Abstract
This study describes trends in emergency department visits for ingestions by children of small neodymium magnets between 2009 and 2019, before, during, and after a 2014 Consumer Product Safety Commission rule restricting their sales.
Magnet ingestions among children have become a serious health risk after the 2009 introduction of high-powered, rare-earth magnets, commercially sold as small (3- to 6-mm) recreational objects.1,2 These neodymium magnets are 5 to 10 times more powerful than traditional ferrite magnets and are sold as sets for entertainment and toys (eg, Bucky Balls building sets, jewelry kits, spinning toys).3 Ingestion of multiple magnets, or a magnet with a metal object, can result in bowel obstruction, perforation, and death when magnets attach through bowel walls.4 After reports of pediatric injuries and deaths related to ingested neodymium magnets, the Consumer Product Safety Commission (CPSC) initiated campaigns to limit sales in 2012 with voluntary recalls and safety standards.5 Other CPSC efforts included awareness campaigns, legislative advocacy, and lawsuits.1 In October 2014, the CPSC published its final rule, Safety Standard for Magnet Sets, prohibiting sales of these small high-powered magnet sets.3 In November 2016, this rule was legally remanded by the US Court of Appeals 10th Circuit after being challenged by Zen Magnets LLC, resulting in a resurgence of these magnets on the market.6 This study examined trends in US emergency department (ED) visits for pediatric magnet ingestions over the period of the changes in federal regulations.
Methods
Data from the National Electronic Injury Surveillance System (NEISS), a national sample of US injury-related ED visits, were obtained for January 1, 2009, through December 31, 2019. Magnet ingestions were identified for children aged 17 years or younger with NEISS diagnosis codes of ingested object (41) or aspirated object (42). Only narratives with the key word magnet were included. We used US Census data, NEISS sample weights, and clusters to calculate age-specific weighted rates of ED visits for ingestions per 100 000 persons of the population. An interrupted time-series analysis using linear regression modeling examined trends during 3 periods: (1) 2009-2012, before CPSC involvement; (2) 2013-2016, during the CPSC federal rule (including increasing CPSC regulations); and (3) 2017-2019, after the CPSC rule was vacated. Mean ED visit rates for each period and slope changes between periods were calculated. Analysis of variance was used to compare demographics. A 2-sided P < .05 was considered significant. Data were analyzed with SAS version 9.3 (SAS Institute Inc) using SURVEYFREQ, SURVEYREG, and SURVEYLOGISTIC, and R for regression analyses (2020; R Foundation). This study was deemed exempt by the Partners Healthcare Institutional Review Board.
Results
A total of 36 701 ED visits were identified for ingested or aspirated objects; 1421 met criteria for magnet ingestions (aged ≤17 years; Table). Those aged 5 years or younger had the highest rate of ED visits (n = 847; weighted rate, 7.0 [95% CI, 5.0-9.0] per 100 000 persons). Following 2012 CPSC involvement, ED visit rates decreased from an aggregate mean of 3.58 (95% CI, 2.20-4.96) per 100 000 persons to 2.83 (95% CI, 1.60-4.06) per 100 000 persons in 2013-2016 (slope change, 0.87 [95% CI, 0.71-1.03] ED visits per 100 000 annually). From 2016 to 2019, the mean ED visit rate increased to 5.16 (95% CI, 3.22-7.11) per 100 000 persons, with an overall upward trend (slope change,−0.58 [95% CI, −0.68 to −0.47] per 100 000 persons annually; Figure). Admissions from the ED increased throughout the study period (Table). The mean number of ED visits among those aged 5 years or younger, boys, and White and Black children significantly differed among the 3 periods, with increases after the CPSC rule was remanded.
Table. Emergency Department Visits for Magnet Ingestions Around Federal Rule Changes in Patients Aged 0 to 17 Years in the United States, 2009-2019.
| Characteristics | ED visits, No. (mean)a | P valueb | |||
|---|---|---|---|---|---|
| 2009-2019 | Before CPSC involvement (2009-2012) | During CPSC federal actions and rule (2013-2016) | After CPSC rule vacated (2017-2019) | ||
| Age group, y | |||||
| 0-5 | 847 (77.0) | 268 (67.0) | 263 (65.7) | 316 (105) | .002 |
| 6-11 | 426 (13.4) | 150 (12.7) | 114 (10.0) | 162 (19.0) | .21 |
| 12-17 | 148 (38.7) | 51 (37.5) | 40 (28.5) | 67 (54.0) | .06 |
| Total | 1421 | 469 | 417 | 535 | |
| 0- to 17-y age-specific weighted rate (95% CI)c | 3.74 (2.71-4.77) | 3.58 (2.20-4.96) | 2.83 (1.60-4.06) | 5.16 (3.22-7.11) | |
| Sex | |||||
| Male | 814 (74.0) | 262 (65.5) | 248 (62.0) | 344 (101) | .004 |
| Female | 607 (55.2) | 207 (51.7) | 169 (42.2) | 231 (77) | .05 |
| Raced | |||||
| White | 795 (72.2) | 231 (57.7) | 242 (60.5) | 322 (107.3) | .001 |
| Black | 73 (6.6) | 30 (7.5) | 19 (4.7) | 24 (8.0) | .03 |
| Asian | 16 (1.4) | 2 (0.5) | 10 (2.5) | 4 (1.3) | .04 |
| Not recorded | 414 (37.6) | 147 (36.7) | 114 (28.5) | 153 (51.0) | .27 |
| Othere | 123 (11.2) | 59 (14.7) | 32 (8.0) | 32 (10.7) | .14 |
| Location of injury | |||||
| Home | 872 (79.2) | 298 (74.5) | 251 (62.7) | 323 (107.7) | .003 |
| School | 74 (6.7) | 13 (3.2) | 26 (6.5) | 35 (11.7) | .03 |
| Not recorded | 465 (42.3) | 154 (38.5) | 136 (34.0) | 175 (58.3) | .11 |
| Disposition | |||||
| Discharged from ED | 1127 (102.4) | 407 (101.7) | 319 (79.7) | 401 (133.7) | .01 |
| Transferred to other facility | 26 (2.4) | 7 (1.7) | 5 (1.2) | 14 (4.7) | .11 |
| Admitted from ED | 251 (22.8) | 53 (13.2) | 85 (21.2) | 113 (37.7) | .007 |
Abbreviations: CPSC, Consumer Product Safety Commission; ED, emergency department; NEISS, National Electronic Injury Surveillance System.
Counts from NEISS.
Calculated using 1-way analysis of variance using mean ED visits per period compared among the 3 periods.
Adjustment for age based on US Census population estimates, with rate expressed as population estimate of injuries per 100 000 persons in US population of that age.
Race/ethnicity reported as documented in the NEISS database; data from NEISS are collected from NEISS staff who abstract race/ethnicity data as reported in the original medical record of the reporting hospital.
The ED record indicated more than 1 race or the recorded race did not fit into the other categories.
Figure. Emergency Department Visits for Magnet Ingestions in Patients ≤17 Years Old, 2009-2019.
Scatterplot of weighted rates per 100 000 persons; linear regression trend lines are shown for interrupted time series. The slope for pre–Consumer Product Safety Commission (CPSC) involvement was 0.59 (95% CI, 0.48-0.70; P < .001); the slope during the rule was −0.28 (95% CI, −0.39 to −0.17; P = .01); and the slope after the rule was vacated was 0.30 (95% CI, 0.12-0.48; P = .05). The change in slope before involvement vs during the rule was 0.87 emergency department visits per 100 000 persons annually (95% CI, 0.71-1.03; P < .001); the change in slope during the rule vs after it was vacated was −0.58 emergency department visits per 100 000 persons annually (95% CI, −0.68 to −0.47; P = .007).
Discussion
The removal of the Safety Standard for Magnet Sets rule was associated with increased ED visit rates for magnet ingestions among children aged 17 years or younger. This followed a decline in magnet ingestions between 2012 and 2016 after CPSC advocacy and the institution of this rule, consistent with previous findings.1 In contrast, ED admissions consistently increased over the 3 periods, but the ED disposition variable in NEISS is limited, without information on the reason for admission, outcome, or severity of the injury. Further study is needed to examine clinical outcomes. Other limitations include using a national ED-based database with possible injury mechanism misclassification. All magnet-related ingestions were analyzed because high-powered magnets (which are more likely to cause intestinal injury) could not be specifically identified in this data set.
Effective prevention of magnet-related ingestions can be achieved with industry regulations, as evidenced by the now-remanded CPSC safety standard. Removal of this rule is associated with increases in ED visits for magnet ingestions. Given that associated deaths and injuries to children are preventable, industry standards should be reconsidered.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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