Leading article/Artykuł redakcyjnyReview/Praca poglądowa

Not all foreign bodies are created equal

Petar Mamula *

Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Associate Professor of Pediatrics, University ofPennsylvania Perelman School of Medicine, Philadelphia, USA

p e d i a t r i a p o l s k a 8 8 ( 2 0 1 3 ) 2 1 3 – 2 1 8

a r t i c l e i n f o

Article history:

Received: 05.02.2013

Accepted: 20.02.2013

Available online: 26.02.2013

Keywords:� Children� Foreign bodies� Management

a b s t r a c t

Foreign body ingestions in children and adolescents can pose significant challenge both

in terms of diagnosis and treatment. The pediatric scientific literature is relatively scarce

and consists mostly of case reports and small case series, therefore making firm guideli-

nes and management recommendations rather difficult. The type of ingestions seen may

vary in different countries and it changes over time depending on implementation of

safety measures, or introduction of new products. Lately, there has been a significant

increase in the incidence of high-powered multiple magnet, and large disc battery inges-

tions. Both of these are associated with potentially serious complications including fatal

outcomes. This paper briefly discusses some of the important aspects of critical foreign

body ingestions, proposed management algorithms, and efforts necessary to increase

public awareness in order to minimize complications and improve prevention.

© 2013 Polish Pediatric Society. Published by Elsevier Urban & Partner Sp. z o.o.

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/pepo

Open access under CC BY-NC-ND license.

During the last decade there has been a significant increasein critical foreign body ingestions with high rate of devas-tating complications. These primarily occur with high powe-red rare-earth neodymium magnet and large lithium discbattery ingestions.

Ingestion of magnets has been reported sporadically inthe scientific literature for many years. However, within thelast 10 years the number of cases has significantly increa-sed. More importantly, the high rate and severity of com-plications has become quite worrisome. This likely stemsfrom the fact that neodymium magnets used in toys are upto ten times more powerful when compared to ordinarymagnets. In cases of multiple magnet or magnet andmetallic object ingestion, this results in attraction of adja-cent magnets through different bowel loops leading toserious bowel injury including perforation (Fig. 1) and canresult in a fatal outcome. The first fairly large series,

* Correspondence address: Division of GI, Nutrition and HepatologyCenter Boulevard, Philadelphia, PA 19104, USA. Tel.: +1 215 590 9146;

E-mail address: mamula@email.chop.edu.0031-3939 © 2013 Polish Pediatric Society. Published by Elsevier Urbanhttp://dx.doi.org/10.1016/j.pepo.2013.02.007

including 24 of these ingestions, was reported from UnitedKingdom in 2002 [1], followed by 20 more cases reported inthe United States Centers for Disease Control and Preven-tion Morbidity & Mortality Weekly Report in 2006 [2]. Thatsame year the United States Consumer Product SafetyCommission (USCPSC) raised the recommended age formagnet toys from 3 to 6 years and then with continuedincrease in reported cases, banned sales of rare-earthmagnets to children younger than 14 in 2009. Around thesame time a mass production of these adult toys in sets ofup to 1000 started due to the expiration of US patent (Fig. 2).Most recently, an informal poll of pediatric gastroenterolo-gists participating in an on-line bulletin board forum revea-led a series of more than 80 magnet ingestions of which onethird required surgery for perforation repair and/or bowelresection. This prompted a formal survey in the fall of 2012among the members of the North American Society for

, The Children's Hospital of Philadelphia, 34th Street and Civicfax: +1 215 590 3680.

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Fig. 1 – Endoscopic view of a duodenal perforation (left lowercorner) in a 9-year-old boy who developed duodeno-colicfistula after multiple magnet ingestion

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Pediatric Gastroenterology, Hepatology and Nutrition(NASPGHAN). The survey concentrated on the period bet-ween 2008 and 2012 and detected 123 cases of which 102occurred during just the last two years. More than half werein children one to three years of age (personal communica-tion). The other large group consisted of older children whowere pretending to have body art or piercing. Majority ofmagnets were located in the upper gastrointestinal tract,but some were in the small bowel including terminal ileumand colon requiring colonoscopic examination for removal.A very high proportion (25%) of the patients requiredsurgery and 9% of those required further therapy due tocomplications.

The commentary published last year discusses a proposedalgorithm (Fig. 3) for single and multiple magnet ingestionmanagement [3]. Several points warrant emphasis. Obviously,the radio-opaque nature of magnets allows for easy detection

Fig. 2 – Neodymium magnet toy set

and follow up of their progression with an x-ray. However, onoccasion it is difficult to determine if there is one or moremagnets present and in those cases multiple x-ray viewsmay be necessary to aid the detection. Further, simple adviceto avoid clothing with metallic objects may help passage ofmagnets while removal of other magnets from the child'senvironment may prevent further ingestion. The timing ofingestion is often not known and there is no data availableyet to determine how long it takes for a bowel injury todevelop. The algorithm uses an arbitrary 12-h cut-off,although injury has been documented to occur in isolatedcases even earlier than that. In cases of prolonged time sinceingestion it is important to involve our surgical colleaguesearly, either as a back-up during endoscopic intervention, orin case of a symptomatic patient where surgical removalmight be a better initial therapeutic option. For multiplemagnets within endoscopic reach cautious attempt should bemade to remove them. No specific endoscopic tool hasemerged as more favorable than others. Since magnets arequite powerful it may be difficult to separate them apart andoccasionally difficult to determine if bowel mucosa is caughtin-between. In extreme cases of multiple magnet ingestion itmay become exceedingly difficult to remove them due totheir clumped size. The above-mentioned survey found thatmore than 20% of patients had 10 or more magnets noted atthe time of endoscopy. A retrieval net will likely be a usefultool, although variety of forceps types may be helpful, too.The magnets beyond endoscopic reach and in asymptomaticpatients should be closely followed. The use of laxatives toaid passage is somewhat controversial and will likely need tobe decided on case-to-case basis. Since multiple subspecia-lists may be involved with these ingestions starting withemergency room physicians or pediatricians and familypractitioners, to ENT and general surgeons, radiologists, andpediatric gastroenterologists, concerted effort to developmultidisciplinary approach and protocols will likely result inbetter outcomes. Finally, prevention of ingestion is clearly thebest strategy and it is of crucial importance to develop andimplement an advocacy plan. NASPGHAN took an active rolein this regard both in educating its members, the public, andreaching out to our sister professional societies. The patientbrochure is available at the Societies' web site (http://www.naspghan.org) as well as the podcast on magnet managementand treatment algorithm. In addition to this, frequent actionand media alerts were sent, media spokespersons identified,newsletters published, and several NASPGHAN members metwith USCPSC staff. These, among other measures as well asincreased public awareness of high rate of complicationscontributed to the USCPSC's decision to engage manufactu-rers of neodymium magnets in discussion regarding volun-tary recall. Majority of the manufacturers in the United Statesdid proceed to voluntary recall while further legal actionresulted in full voluntary discontinuation of high poweredrare-earth neodymium magnet toys.

The second major type of foreign body associated withsignificant morbidity and mortality are batteries. In particu-lar, 20-mm lithium disc batteries can have devastating effectif lodged in the esophagus. Recently, Litovitz et al. publishedtwo seminal articles on battery ingestions [4, 5]. The firstone described outcomes with more than 56,000 battery

Fig. 3 – Algorithm for magnet ingestion management (reprinted with permission from JPGN)

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ingestions recorded in the US National Poison Data System[5]. While a consistent change in the ingestion frequencytrend could not be detected, clinically significant severeoutcomes defined as major or fatal increased 6.7 fold fromthe beginning to the end of the 25-year study period from1985 to 2009. More than two thirds of ingestions wererecorded in children 6 years of age and younger. Additional8648 battery ingestions reported to the US National BatteryIngestion Hotline were analyzed and the data showedsignificant increase from 1% at the beginning, to 7% at theend of the 18-year study period for ingestion of batteries�20 mm in size with similar pattern for lithium batteries(from 1% to 24% of all ingested batteries). Finally, the dataon 13 fatal and 73 major outcomes revealed that 94% ofcases with known battery size involved those equal or largerthan 20 mm in size. Based on these data and the reportedsignificant esophageal injury within less than three hoursfrom the time of ingestion, the triage and treatmentguidelines were recommended.

It is not entirely clear why large disc lithium batteries areassociated with a high risk of esophageal injury. The reasonfor their recent ubiquitous use is decrease in productioncost and two-fold increase in voltage to 3 V which makesthem suitable for a variety of consumer electronic and toyproducts ranging from remote control batteries, those most

frequently involved in ingestions, to hearing aids andgreeting cards. The likely explanation is multifactorial andconsists of their size and physical pressure, generatedelectric current, and most importantly liquefying alkalinedeep tissue hydrolysis. This process continues even aftera battery removal as it was shown in a case series ofingestions with fatal outcome [6]. Additionally, a ‘‘sentinel’’mild bleeding in this series was seen in 70% of patients whosubsequently exsanguinated, allowing for a potential win-dow of opportunity for surgical repair, which in case ofaorto-esophageal fistula and severe bleeding seems other-wise universally fatal. The aorto-esophageal fistula was themost common cause of death while other causes includederosion into thyroid artery, subclavian artery, and medias-tinal vessels, and all involved children 3 years of age oryounger. The authors also proposed a management guide-line. Aside from life-threatening bleeding, the inflammatoryinjury due to esophageal battery ingestion could result ina variety of potentially serious and fatal outcomes includingtracheo-esophageal fistula (Fig. 4), esophageal stricture(Fig. 5) or perforation, tracheal stenosis and tracheomalacia,and vocal cord paralysis. Since the point of injury origin isbatteries' negative pole, a very useful 3n mnemonic wasrecently coined by Dr. M. Kay describing tissue necrosis,narrowest esophageal point, and negative battery pole.

Fig. 4 – Tracheo-esophageal fistula in a 3-year old boy with ahistory of battery ingestion

Fig. 6 – Lateral chest x-ray battery view with a ‘‘hallo’’ sign

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Several points in the diagnosis and management algo-rithm of large disc batteries warrant further discussion.While batteries are easily seen on an x-ray it takes an astuteclinician to suspect ingestion since the majority of patientsare very young and unable to describe the event. Batterieson an x-ray may appear as coins and any sign of a hallo(Fig. 6) or a step-off due to an uneven thickness of a batteryshould be a clue. The time to severe injury has been

Fig. 5 – Esophageal stricture in a 2-year-old girl with history of bwas repaired. The image on the left depicts the proximal esophendoscopic dilation

reported to range from a few hours to 18 days. Surprisingly,significant injury to the adjacent organs may be detectedwithout (Fig. 7) evidence of esophageal perforation. There-fore, imaging with MR after battery removal, or a CT/CT

attery ingestion causing tracheo-esophageal fistula whichageal stricture and the one on the right the same area after

Fig. 7 – Magnetic resonance chest image depictingsignificant mediastinal inflammatory reaction in a 4-yearold boy with esophageal battery ingestion withoutesophageal perforation

Fig. 8 – Battery management algorithm (s

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angiography could serve as a guide for further management.Last, but certainly not least, is the timing of endoscopy foresophageal disc battery removal. We treat these ingestionsas true endoscopic emergencies (Fig. 8) and make everyattempt to remove esophageal batteries within two hoursfrom ingestion. Fig. 9 depicts effect of a 20-mm disc batteryon a hot dog. It is likely that similar esophageal injury canoccur within just a couple of hours from ingestion. Thetiming of endoscopy for large disc batteries in the stomachis a bit more controversial. While the guidelines suggestthat stomach battery can be observed for 4 days our practiceis to use a more conservative 48-h mark especially sincesignificant gastric mucosal injury within 4 h has beenobserved with multiple disc battery ingestion [7]. Also, inthe above-mentioned report describing fatal outcomes, onepatient who was found to have the battery in the stomachat the time of presentation later died of esophageal injury. Itis quite likely that the battery was first lodged in theesophagus and then later spontaneously advanced into thestomach, which points out that a very cautious approach isrequired even for those batteries that are first detected inthe stomach or elsewhere in the GI tract.

In conclusion, rare-earth magnet and large disc batteryesophageal ingestions are associated with high morbidityand mortality, and may present as diagnostic dilemma orendoscopic and therapeutic emergency. It is of outmostimportance for all those involved in the care of childrenwith such ingestions to be cognizant of management

pecial thanks to Dr. Benjamin Sahn)

Fig. 9 – Effect of a 20-mm disc battery on a hot dog at 120 min

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algorithms. Additionally, we need to educate patients andtheir families, as well as the general public and ourcolleagues on the dangers of critical foreign body ingestions.This would hopefully lead to prevention of ingestions,which is the clearly the best and preferred strategy, butwould also help with accurate and timely diagnosis andtherapy, thus minimizing potentially devastating conse-quences. Finally, we need to work with our governments

and legislators to better regulate these products and keepthem out of reach of children.

Financial support/Finansowanie

None declared.

Conflict of interest/Konflikt interesu

None declared.

Ethics/Etyka

The work described in this article have been carried out inaccordance with The Code of Ethics of the World MedicalAssociation (Declaration of Helsinki) for experiments invol-ving humans; EU Directive 2010/63/EU for animal experi-ments; Uniform Requirements for manuscripts submitted toBiomedical journals.

r e f e r e n c e s / p i �s m i e n n i c t w o

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[2] Centers for Disease Control and Prevention (CDC).Gastrointestinal injuries from magnet ingestion in children–United States, 2003–2006. MMWR Morb Mortal Wkly Rep2006;55(48):1296–1300.

[3] Hussain SZ, Bousvaros A, Gilger M, Mamula P, Gupta S,Kramer R, Noel RA. Management of ingested magnets inchildren. J Pediatr Gastroenterol Nutr 2012;55(3):239–242.

[4] Litovitz T, Whitaker N, Clark L. Preventing batteryingestions: an analysis of 8648 cases. Pediatrics 2010;125(6):1178–1183.

[5] Litovitz T, Whitaker N, Clark L, White NC, Marsolek M.Emerging battery-ingestion hazard: clinical implications.Pediatrics 2010;125(6):1168–1177.

[6] Brumbaugh DE, Colson SB, Sandoval JA, Karrer FM, Bealer JF,Litovitz T, Kramer RE. Management of button battery-induced hemorrhage in children. J Pediatr GastroenterolNutr 2011;52(5):585–589.

[7] Takagaki K, Perito ER, Jose FA, Heyman MB. Gastric mucosaldamage from ingestion of 3 button cell batteries. J PediatrGastroenterol Nutr 2011;53(2):222–223.