What is the management for a child who has ingested a magnet?

Management of Magnet Ingestion in Children

Immediate imaging with plain radiographs is essential to determine the number and location of magnets, as multiple magnets or magnets with other metallic objects require urgent intervention to prevent life-threatening intestinal perforation. 1, 2

Immediate Assessment and Imaging

• Obtain biplanar radiographs (AP and lateral views) immediately to identify the number of magnets, their location, and whether other metallic foreign bodies are present 1, 3
• CT scan should be performed if perforation or complications are suspected, as it has 90-100% sensitivity compared to only 32% for plain radiographs 4
• Critical distinction: Single magnet ingestion versus multiple magnets fundamentally changes management - multiple magnets attract across bowel loops causing pressure necrosis, perforation, and potentially fatal complications 5, 1, 2
• Even if imaging suggests a single magnet, assume multiple magnets may have been ingested unless definitively proven otherwise, as misdiagnosis leads to preventable severe complications 5

Management Algorithm Based on Number and Location

Single Magnet Ingestion

• If in the esophagus: Emergent endoscopic removal within 2-6 hours is mandatory 6, 7
• If beyond the esophagus and asymptomatic: Close observation with serial radiographs every 4-6 hours to document passage 2, 8
• If the magnet fails to progress or becomes impacted (e.g., at the pylorus), endoscopic removal is indicated 2
• Most single magnets pass spontaneously without complications 2

Multiple Magnets or Magnet + Other Metallic Object

• This is a surgical emergency requiring immediate joint gastroenterology and surgical consultation 1, 8
• If in the esophagus or stomach: Emergent endoscopic removal within 2 hours is critical 1, 8
• If beyond the stomach: Surgical consultation is mandatory, as 50% of children with multiple magnetic foreign bodies develop intestinal perforation requiring operative repair 2
• Serial radiographs every 4-6 hours to monitor for signs of obstruction or perforation if magnets are separated and observation is attempted 8, 3
• Immediate surgical exploration is required if: signs of peritonitis develop, magnets remain in the same location on serial films (indicating attraction across bowel loops), or symptoms of obstruction or perforation occur 1, 2, 8

Clinical Warning Signs Requiring Immediate Surgical Intervention

• Abdominal pain, vomiting, or signs of peritonitis (fever, guarding, rebound tenderness) indicate bowel perforation until proven otherwise 2, 8
• Magnets that remain stationary on serial radiographs suggest they are attracted across bowel loops, causing pressure necrosis - this requires urgent surgical exploration even without overt peritonitis 5, 3
• The longer the duration between ingestion and intervention, the higher the risk of complications including perforation, fistula formation, and intestinal necrosis 1, 8

Critical Pitfalls to Avoid

• Never assume a single magnet was ingested based on history alone - children may have ingested multiple magnets in a staggered fashion or parents may be unaware of the total number ingested 5, 1
• Do not wait for symptoms to develop before intervening with multiple magnets - complications can occur rapidly and may be irreversible by the time symptoms appear 5, 2
• Do not administer anything by mouth except in specific circumstances (honey for button batteries in children >1 year), and never induce vomiting 6
• Traditional foreign body algorithms advocating spontaneous passage do not apply to multiple magnet ingestion 5, 8

Special Considerations for High-Power Earth Magnets

• Earth magnets (rare-earth magnets) have significantly higher magnetic strength and carry worse outcomes with higher complication rates 1
• These require even more aggressive management with lower threshold for surgical intervention 1

Post-Removal Monitoring

• After successful removal, monitor for delayed complications including perforation, as tissue damage may have already occurred 8
• Keep the patient nil by mouth initially and advance diet cautiously based on clinical status 4
• Watch for signs of mediastinitis if esophageal removal was required (severe sore throat, chest pain, fever, crepitus) 4