Clinical Profile, Management Strategies, and Outcomes of Children with Multiple Magnet Ingestion: A Retrospective Case Series

ABSTRACT

Multiple magnet ingestion in children can cause severe gastrointestinal injury due to magnetic attraction across the bowel walls. We report three children requiring surgery for obstruction, perforation, and fistula formation. One child had extensive injury despite minimal symptoms. Early imaging, prompt intervention, and intra-operative radiography are crucial to prevent the serious complications.

INTRODUCTION

Foreign body ingestion is common in young children and usually benign; however, ingestion of multiple high-powered neodymium magnets represents a dangerous exception. Their strong mutual attraction across the bowel walls can result in pressure necrosis, obstruction, ischemia, perforation, and fistula formation. The diagnosis is frequently delayed as clustered magnets may appear as a single object on radiographs and early symptoms can be minimal, increasing the risk of severe gastrointestinal injury.[1,2]

CASE SERIES

We report three children (aged 14 months to 4 years) who presented with vomiting and abdominal pain following suspected magnet ingestion. Abdominal radiographs in all cases demonstrated radiopaque foreign bodies with the features of obstruction. In the first case, a 14-month-old boy initially appeared clinically stable, yet exploratory laparotomy revealed two jejunal perforations with a jejuno-colic fistula caused by 17 bead magnets [Figure 1a-c]. Two additional gastric magnets were retrieved through the jejunal perforation, with intra-operative serial radiography confirming complete removal. Due to unhealthy bowel margins, primary repair with transverse colostomy was performed, followed by uneventful recovery.

Figure 1.

(a) Intra-operative view showing magnetic bead string entering the jejunum from the colon with jejunal perforation; (b) retrieval of the bead magnets; (c) preoperative abdominal radiograph demonstrating clustered radiopaque magnets; (d) closed-loop obstruction caused by magnetically aligned bowel loops; (e) intra-operative image showing entero-enteric fistula with perforation

The second child, a 3-year-old girl, presented with bilious vomiting and abdominal pain. Laparotomy revealed two magnets aligned across adjacent jejunal and ileal loops, resulting in a closed-loop obstruction with stricture and jejuno-ileal fistula [Figure 1d and e]. Resection of the affected bowel with primary anastomosis was performed. The third child, a 4-year-old boy, had ileo-ileal fistula approximately 20 cm proximal to the ileocecal junction, requiring repair and proximal ileostomy. All children recovered well and remained asymptomatic at a 6-month follow-up.

DISCUSSION

These cases highlight the deceptive nature of multiple magnet ingestion, where extensive bowel injury may occur despite relatively mild clinical findings. All patients in this series required surgical intervention and demonstrated fistula formation or perforation, reflecting the aggressive pathology associated with magnet ingestion. Compared with published reports, our series showed a higher rate of severe intestinal injury, with the maximum number of retrieved magnets being 19, correlating with extensive tissue damage [Table 1].[1,2,3,4,5,6] Importantly, plain radiographs may underestimate both the number and distribution of magnets, as closely apposed objects can simulate a single foreign body, potentially delaying definitive management.

Table 1.

Published evidence, guideline recommendations, and findings from the present case series on multiple magnet ingestion in children

Study/guideline	Mean age	Clinical presentation	Recommended initial evaluation	Indications for surgery	Reported fistula/perforation rate	Maximum number of magnets	Key observations
Oestreich, 2009[3]	~3 years	Abdominal pain, vomiting	AP and lateral abdominal radiographs; presume multiple magnets if clustering seen	Lack of progression on serial imaging; obstruction; perforation	Not specified	-	Emphasizes importance of early diagnosis
Blevrakis et al., 2018[4]	~3 years	Abdominal pain	Immediate evaluation with multiple radiographic views	Any suspicion of >1 magnet	50%–90%	-	High risk of bowel necrosis and fistula
Bousvaros, 2017[5]	-	Variable	Prompt removal of accessible magnets	Delay increases morbidity	-	-	Highlights role of public safety regulation
Chang et al., 2022[1]	~3 years	Vomiting, abdominal pain	Endoscopic retrieval when feasible; close monitoring	Failed endoscopy; symptomatic patients	~60%	Up to 40	>65% require operative intervention
Nugud et al., (ESPGHAN) 2023[6]	Pediatric	Variable	Endoscopy for gastric magnets; serial radiographs for progression	Nonprogression, obstruction, peritonitis, unclear magnet count	-	-	Early recognition with timely intervention
Kelaidi et al., 2025[2]	~3 years	Abdominal pain, vomiting	Early surgical consideration in confirmed multiple ingestion	Presence of fistula or perforation	50%–90%	-	Systematic review of 130 pediatric cases
Present series (n=3)	~3 years	Vomiting, abdominal pain	Radiographs followed by operative exploration	Obstruction, fistula, perforation	100%	19	Intra-operative serial radiography crucial; asymptomatic extensive injury observed (case 1)

AP: Anteroposterior, ESPGHAN: European Society for Paediatric Gastroenterology, Hepatology and Nutrition

The current guidelines recommend prompt recognition, orthogonal radiographic assessment, urgent endoscopic retrieval when feasible, and early surgical exploration in cases of nonprogression, obstruction, peritonitis, or uncertainty regarding magnet number [Table 1].[1,2,3,4,5,6] Our experience emphasizes two additional practical points: First, significant fistula formation can occur even in clinically stable children, underscoring the need for a low threshold for operative intervention; and second, intra-operative serial radiography is invaluable for confirming complete magnet retrieval and preventing retained foreign bodies, particularly when multiple magnets are involved.

Decision-making should prioritize early exploration once endoscopic retrieval fails or when magnet progression is uncertain, as delay may lead to escalating morbidity, bowel loss, and stoma formation.[6] A multidisciplinary approach involving pediatric surgeons, gastroenterologists, and radiologists is essential for the timely diagnosis and management.[1,2]

Although regulatory measures initially reduced magnet ingestion in some countries,[6] recent relaxation has led to a global resurgence and the absence of similar regulations in India underscores the need for stricter legislation and public awareness.

This study is limited by its retrospective design and small sample size; however, it reinforces that confirmed multiple magnet ingestion not amenable to endoscopic removal warrants early surgical consideration, even before overt peritonitis develops.

CONCLUSION

Multiple magnet ingestion is a serious pediatric surgical emergency that can cause extensive bowel injury even in minimally symptomatic children. Early recognition, careful radiologic evaluation, and timely surgical intervention are essential to prevent morbidity. Intra-operative radiography aids complete magnet retrieval. Strengthened public awareness and regulatory control of magnetic toys are urgently needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.