meet the discharge criteria.
  • Interpretation of the abdominal x-ray and the finding of progression of the rare earth magnet through the gastrointestinal tract should be formally confirmed by a radiologist o.
  • Patient Advice leaflet should be given to any parent/patient discharged

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Background

Reason for development is to raise awareness of the risks associated with ingestion of rare earth magnets and provide guidance for clinical management of paediatric patients who are suspected to have ingested super-strong magnets.
Points to note

  • Neodymium magnets (also known as NdFeB, NIB, Neo magnet or Super Strong RareEarth Magnets)
  • Promoted and often sold as adult desk toys or stress relievers.
  • Rare earth magnets are between five and ten times stronger than ceramic magnets.
  • The ingestion of a single rare earth magnet is unlikely to cause significant harm, however, if multiple magnets are ingested, or if a magnet is swallowed along with a metal object significant injury can occur.
  • Unlike most other ’foreign body’ ingestions, passage of rare earth magnets into the stomach must not be used as an indication that a child is free from any potentially catastrophic underlying injury.
  • Ingestion of a magnet with a button battery is a time critical emergency.
  • Magnets can attract each other across layers of bowel to cause ischemia and pressure necrosis of the gut and serious complications. The types of injuries have included ulceration, necrosis, perforation, rupture, stricture, fistula, haemorrhage, mediastinitis, gastric outlet or bowel obstruction, volvulus, sepsis and death
  • Ceramic or ‘ordinary’ magnets can also cause serious injury – if there is any uncertainty the safest course is to assume it’s a rare earth variety .

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Presentation

  • Parents or the child may inform you they have ingested a magnet.
  • Consider the possibility of magnet ingestion or aspiration in children presenting with respiratory or abdominal symptoms and who have access to magnets in their environment.
  • Abdominal symptoms may not manifest for weeks following magnet ingestion however intestinal injury can occur early, within 8-24 hours following ingestion, despite the child often remaining well.
  • Symptoms may include, abdominal pain, vomiting, food refusal, blood in motions
  • Aspiration or upper GI symptoms may include coughing, wheeze, noisy breathing, drooling, chest pain, difficulty swallowing, gagging/retching when trying to swallow.

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Imaging

  • Do not use metal detectors for the assessment of children with suspected rare earth magnet ingestion.
  • Chest X-ray and abdominal X-ray (with the patient lying down, ideally prone) should be requested to assess both the position of any magnets and the number of magnets.
  •  In the case of a single magnet being identified on an abdominal X-ray, a lateral abdominal X-ray should also be requested to confirm that only one magnet has been ingested.

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Criteria for discharge

  • Single magnet
  • Accidental ingestion (not self-harm)
  • Within 24 hr of ingestion
  • Well, asymptomatic children
  • No safeguarding concerns
  • Able to return to ED in 6-12 hours for repeat X-ray.

If all criteria are met the child can be discharged and brought back to the PED in 6-12 hrs.

Please book a repeat X-ray before the child leaves (only repeat CXR if magnets seen in the chest on the first image). Please request the X-ray as URGENT on the request form.

Children should be booked at ED reception as a scheduled attendance 6-12 hrs after initially seen.

If the child cannot safely return in 6-12 hrs due to logistical or safeguarding concern consider admission to CAT unit.

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Repeat Imaging

  • All patients who are being discharged with rare earth magnet ingestion require follow-up imaging after 6-12 hours, repeated earlier imaging is not indicated.
  •  If the child becomes symptomatic before the repeat radiograph urgent surgical review will be required.
  •  Follow up abdominal X-ray should be requested (only repeat CXR if magnets seen in the chest on the first image).
  •  It is essential that the abdominal radiographs are always performed in the same position (lying down, ideally prone).
  •  Interpretation of the abdominal x-ray and the finding of progression of the rare earth magnet through the gastrointestinal tract should be formally confirmed by a radiologist. (please put on request as URGENT when requesting repeat X-rays).
  • The X rays will then need to be discussed with and reported by the Duty Paediatric Radiologist in hours (Contact Via Secretaries on 22336) or the on-call Radiology Registrar out of hours (Bleep 2342). This will ensure we meet the reporting standards outlined by RCEM.
  • Follow-up AXRs should continue to be performed until it can be demonstrated (and confirmed by a radiologist) that the magnet has passed through the stomach and serial X-rays (at least 6-12hrs apart) show that it is progressing through the small bowel or beyond.
  • Failure of the magnet to progress through the gastrointestinal tract, (defined as: the magnet having not moved from the last demonstrated position on AXR irrespective of location in GI tract after a period of 6-12hrs and confirmed by a radiologist) is an indication for surgical referral.

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Surgical Referral

The following patients should be referred to the surgical team for ongoing assessment and management.

  • Multiple magnet ingestion
  • Patients with metallic FB on imaging who are symptomatic.
  • Magnets with other metallic FB
  • Any Button Battery ingestion
  • Patients who on repeat imaging demonstrate failure of the magnet to progress through the gastrointestinal tract, (defined as: the magnet having not moved from the last demonstrated position on AXR irrespective of location in GI tract after a period of 6-12hrs and confirmed by a radiologist)

Patients referred to paediatric surgery for assessment from other hospitals will be discussed and accepted by the paediatric surgery consultant or registrar on call and if admission required should attend the paediatric surgical ward or CAT following arrangement with bed manager. This group of patients should not attend the paediatric emergency department.

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Provenance

Record: 7181
Objective:

This Guideline covers the initial investigation and management of children presenting to the Paediatric Emergency department following ingestion of magnets. It does not include the surgical management of these children or the ongoing follow up and management of these children after they have been referred to the paediatric surgical team.

Clinical condition:

Ingestion of super strong Magnets

Target patient group: Children
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

This guideline has been produced following a National Patient safety alert (NatPSA/20021/002/NHSPS) and is based on the Royal College of Emergency Medicine Best Practice Guideline

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

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