What is the recommended evaluation and management for a child under five years old who has ingested a magnet?

Management of Magnet Ingestion in Children Under Five Years

Immediately obtain plain radiographs (chest and abdomen) to confirm the presence, number, and location of magnets, and proceed directly to emergent endoscopic removal within 2-6 hours if multiple magnets or a magnet with another metallic object are identified, as these create life-threatening risk of pressure necrosis, perforation, and fistula formation between attracted objects across bowel walls. 1, 2

Immediate Diagnostic Evaluation

Plain Radiography First

• Obtain anteroposterior and lateral chest/abdominal radiographs without delay to identify the number of magnets and their anatomic location 1, 2
• Biplanar views help distinguish whether magnets are in the same bowel loop or separated across multiple loops 2
• Critical pitfall: Plain radiographs have up to 47% false-negative rate for foreign bodies, so negative imaging does NOT exclude magnet ingestion when history is suggestive 1

Advanced Imaging When Indicated

• Obtain CT scan immediately if plain films are negative but history strongly suggests ingestion, or if complications are suspected (CT has 90-100% sensitivity versus only 32% for plain radiographs) 1
• CT definitively identifies exact number of magnets, precise location, and early complications such as perforation, obstruction, or fistula formation 1
• Do not perform contrast swallow studies—they increase aspiration risk and impair subsequent endoscopic visualization 1

Risk Stratification and Management Algorithm

High-Risk Scenarios Requiring Emergent Intervention (Within 2-6 Hours)

Multiple magnets identified on imaging:

• Proceed immediately to emergent flexible endoscopy regardless of symptoms because magnets attract across bowel walls causing pressure necrosis, ischemia, perforation, and fistula formation 1, 2, 3
• The powerful neodymium (rare-earth) magnets can attract with formidable forces that squeeze intestinal loops between them 2
• Complications develop rapidly—bowel damage can occur within hours of ingestion 3, 4

Single magnet with possibility of co-ingestion:

• Even a single visible magnet is dangerous if there is any possibility of multiple magnets or co-ingestion with other metallic objects (coins, batteries, metal toys) 1, 2
• Treat as high-risk and proceed to emergent endoscopy if ingestion was unwitnessed or if child has history of pica or excessive mouthing behaviors 2, 3

Moderate-Risk: Single Confirmed Magnet, Witnessed Ingestion

If truly single magnet with reliable witnessed ingestion:

• May observe with serial radiographs every 4-6 hours to document progression through GI tract 4
• Observation period should not exceed 2-3 days 4
• Surgical removal is warranted if magnet fails to migrate on serial films or if any symptoms develop (vomiting, abdominal pain, fever) 4

Endoscopic Removal Technique

• Perform emergent flexible endoscopy within 2-6 hours of presentation 1, 2
• Remove all magnets in a single session if possible 2
• If endoscopic removal fails, proceed immediately to surgical exploration 4

Surgical Indications

Immediate surgical exploration is required for:

• Failed endoscopic removal 4
• Signs of peritonitis, obstruction, or perforation (fever, severe abdominal pain, peritoneal signs, sepsis) 3, 4
• No magnet migration on serial radiographs over 2-3 days 4
• CT findings suggesting transmural necrosis, perforation, or fistula formation 1

Surgical findings typically include:

• Multiple intestinal perforations requiring repair 3
• Fistula formation between bowel loops 2, 5
• Bowel obstruction from magnets attracting across loops 2, 5

Critical Pitfalls to Avoid

• Never rely on negative plain radiographs alone to exclude magnet ingestion when history is positive—proceed to CT if clinical suspicion remains high 1
• Do not delay intervention waiting for symptoms to develop—by the time peritonitis appears, extensive bowel damage has already occurred 3
• Do not assume a single magnet on x-ray means only one was ingested—children often ingest magnets at different times over days to weeks, and earlier magnets may have already passed 3
• Avoid MRI in children with suspected magnet ingestion—the magnetic field can cause magnets to move and create or worsen perforations 6
• Do not use "watchful waiting" for multiple magnets—these require emergent removal regardless of symptoms 1, 2

Special Considerations for Children Under Five

• Ingestion is often unwitnessed in this age group, making history unreliable 6, 3
• Symptoms are frequently nonspecific (vomiting, abdominal pain, irritability) and may be misattributed to common pediatric illnesses like viral gastroenteritis or otitis media 3
• Children with developmental delays, pica, or excessive mouthing behaviors are at highest risk and should have lower threshold for imaging 2, 3
• Median age of presentation is approximately 34 months, with vomiting and abdominal pain as most common initial symptoms 4

Post-Removal Monitoring

• All children require observation for at least 24-48 hours after removal to monitor for delayed perforation or complications 2
• Obtain follow-up radiographs to confirm complete removal of all magnetic material 2
• Counsel families about prevention and the unique dangers of high-powered neodymium magnets 5