Video Abstract

Video Abstract

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BACKGROUND AND OBJECTIVES

High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk.

METHODS

Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk.

RESULTS

Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children’s toys and only 6.9% knew high-powered magnets were previously removed from the United States market.

CONCLUSIONS

Over 90% of subjects from the IMPACT study didn’t know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children’s toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.

What’s Known on this Subject:

High-powered magnets cause significant morbidity in children. Manufacturers contend that warning labels prevent these exposures, but physician groups and consumer advocates disagree. There are no published data on the utility of warning labels or parental knowledge vis-à-vis magnets.

What This Study Adds:

This is the first study on the utility of warning labels and parental perceptions in magnet exposures. Over 90% of subjects didn’t know if warning labels were present or didn’t read them, whereas almost half believed magnets were children’s toys.

High-powered magnets were first sold as desk toys or stress relievers in 2008.1  Each set typically contains hundreds of small magnets 5 mm or less in diameter that are many times stronger than typical ferrite refrigerator magnets. Since that time, high-powered magnets have been linked to thousands of injuries in children,2,3  including perforation, fistula, abscess, volvulus, and even death.4,5 

Industry has resisted the federal government’s attempts to effectively ban these products.6  For example, the United States Consumer Product Safety Commission (CPSC) announced a notice of proposed rulemaking, recall effort, and stop sale order in 2012. In response, United States based manufacturers responded with full page newspaper advertisements, media campaigns, and lawsuits.7,8  In many ways, these efforts were ultimately successful; though high-powered magnets were effectively banned in 2012, courts overturned CPSC enforcement actions in late 2016.9 

Since reentering the market, high-powered magnet injuries have increased, but industry resistance to a “ban” has remained.1012  In public statements, court filings, petitions to the CPSC, and in meetings with regulatory bodies, US manufacturers insist that warning labels are effective in preventing childhood injuries and, as a result, an “all ages market removal of the magnets is not required.”13  As evidence, US manufacturers have often pointed to a lack of reported injuries from their branded products, which contain warning labels and are intended for ages 14 and up. Instead, US companies place blame on others (eg, international distributers) with generic products that often lack such safety features.14 

Though consumer safety groups and professional societies like the American Academy of Pediatrics and the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition disagree with manufacturers’ assertions, no published data on the utility of warning labels exist. But the argument is substantive – as the CPSC issued a new recall from 2 companies in 202115  and currently weighs a new federal rule, child safety and the viability of a couple small US companies lies in the balance.16,17  For this reason, we sought to prospectively query parents of children with magnet exposures (ie, bodily ingestion or insertion) from the IMPACT of Magnets (Injuries, Morbidity, and Parental Attitudes Concerning Tiny high-powered Magnets) study to determine if there were warning labels on the associated product and if the warning label changed consumer use; whether the manufacturer was domestic or foreign; and to assess the circumstances surrounding the child’s exposure and parental opinions on high-powered magnet sets.

IMPACT of Magnets is a collaborative project investigating children ages 0 to 21 years with documented high-powered magnet exposures (ie, ingestion or bodily insertion). Cases with a clear ferrite or ceramic magnet and cases that could not be confidently identified as high-powered magnets were excluded. Study cases were identified at 1 of 25 participating US children’s hospitals between 2017 and 2019. In brief, IMPACT of Magnets consists of 2 studies: (1) retrospective cohort study with collection of site-specific patient and morbidity data, which has previously been published5  and (2) a prospective survey assessing product and parental beliefs. Here we describe the prospective portion of this research; site selection, case identification methods, the rationale for examining race and ethnicity, and morbidity data have been previously published.5  Institutional review board approval under waiver of informed consent was obtained at each participating site.

Investigators from the IMPACT of Magnets research consortium were provided the opportunity to participate in the prospective survey study. Subjects from participating institutions were notified of the study by mail and provided instructions for opting out. Letters were sent to the parent or guardian if the patient was under the age of 18 years or if the patient had a consent-limiting condition, as indicated by the electronic medical record. Letters were sent directly to subjects aged over 18 years at the time of contact if they did not have a consent-limiting condition. After 3 weeks, site researchers contacted subjects by phone with the opportunity to decline participation or provide verbal consent via a standardized script. Sites did not attempt to contact a patient or family more than 3 times. Sites collected data from May 2020 through March 2021.

Consenting participants were interviewed by telephone using a standardized questionnaire designed to capture parent or adult attitudes or beliefs around magnets, specific product data, such as the manufacturer name and presence or absence of warning labels, as well as circumstances surrounding any subsequent injuries. Questionnaires were developed by IMPACT researchers at multiple institutions and reviewed by the Nationwide Children’s Hospital Parent Advisory Board before dissemination. Each interviewer underwent training with 1 of the study principal investigators (L.M.) before site initiation of the phone surveys. Product brands identified during family interviews were explored during manuscript preparation by the study senior investigator (B.R.) for the manufacturing location (domestic or foreign) and presence of warnings on the manufacturer’s Web site or product packaging.

All deidentified case data were entered directly into a Research Electronic Data Capture database maintained at Nationwide Children’s Hospital. Research Electronic Data Capture is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources.18,19 

Descriptive statistics were calculated for all variables of interest, with categorical variables reported as a frequency (percent) and continuous variables as a median (interquartile range [IQR]). SAS Enterprise Guide version 8.1 (SAS Institute Inc, Cary, NC, USA) was used for all analyses.

Of the 25 Children’s Hospitals participating in the IMPACT of Magnets study, 21 sites prospectively contacted families. These sites attempted to contact all identified cases at their institutions. Ultimately, 434 (72.8%) of the 596 total subjects from the retrospective cohort study were approached with letters; 4.6% of these subjects opted out of being contacted and 49.3% could not be reached by phone. A total of 200 (46.1%) subjects were reached by phone and, of these, 87% agreed to participate in the questionnaire (Fig 1). Of the 174 participants, 173 were parents and 1 was an adult patient. There was no statistically significant difference in patient characteristics among those who consented and those who opted out, declined, or could not be reached (data not shown).

FIGURE 1

Flowchart of patient enrollment.

FIGURE 1

Flowchart of patient enrollment.

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The mean age at the time of magnet exposure was 7.5 years (IQR 4.4–11.1). The majority were male (61.5%), White (75.3%), and non-Hispanic (74.7%) (Table 1). Of the 174 exposures, 69.5% occurred in the child’s or another family member’s home, 17.2% at school, 3.5% at a friend’s house, and 5.2% in another location (eg, at a park, outdoor event, grocery store, or in a car). The remainder did not know where the exposure occurred. The majority of exposures (75.4%) were unwitnessed by a parent or adult, though most parents reported directly supervising the child at the time (54%) (Tables 1 and 2).

TABLE 1

Characteristics Among Children with Magnet Exposure

Result
Age, y 7.5 (4.4–11.1) 
Gender  
 Female 67 (38.5) 
 Male 107 (61.5) 
Race  
 White 131 (75.3) 
 African American 10 (5.8) 
 Asian 9 (5.2) 
 Other 24 (13.8) 
Ethnicity  
 Hispanic 17 (9.8) 
 Non-Hispanic 130 (74.7) 
 Unknown 27 (15.5) 
Location exposure occurred  
 Home or family member’s home 121 (69.5) 
 School 30 (17.2) 
 Don’t know 8 (4.6) 
 Friend’s house 6 (3.5) 
 Other 9 (5.2) 
Ingestion or insertion witnessed  
 Yes 31 (17.8) 
 No 133 (76.4) 
 Don’t know 10 (5.7) 
Mechanism of exposure  
 Playing with magnets in mouth 68 (39.1) 
 Age-appropriate mouthing behavior 27 (15.5) 
 Simulating a piercing 24 (13.8) 
 Don’t know 19 (10.9) 
 Developmental delays 11 (6.3) 
 Thought it was food or candy 8 (4.6) 
 Age-inappropriate mouthing behavior 7 (4) 
 Convinced by another child 6 (3.5) 
 Other 3 (1.7) 
 Suicide attempt 1 (0.6) 
Child knew magnets were dangerous  
 Yes 68 (39.1) 
 No 93 (53.4) 
 Don’t Know 13 (7.5) 
Result
Age, y 7.5 (4.4–11.1) 
Gender  
 Female 67 (38.5) 
 Male 107 (61.5) 
Race  
 White 131 (75.3) 
 African American 10 (5.8) 
 Asian 9 (5.2) 
 Other 24 (13.8) 
Ethnicity  
 Hispanic 17 (9.8) 
 Non-Hispanic 130 (74.7) 
 Unknown 27 (15.5) 
Location exposure occurred  
 Home or family member’s home 121 (69.5) 
 School 30 (17.2) 
 Don’t know 8 (4.6) 
 Friend’s house 6 (3.5) 
 Other 9 (5.2) 
Ingestion or insertion witnessed  
 Yes 31 (17.8) 
 No 133 (76.4) 
 Don’t know 10 (5.7) 
Mechanism of exposure  
 Playing with magnets in mouth 68 (39.1) 
 Age-appropriate mouthing behavior 27 (15.5) 
 Simulating a piercing 24 (13.8) 
 Don’t know 19 (10.9) 
 Developmental delays 11 (6.3) 
 Thought it was food or candy 8 (4.6) 
 Age-inappropriate mouthing behavior 7 (4) 
 Convinced by another child 6 (3.5) 
 Other 3 (1.7) 
 Suicide attempt 1 (0.6) 
Child knew magnets were dangerous  
 Yes 68 (39.1) 
 No 93 (53.4) 
 Don’t Know 13 (7.5) 

Data on n = 174 patients. Results expressed as median (IQR) or n (%), as appropriate.

TABLE 2

Parental Behavior and Beliefs Regarding Children with Magnet Exposure

Result, n (%)
Who owned the magnets  
 Child or sibling 70 (40.2) 
 Parent 43 (24.7) 
 Child’s friend 31 (17.8) 
 Another adult 16 (9.2) 
 Don’t know 14 (8.0) 
How child obtained the magnets  
 Child owned them 49 (28.2) 
 Provided to child 18 (10.3) 
 Taken by child 75 (43.1) 
 Found by child 6 (3.4) 
 Don’t know 26 (14.9) 
Child being directly supervised  
 Yes 94 (54.0) 
 No 69 (39.7) 
 Don’t know 11 (6.3) 
Magnets stored out of reach of child  
 Yes 35 (20.1) 
 No 113 (64.9) 
 Don’t know 26 (14.9) 
Magnets stored in original container  
 Yes 32 (18.4) 
 No 104 (59.8) 
 Don’t know 38 (21.8) 
Magnets discarded after exposure  
 Yes 118 (67.8) 
 No 42 (24.1) 
 Don’t know 14 (8.0) 
Parents knew magnets were dangerous  
 Yes 101 (58.0) 
 No 73 (42.0) 
Knew magnets previously removed from US market  
 Yes 12 (6.9) 
 No 162 (93.1) 
Result, n (%)
Who owned the magnets  
 Child or sibling 70 (40.2) 
 Parent 43 (24.7) 
 Child’s friend 31 (17.8) 
 Another adult 16 (9.2) 
 Don’t know 14 (8.0) 
How child obtained the magnets  
 Child owned them 49 (28.2) 
 Provided to child 18 (10.3) 
 Taken by child 75 (43.1) 
 Found by child 6 (3.4) 
 Don’t know 26 (14.9) 
Child being directly supervised  
 Yes 94 (54.0) 
 No 69 (39.7) 
 Don’t know 11 (6.3) 
Magnets stored out of reach of child  
 Yes 35 (20.1) 
 No 113 (64.9) 
 Don’t know 26 (14.9) 
Magnets stored in original container  
 Yes 32 (18.4) 
 No 104 (59.8) 
 Don’t know 38 (21.8) 
Magnets discarded after exposure  
 Yes 118 (67.8) 
 No 42 (24.1) 
 Don’t know 14 (8.0) 
Parents knew magnets were dangerous  
 Yes 101 (58.0) 
 No 73 (42.0) 
Knew magnets previously removed from US market  
 Yes 12 (6.9) 
 No 162 (93.1) 

Includes 1 adult patient. Data on n = 174 patients. Results expressed as n (%).

Subjects provided varying reasons why the magnet(s) were ingested. In 39.1% of the cases the child was playing with magnets in their mouth and unintentionally swallowed them; 15.5% were young and demonstrating age-appropriate mouthing behaviors; 4% were demonstrating age-inappropriate mouthing behaviors; 13.8% were simulating a piercing; 4.6% thought it was food or candy; 6.3% had developmental delays and demonstrate frequent mouthing behaviors; and 3.5% were convinced by another child. The remaining subjects reported not knowing how their child’s exposure occurred (10.9%) or provided an alternative explanation (1.7%) (eg, the child wanted to “see what happens” or was “sleep walking”). One patient ingested magnets in an attempted suicide (Table 1). When excluding patients with developmentally appropriate and inappropriate mouthing behavior, the median age of exposure was 9 years of age(IQR 5.8–11.4). Of those simulating a piercing, the median age was 11.8 (IQR 9.3–13.2).

The magnets were owned by the child or sibling in 40.2% of exposures or a child’s friend in 17.8% exposures. Parents (24.7%) or another adult (9.2%) were reported to own the magnets in the minority of cases, with 8% of respondents not knowing who owned them. Magnet exposures occurred with the child’s own magnets in 49 (28.2%) cases; magnets were provided, taken, or found by the child in 10.3%, 43.1%, and 3.4% of exposures, respectively (Table 2).

Subjects reported that warning labels were present or absent in 24.1% and 22.3% of cases, respectively; in 53.6% of cases, subjects did not know if a warning was present. Of the 28 participants who reported the presence of a warning label, only 13 (46.4%) reported reading the warning (Table 3).

TABLE 3

Product Information, Per Parent

Result, n (%)
Magnet size (n = 113)  
 ≤5 mm 78 (69) 
 >5 mm 35 (31) 
Intended use  
 Children’s toy 77 (44.3) 
 Fastener or hook 25 (14.4) 
 Desk toy or stress reliever 37 (21.3) 
 Don’t know 23 (13.2) 
 Jewelry 5 (2.9) 
 Science or educational 5 (2.9) 
 Other 2 (1.2) 
Brand identifiable  
 Yes 28 (16.1) 
 No 135 (83.9) 
Where purchased  
 Online 63 (36.7) 
 Store 29 (16.6) 
 Don’t know 82 (47.1) 
Warning label present  
 Yes 28 (24.1) 
 No 25 (22.3) 
 Don’t know 60 (53.6) 
Read warning label (n = 28)  
 Yes 13 (46.4) 
 No or don’t know 15 (53.6) 
Result, n (%)
Magnet size (n = 113)  
 ≤5 mm 78 (69) 
 >5 mm 35 (31) 
Intended use  
 Children’s toy 77 (44.3) 
 Fastener or hook 25 (14.4) 
 Desk toy or stress reliever 37 (21.3) 
 Don’t know 23 (13.2) 
 Jewelry 5 (2.9) 
 Science or educational 5 (2.9) 
 Other 2 (1.2) 
Brand identifiable  
 Yes 28 (16.1) 
 No 135 (83.9) 
Where purchased  
 Online 63 (36.7) 
 Store 29 (16.6) 
 Don’t know 82 (47.1) 
Warning label present  
 Yes 28 (24.1) 
 No 25 (22.3) 
 Don’t know 60 (53.6) 
Read warning label (n = 28)  
 Yes 13 (46.4) 
 No or don’t know 15 (53.6) 

Includes 1 adult patient. Data on n = 174 patients unless otherwise specified. Results expressed as n (%).

A manufacturer or brand was definitively identified in only 28 cases (16.1%) (Table 3), and all manufacturers, except 3, were domestic. Of the 28 products in which a brand was identified, 24 (85.7%) were high-powered magnet sets (eg, desk toys); 3 (10.7%) were children’s toys (eg, magnets within building blocks); and 1 (3.6%) was a consumer product (a high-powered magnet within a cell phone holder). Among these, every product except the cell phone holder had some form of warning (data not shown).

Magnets were stored within reach of children and out of their original containers in 64.9% and 59.8% cases, respectively (Table 2). Many parents (58.0%) reported knowing magnets were dangerous before the event and that their children knew they were dangerous (53.4%) (Tables 1 and 2). Although parents may have known these products were dangerous, 93.1% did not know they were previously removed from the United States market by the CPSC and 24.1% reported not discarding magnets after the exposure (Table 2).

Magnet size could only be determined in 64.9% of cases. Of these, 69% were ≤5 mm (Table 3). When asked about the intended use of the products, 44.3% of parents reported thinking the products were children’s toys; 21.3% desk toys or stress relievers; 14.4% fasteners or hooks (eg, devices to secure things to a magnetic board); 2.9% jewelry; and 2.9% science or educational products. Among the 2 cases identified as having another intended purpose, 1 was for “crafting” and the other was a single rare-earth magnet >5 mm within a cell phone holder. Many parents did not know where the magnet products were purchased (47.1%) but many were purchased online (36.7%) (Table 3).

Human factors experts at the US CPSC note that “warnings are the least effective strategy” for addressing the hazard imposed by magnet sets.20  Data from this multicenter, prospective survey study – for the first time in the published literature – appear to support the government’s argument.

In an exhaustive briefing packet arguing against a manufacturer’s call for mandatory warning labels, CPSC experts and staff write that “consumers commonly recognize magnet sets as suitable playthings for children; this hinders the perceived credibility of warning information. Studies have found that the more familiar consumers are with a product, the less likely they are to look for, or read, warnings.”20  In our study, this is evidenced by the fact that many parents believed the products were intended as children’s toys. Perhaps as a result, over 90% of participants didn’t know if warning labels were present or failed to read them if they were.

CPSC experts also argue high-powered magnets are a “hidden hazard” in which parents “are unlikely to anticipate the vulnerability of children, especially teens, who do not have a history of mouthing or ingesting inedible objects. Therefore, consumers are unlikely to keep the magnets away from these populations, regardless of warning information, which consumers are likely to perceive as not pertaining to these children.”20  In our study, 58% of the magnet products were owned by the child, the child’s sibling, or the child’s friend, with 64.9% of parents storing the product within the child’s reach. Interestingly, 58% of parents reported knowing magnets were dangerous but only 6.9% knew magnets were previously removed from the US market and few discarded magnets after the exposure. Taken together, this suggests that parents may have underestimated their child’s vulnerability to magnet exposures.

The CPSC also notes that “magnets from magnet sets are often acquired by children without the packaging or instructions.”20  Again, this is supported by our findings, in which only 18.4% of magnet sets were definitely stored in their original container. Further, writes CPSC staff, “older children and teens may knowingly choose to disregard warnings,” which is evidenced by the median patient age (11.8 years) of those simulating a piercing.

Importantly, we did not find evidence that exposures are primarily caused by foreign producers with absent or lax safety labels. Though a limited sample size, data suggest the opposite: out of 28 identifiable manufacturers, only 3 (10.7%) were foreign companies. Further, each of these products, except 1, contained some form of warning – either on the product packaging or Web site – at the time this manuscript was submitted for publication. We cannot exclude the possibility, however, that some warnings changed or were absent when purchased by consumers.

There are several other potential limitations to this study, including the possibilities of recall and reporting biases by parents. In addition, interpretation may be limited by the relatively low number of patients who could be reached by phone (46.1%), though there was no statistically significant difference in patient characteristics among those who consented and those who opted out, declined, or could not be reached. Additionally, selection bias is inherent to our study design; because we only included patients with a confirmed high-powered magnet exposure, we cannot assess the ability of warning labels to prevent exposure in all children. Section bias in terms of included sites (ie, mostly large academic Children’s Hospitals) may also limit our study’s generalizability. Nevertheless, the large number of exposures and the percent of parents that either didn’t know if warnings were present or ignored them suggest that warning labels, at most, have limited efficacy.

Warnings labels do not prevent many high-powered magnet exposures in children. Injuries caused by high-powered magnets are likely to continue without federal effort to remove these products from the market.

We thank Diane Studzinski, Kyra Shreeve, Amir Kimia, Aaron M. Lipskar, Katherine Battisti, Megan W. Wong, Carley Bright, Julia Lieberman, Shelby L. Hall, Caroline Morris, Roberto Gugig, Edaire Cheng, and Christian J Streck.

Drs Middelberg and Rudolph conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection and transfer from other sites, performed data analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Leonard conceptualized and designed the study, designed the data collection instruments, performed data analyses, and reviewed and revised the manuscript; Dr Shi performed data analyses and drafted and revised the manuscript; Drs Aranda, Brown, Cochran, Eastep, Haasz, Hoffmann, Koral, Lamoshi, Levitte, Lo, Montminy, Ms Myers, Ms Novotny, Ms Parrado, Ms Ruan, Ms Stewart, Ms Talathi, Ms Tavaraz, Ms Townsend and Ms Zaytsev collected retrospective data, performed prospective interviews, and reviewed data for quality at their sites. They drafted and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

COMPANION PAPER: A companion to this article can be found at http://www.pediatrics.org/cgi/doi/10.1542/peds.2021.054543.

This study is a product of the IMPACT of Magnets (Injuries, Morbidity, and Parental Attitudes Concerning Tiny high-powered magnets) research collaborative.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: Dr Rudolph was contracted by the US Consumer Product Safety Commission as an expert witness. The remaining authors have no conflicts of interest relevant to this article to disclose.

     
  • CPSC

    Consumer Product Safety Commission

  •  
  • IMPACT

    of magnets, Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets

  •  
  • IQR

    interquartile range

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