The Journal of Pediatrics Volume 164, Issue 1 , Pages 4-5.e1, January 2014
Advocating for Child Health: How the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Took Action against High-Powered Magnets
Athos Bousvaros, MD, MPH , Camille Bonta, MHS , Mark Gilger, MD , R. Adam Noel, MD
Sometimes, events take you in a direction you were not expecting. In 2012, this was the case for members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), which is composed primarily of pediatric gastroenterologists and gastroenterology nurses. The society's primary roles in the past have included developing practice guidelines, planning educational programs such as our annual meeting, managing The Journal of Pediatric Gastroenterology and Nutrition, and awarding research grants through the NASPGHAN Foundation to promising fellows and junior faculty. Establishing visibility through government advocacy also has been an important goal of NASPGHAN. We had previously talked with Congressional leaders about making medical foods more accessible for children with chronic medical conditions, but did not have any other “high priority” issues. In April 2012, Dr Adam Noel, a pediatric gastroenterologist in New Orleans, was caring for a 2-yearold child in the intensive care unit who had swallowed a group of high powered neodynium magnets. These magnets pinched several loops of bowel together, causing bowel ischemia, necrosis, and resulted in the development of short bowel syndrome. Noel had heard of similar magnet ingestion cases elsewhere, including a case publicized in the Washington Post, 1 but he did not know how common this problem was. Noel posted a query about magnet ingestions on NASPGHAN's pediatric gastroenterology e-mail listserver (a bulletin board subscribed to by more than 2000 pediatric gastroenterologists worldwide). Within a few days, more than 50 pediatric gastroenterologists reported cases from across the country, with many children needing surgery. The vast majority of cases had occurred within the last year. We had identified a major ingestion hazard that was increasing with alarming speed. Why do these magnets pose such a unique risk to children? First, these magnets are quite innocent-appearing. They are small, round, shiny, 2-3 mm in size, and about the size of a ball bearing. Second, neodymium magnets are incredibly powerful, and if 2 or more such magnets are ingested, they can attract 2 different bowel loops within the abdomen from centimeters away. Lastly, the injury caused by such magnets is difficult to detect. If two magnets attract through the intestine, a child can be completely asymptomatic until the intestinal wall ulcerates and perforates, leading to peritonitis. Thus, even though a known ingestion is amenable to endoscopic magnet retrieval by the gastroenterologist, an unknown ingestion (as is the case with many toddlers) will present with peritonitis and require a surgical approach. Why did these magnet ingestions have such a dramatic rise in prevalence in the past year? Simply put, these magnets were quite popular, marketed aggressively, and were for sale in many major retailers across North America. Although the US Consumer Product Safety
Commission (CPSC) had mandated these to be marketed as “adult toys” and not be sold to children under the age of 14 years, tens of thousands of sets had been sold, and were in houses across the US. Many of these magnet sets contain up to 200 high-powered magnets, which are difficult to account for after the set is removed from its original packaging. Consequently, these magnets are easily and unknowingly ingested by toddlers, children with developmental delays, or teenagers who want to mimic a tongue piercing. After NASPGHAN realized the magnitude of the problem, our society formulated a 5-pronged approach in the spring of 2012: (1) educate pediatric gastroenterologists and other pediatric physicians about the management of this new hazard, and the need for urgent intervention if more than two magnets have been swallowed; (2) educate the public by putting appropriate information on our website, and by working with local and national media; (3) gather additional primary data on the prevalence and complications of magnet ingestions; (4) advocate with government leaders for the removal of this hazardous toy from the shelves of retailers, and possibly for a ban; and (5) partner with other societies, such as the American Academy of Pediatrics (AAP) and American Pediatric Surgical Association, in our efforts. Camille Bonta, NASPGHAN's Washington advocate, advised us on how to proceed. The CPSC has an easy way of reporting unsafe products on the front page of their website (www.cpsc.gov), but our physicians were unaware of this mechanism. We sent an e-mail to our members, encouraging them to report such cases to the CPSC. Members of our society, led by Dr Noel and Dr Sunny Hussain, drafted an algorithm for the management of these ingestions, emphasizing the high risk of multiple magnet ingestions. With the agreement of The Journal of Pediatric Gastroenterology and Nutrition's editor and publisher, we made this freely available online prior to the print publication.1 We prepared a patient education handout that is available on our patient website (www.gikids.org). We also developed an institutional review board-approved survey that was e-mailed to every NASPGHAN member. Bonta arranged for members of our advocacy committee to meet with CPSC officials to tell them what we knew. Although the CPSC was well aware of the potential for these toys to cause damage (there had been rare reports of perforations going back several years), our meeting and Noel's informal survey provided additional information to the CPSC. NASPGHAN members, armed with high-powered magnets and patient radiographs, also went to Capitol Hill to educate lawmakers about ingestions. Lawmakers took note and several communicated their concerns about high-powered magnets to the CPSC. Less than 2 months after NASPGHAN's visit to Washington, DC, the CPSC asked for a voluntary recall of these magnet toys, and the majority of manufacturers complied. The largest seller (Maxfield and Oberton, maker of Buckyballs; New York, New York) did not comply, which resulted in legal action (an administrative complaint) against this and another company, Zen Magnets. The type of legal action taken by the CPSC is rare and had been used only one other time in the past 11 years. About 6 weeks later, on September 4, 2012, the CPSC issued proposed safety standards for highpowered magnet sets—standards that would effectively ban the future sale of these magnet sets. 2 At that point, our advocacy efforts intensified. Maxfield and Oberton launched a very well organized public relations campaign, under the catchy title “Save Our Balls.” In this campaign, the company made the argument that they had complied with the government's request to label and market the product for individuals over 14 years of age. Thus, any inadvertent ingestion was the result of inappropriate use. The Buckyball argument was well publicized by some members of the mass
media, who accused the CPSC of being “nanny state job killers.” 3 What we originally envisioned as a public education initiative was quickly turning into a “street fight” on television and the internet. We asked our members to help, and they came through. Hundreds of NASPGHAN members commented to the CPSC in support of its proposed magnet safety standards, effectively countering posts to the CPSC and other websites defending Buckyballs, such as “parents who let their kids swallow these are stupid” and “get government off our backs.” An ABC Nightline program raised awareness of both sides of the issue, covering the impact of government regulation on business and the risks to children. The dangers of high-powered magnets also received public attention during the holiday shopping season; these products were highlighted in the 2012 “Trouble in Toyland” report issued by US Public Interest Research Group.4 The report identified highpowered magnets among the most dangerous toys available for sale. At a press conference unveiling the 2012 report, Bryan Rudolph, MD, a pediatric gastroenterology fellow, served as NASPGHAN's spokesperson. The event received widespread media coverage, including coverage by major television networks and the Associated Press. Our partnership with other societies has been truly gratifying. The AAP posted magnet warnings on their website, informed their membership, and has worked with us on joint advocacy efforts.5 Most importantly, both AAP and NASPGHAN issued statements strongly supporting the CPSC in their actions, and combating some of the misinformation in the media. Gilger and Noel presented the findings of our NASPGHAN survey at the AAP national conference in October 2012, demonstrating hundreds of magnet ingestions, with approximately 80% needing endoscopic and/or surgical intervention. Subsequent reports have confirmed the dramatic rise in magnet ingestions over the past decade.5, 6, 7 As a result of our efforts and those of the CPSC, most large retailers stopped selling these magnets, and Maxfield and Oberton stopped doing business in December 2012. One year after our society became aware of the public health implications of high powered magnets, we have helped reduce sales of these products and inform the public. However, we still have work to do. Many families remain unaware of the danger, and just recently another toddler went to surgery for fistulae at our institution following magnet ingestion. Although the CPSC works to finalize its proposed magnet safety regulations, high-powered toy magnets are still for sale on the internet. In fact, one new company is advertising these magnets as “do-it-yourself fashion jewelry.” We need to continue to educate our policymakers and our patients about the hazards of high-powered magnets, or our patients will continue to suffer the consequences of their availability for years to come.
References 1. Hussain SZ, Bousvaros A, Gilger M, Mamula P, Gupta S, Kramer R, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55:239–242. 2. United States Consumer Product Safety Commission. Magnet Information Center. Available at http://www.cpsc.gov/Safety-Education/Safety-Education-Centers/Magnets. Accessed October 25, 2013. 3. Malkin M. Michelle Malkin: Nanny State job-killers: The feds' war on…Buckyballs! Available at http://michellemalkin.com/2012/08/01/nanny-state-job-killers-the-feds-war-on-buckyballs. Accessed October 25, 2013. 4. U.S. PIRG. Report: Safeguarding public health. Available at http://www.uspirg.org/reports/usp/troubletoyland-2012. Accessed October 25, 2013.
5. Agbo C, Lee L, Chiang V, Landscahft A, Kimia T, Monuteaux MC, et al. Magnet-related injury rates in children: a single hospital experience. J Pediatr Gastroenterol Nutr. 2013;57:14–17 6. Magnet ingestions in children presenting to US emergency departments 2002-2011. J Pediatr Gastroenterol Nutr. 2013;57:18–22 7. Abbas MI, Oliva-Hemker M, Choi J, Lustik M, Gilger MA, Noel RA, et al. Increase in pediatric magnet-related foreign bodies requiring emergency care. Ann Emerg Med. 2013;e-pub ahead of print