The accidental ingestion of foreign bodies (FBs) is common in children. More than 100,000 FBs are ingested per year by children in the United States (US) alone.1 Most FB ingestions do not result in life-threatening complications, but cases involving rare-earth magnets are prone to having severe complications, including bleeding, gastrointestinal perforation, and even death.2 The rare-earth magnets composed of iron, boron, and neodynium are at least 5 to 10-times more powerful than traditional magnets. Although initially very expensive to produce, rare-earth magnets (such as neodymium magnets) have become less expensive, and are currently marketed as construction toys for children. With their increasing availability, the frequency and severity of rare-earth magnet ingestion has become a significant threat to children’s health. A 2012 survey of 201 pediatric gastroenterologists in the US identified 481 cases of magnet ingestion over the past 10 years.3 Despite the magnitude of the problem, the sale of magnets continues to grow, and along with it, the frequency of complications. In response, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has called for a ban on their sale. Outside the US, cases of magnet ingestion have been reported in Japan,4 Canada,5 and France, where a retrospective multicenter study reported 40 cases of FB ingestion, 60% of which involved multiple magnets.6 To the best of our knowledge, there are no published Latin American reports of magnet ingestion in children. Given that the majority of such cases are likely to go unreported, the aim of the present study was to establish whether the problem has been seen by pediatric gastrointestinal endoscopists in Latin America, in an effort to assess the magnitude of this potential threat to Latin American children and appropriately address the situation.

A survey was developed for administration to pediatric endoscopists present at the 2nd World Congress of Gastrointestinal Endoscopy (ENDO 2020), held in Rio de Janeiro, Brazil, in January 2020. The questionnaire was distributed to endoscopists attending a pediatric session. They were given the option of completing it during the session or returning it by mail, if they did not have enough information at hand to answer the questions. The questionnaire consisted of 15 items and spanned a period of 3 years. The questions included the average number of endoscopies performed per year, the number of endoscopies conducted due to FB ingestion, and in cases of magnet ingestion (Table 1), the location of the magnet within the gastrointestinal tract, the number of magnets ingested, and a description of complications and surgical interventions (Table 2). In addition, the participants were asked if they knew other practitioners in their countries that had treated similar cases of magnetic FB ingestion. The ratio of magnet ingestion cases to the total number of esophagogastroduodenoscopies (EGDs) and the ratio of complications per country were calculated.

The endoscopists that participated in the survey came from 12 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Dominican Republic, Mexico, Nicaragua, Paraguay, Peru, Uruguay, and Venezuela. Ten (40%) of the patients were females, 12 (48%) were males, and the sex of 3 (12%) subjects was not known (Table 2). Mean age of the children was 5.14 years (SD 2.50), ranging from one to 10 years of age. Over a 3-year period (2017, 2018, and 2019), a total of 23,439 endoscopies were performed at the participating endoscopists’ centers. Of those procedures, 2,363 (10.08%) were due to FB ingestion (Table 1) and 25 cases (1.05%) were specifically due to magnets. There were 16 cases (64%) of multiple magnets in the gastrointestinal tract and 9 (36%) cases of single magnet ingestion. The most common locations seen on the imaging studies were: stomach 15 (60%), small bowel 5 (20%), esophagus 4 (16%), and duodenum one (4%). Of the 25 cases of magnet ingestion reported, 3 (12%) developed serious complications and 2 (8%) of the patients underwent surgical interventions. Seven of the specialists surveyed responded that they knew of colleagues that had treated cases of magnet ingestion, not included in the present study. No deaths were reported.

This preliminary study is the first to survey pediatric endoscopists in Latin America, regarding the ingestion of magnets in children. The study was carried out on a convenience sample of experts that attended an international meeting. Our study suggests that although the ingestion of magnets in this geographic area does not appear to be common, it does exist, and cases are prone to complications. The endoscopists in our sample reported 25 cases of magnet ingestion. Three of those cases were associated with complications (12%) and there were 2 cases of perforations. Importantly, the low number of magnet ingestion reported in the survey should not be interpreted as an inconsequential problem. In some of the cases described, the ingested magnets were attached to each other, but did not result in a perforation that most likely would have occurred, had a timely procedure not been performed.

The strengths of our study include the wide representation of Latin American countries among the responders and the fact that the questionnaire was completed by experts that attended an international meeting dedicated to endoscopy. Given the expertise of the responders, the most difficult cases (such as those involving magnets) were likely to have been referred to them, and they were probably aware of many of the local cases, as well. To account for the possibility of cases that were not managed by the responders, they were asked if they were aware of cases of magnet ingestion treated by other practitioners in their cities. Seven of the 22 gastroenterologists responded in the affirmative, implying that there are more cases than those described in the present study. It is also likely that some cases of magnet ingestion are seen at local emergency rooms and treated by surgeons, without the intervention of a pediatric gastroenterologist, reinforcing the supposition that the problem is more widespread than our data show. In all probability, the low number of cases is an underrepresentation of the real data of each country because EGDs are not readily available in many regions and patients have to travel for hours to reach a pediatric gastroenterologist equipped with an endoscope. Multiple magnet ingestion was reported in more than one city in some countries, whereas no magnet ingestion was reported in other countries, which could reflect the differences between regions in relation to access to magnets by children, the marketed use of magnets, and to having endoscopy as a diagnostic/therapeutic option.

The limitations of our study include its poor generalizability and the feasible selection bias regarding the practitioners that completed the survey. The participants were a particular selected group of endoscopists that traveled to attend an international meeting and are not necessarily representative of the majority of endoscopists in their countries, nor indicative of the reality of all the cities in their countries. Moreover, only a small group of the total of 200 attendees completed the survey. However, our study was not intended to provide a complete representation of Latin America regarding magnet ingestion, but rather to call attention to the problem. Not all the endoscopists contacted their offices or searched a database to answer the questions. Thus, there is the possibility of recall bias, albeit the rarity of magnet ingestion and the peril associated with it make the vivid recollection of those cases more likely.

To the best of our knowledge, the present study is the first report describing magnetic FB ingestion in a Latin American population. Given the general lack of use of electronic medical records and centralized reportable databases inherent in Latin American countries, the prevalence of cases of ingested magnets is still unknown. Nevertheless, our study shows that despite being infrequently reported, magnet ingestion has high morbidity. Given its low numbers, magnetic ingestion may be seen as a small threat, but it should be viewed as a significant problem that can lead to complications. We speculate that with the phenomenon of business globalization, magnetic FB ingestion rates are likely to increase, along with the potential of dangerous complications. Therefore, the development of educational campaigns among pediatricians, emergency doctors, teachers, and parents is of the utmost importance, to prevent children from having contact with magnetic toys and to recognize the complications derived from the ingestion of magnets. Larger prospective studies need to be conducted, and if their data confirm our findings, the prohibition of the commercialization of those types of toys should be considered, a task that has been difficult to achieve in the US, despite the NASPGHAN’s best efforts.

No financial support was received in relation to this article.

The authors declare that there is no conflict of interest.