Magnetic Mishap: Multidisciplinary Care for Magnet Ingestion in a 2-Year-Old
Yi Horng Lee
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe case clearly demonstrates the value of collaboration between different specialties. The authors are fortunate to be at a hospital where these specialties are available. It is not clear if the interventions from all specialties were performed in a single anesthetic setting or in different settings. The time frame was also not described. It would be helpful to note the duration between ingestion and initial presentation , and the timing of various interventions to the time of passage of these magnets. How long did it take for bowel prep to work and to evacuate all magnets?
These are all important questions to consider as many different institutions will try to replicate this scenario. One important factor is how much will they have to get all the specialists together. Do authors have any recommendation as to how much time do they allow for passage of these magnets before they will take him back to the OR for additional intervention?
Also, why did the General Surgery service perform laparoscopy at all? Why not simply attempt bowel prep to begin with? I am not sure of the value for the laparoscopy in this case or colonoscopy in an unprepped colon. Can authors share their thoughts on this decision, and can they discuss if they would still make the same decision knowing the eventual outcome?
Comments on the Quality of English LanguageNo concerns
Author Response
Comment 1:
The case clearly demonstrates the value of collaboration between different specialties. The authors are fortunate to be at a hospital where these specialties are available. It is not clear if the interventions from all specialties were performed in a single anesthetic setting or in different settings. The time frame was also not described. It would be helpful to note the duration between ingestion and initial presentation, and the timing of various interventions to the time of passage of these magnets. How long did it take for bowel prep to work and to evacuate all magnets? These are all important questions to consider as many different institutions will try to replicate this scenario. One important factor is how much time do they allow for passage of these magnets before they will take him back to the OR for additional intervention?
Response 1:
Thank you for pointing this out. We clarified that interventions occurred across multiple anesthetic sessions and added more details on timing for ingestion and procedure.
Updated text on Page 2 Line 51, Page 2 Line 64, Page 3 Line 77
Comment 2:
Do authors have any recommendation as to how much time do they allow for passage of these magnets before they will take him back to the OR for additional intervention?
Response 2:
We conducted serial monitoring, with no strict time, but just ensuring appropriate movement of the foreign bodies on serial imaging.
Comment 3:
Also, why did the General Surgery service perform laparoscopy at all? Why not simply attempt bowel prep to begin with? I am not sure of the value for the laparoscopy in this case or colonoscopy in an unprepped colon. Can authors share their thoughts on this decision, and can they discuss if they would still make the same decision knowing the eventual outcome?
Response 3:
We justified laparoscopy based on suspicious gas patterns. Colonoscopy was attempted un prepared to avoid delays. We believe the chosen approach was appropriate but may consider earlier bowel prep in future cases.
Page 3 line 77 and page 3 line 81
Reviewer 2 Report
Comments and Suggestions for AuthorsThe article is an interesting read, but it needs overall English writing and grammar improvement.
The introduction needs to be improved: the authors need to briefly mention recent statistics or trends in magnet ingestion cases, morbidity, and mortality rates; it would be of more impact if the authors would close the introduction by emphasizing the importance of case reports like yours in understanding clinical management and improving prevention strategies.
The discussion part is so, so short. Please reinforce the importance of early detection, imaging, and a multidisciplinary approach; at the same time, highlight why this case is unique or educational (e.g., involvement of multiple retrieval techniques, delayed passage of magnets); the authors need to compare with more literature cases; there is a need to address why magnet ingestion is on the rise (e.g., increased availability of high-powered magnets, insufficient regulations) and the authors need to suggest policy changes that could prevent similar cases (e.g., bans, packaging warnings, public education campaigns). Please extend the number of references so that your article will prove that it is well documented.
Comments on the Quality of English LanguagePlease make an overall improvement in the English writing and grammar.
Author Response
Comment 1:
The introduction needs to include recent statistics/trends in magnet ingestion, morbidity/mortality rates, and emphasize the value of case reports.
Response 1:
We agree. The introduction has been expanded to include recent statistics on the increasing incidence and severity of magnet ingestion in children. We also added morbidity and mortality data, and emphasized the importance of case reports like this one in shaping clinical management and prevention.
Revised on Page 2, Paragraph 1.
Comment 2:
The discussion is too short. Emphasize early detection, multidisciplinary care, uniqueness of the case. Compare to more literature, explain rising ingestion rates, and suggest policy changes. Increase references.
Response 2:
We appreciate this comment and have significantly expanded the discussion, keying in on the importance of multi-disciplinary care and regulations. Added a few references
Starting on Page 5, line 102
Reviewer 3 Report
Comments and Suggestions for AuthorsThe authors presented a child who ingested multiple magnets, requiring involvement of multiple specialties.
Could the authors elaborate what clinical signs or imaging anomalies prompt the decision of laparoscopy.
The report could be more illustrative if the authors could review the literature on the topic and provide a working management algorithm for clinicians in the discussion.
If some paediatric surgeons are skilled in laryngoscopy, gastroscopy, colonoscopy, laparoscopy and laparotomy, is multi-discipline approach still necessary? Some literature data may be helpful in arriving at the conclusion.
Author Response
Comment 1:
Could the authors elaborate what clinical signs or imaging anomalies prompt the decision of laparoscopy?
Response 1:
We agree and have elaborated on this in the manuscript. Laparoscopy was pursued due to suspicious gas patterns on imaging and concern for bowel wall compromise.
Updated on Page 3, Line 77.
Comment 2:
The report could be more illustrative if the authors could review the literature on the topic and provide a working management algorithm for clinicians.
Response 2:
Agree. We have added a brief literature review on magnet ingestion strategies and referenced NASPGHAN
Added to Page 1, Line 38.
Comment 3:
If some pediatric surgeons are skilled in laryngoscopy, gastroscopy, colonoscopy, laparoscopy, and laparotomy, is a multidisciplinary approach still necessary? Some literature data may be helpful in arriving at the conclusion.
Response 3:
Thank you. In our pediatric quaternary care center, and in most US centers, different specialists are responsible for different procedures and need to be consulted.
Reviewer 4 Report
Comments and Suggestions for AuthorsDear researchers,
thank you for sending this interesting case report. In my opinion, the work is very interesting and in line with the objectives of the journal. however, I believe that some elements need to be further investigated. Specifically, the introduction needs to be expanded, because foreign body suffocation is a very important topic, so the concept of suffocation and possible cardiac arrest related to it should be included. This is to open up the discussion for the reader.
In addition, the discussion should be expanded to include some comments from surgeons regarding risks to patients, and it would be very interesting to understand if you have internal protocols for managing these risks
Author Response
Comment 1:
The introduction needs to be expanded. Foreign body suffocation is a very important topic—please include the concept of suffocation and possible cardiac arrest to open the discussion.
Response 1:
Thank you for this suggestion. We expanded the introduction to include the risk of airway obstruction associated with foreign body ingestion. We chose not to include cardiac arrest, as it is extremely rare in this context.
Page 1 Line 34
Comment 2:
The discussion should include surgical comments regarding patient risks and whether internal protocols exist for managing these cases.
Response 2:
Agree. We added comments from a surgical perspective, highlighting concerns for bowel necrosis and perforation. We also clarified that our institutional approach follows NASPGHAN guidelines and relies on real-time coordination among relevant specialties.
See Page 1, Line 38, Page 3, Line 86
