Sharon Grigsby pleaded with the operator at the federal safety hot line. A popular new toy, Magnetix, nearly killed one of her preschoolers.
Please do something, Grigsby remembers urging.When the plastic building sets broke, she told the operator, they shed powerful magnets inside her northern Indiana preschool. Grigsby didn't see the loose magnets, not much bigger than baby aspirin.
But one of her 5-year-old students did. He found some and swallowed them. The extraordinarily strong magnets connected in the boy's digestive tract, squeezed the folds of his intestines and tore holes through his bowels. Only emergency surgery saved his life.
If this product isn't recalled, Grigsby remembers warning, children will die.
The U.S. Consumer Product Safety Commission responded with a form letter.
"Because of limited resources and the volume of incidents reported to us, only a few complaints may be selected for follow-up investigation at this time," stated the letter, which arrived a week after Grigsby's May 2005 call to the hot line.
If Grigsby's complaint were important enough, the agency informed her, an investigator would call within 30 days.
Thirty days went by, then another 30. No recall, no word from government investigators. The magnets that doctors removed from the preschooler's intestines -- corroded globs in a hospital specimen jar -- sat in a drawer in Grigsby's office waiting for an investigator to examine them.
"I felt like I was pushed aside," Grigsby said. "I thought I was helping the next family."
Precisely what she feared would happen did, six months later and more than 2,000 miles away.
Kenny Sweet Jr., a suburban Seattle toddler with wispy blond hair, died from Magnetix injuries on Thanksgiving Day 2005. Kenny's parents thought he had a stomach bug. By the time they realized something was seriously wrong, it was too late. His heart stopped within minutes of his arrival at the emergency room.
But this is not a story about just one defective product and one family's grief. A Tribune investigation found that Kenny Sweet's death is emblematic of how a weakened federal agency, in its myopic and docile approach to regulation, fails to protect children. The result: injury and death.
For instance, the safety agency waited years to respond to consumer and attorney complaints that soapmaking kits were landing children in hospital burn units. In the meantime, more kids suffered disfiguring injuries.
The safety commission also recalled several types of playpens after they collapsed and suffocated babies. But the agency did not act on reports that yet another style of playpen posed the same hazard. It recalled those only after another baby suffocated.
As the agency slowly moved to address dangers of Magnetix toys, injuries mounted. To date, at least 27 children have suffered serious intestinal injuries after swallowing loose Magnetix magnets.
The Consumer Product Safety Commission, or CPSC, declined to explain why it didn't act sooner on warnings about any of these unsafe children's products. In refusing to answer questions about Magnetix, the agency cited a provision of federal law that protects manufacturers' reputations.
That law gives manufacturers great sway in how government officials regulate children's products. Combined with skimpy budgets and reduced staffing, the provision undermines the agency's power.
The Reagan administration gutted the CPSC in the early 1980s, less than a decade after its inception. Bipartisan neglect since then has left the agency with fewer than half the number of employees it had in 1980 -- deeper cuts than in any other federal health and safety regulator.
Yet the number of products the CPSC oversees, everything from chain saws to baby cribs, has exploded. As consumers clamor for the latest high-tech toys and nursery gear at ever-cheaper prices, companies are offering more complex products that introduce new hazards.
Childhood play always has come with risks. Parents expect skinned knees, even the occasional broken bone, from a fall off a bike or jungle gym. They don't expect pieces from a broken toy to rip holes through a child's gut like a gunshot, which is what happened with Magnetix.
Government regulators knew magnets could cause these dire injuries. And they knew it well before magnets started falling out of Magnetix toys, which allow kids to fashion complicated geometric structures out of colorful plastic pieces.
CPSC investigators in 2000 and again in 2003 documented cases of children suffering intestinal injuries after swallowing magnets from other products.
The CPSC didn't act, though, even as toymakers' use of such magnets skyrocketed. Nor did the agency respond when parents and caregivers complained that magnets were falling out of Magnetix toys. It didn't listen when Grigsby warned that a boy had been severely injured and that Magnetix could kill.
The agency didn't take action until after Kenny Sweet died.
"If they would have taken me seriously," Grigsby said, "that little boy would be alive."
A hidden 'gunshot wound'
What's so insidious about a small-magnet injury is that initially it seems like a stomach bug. All of the parents interviewed for this report said they -- and some of their doctors -- thought their children had a stomach virus. Yet if kids injured by magnets don't get surgery quickly enough, they can die.
The threat of such injuries has soared in recent years. That's because the magnets, made of neodymium iron boron, have become more affordable, popping up in all sorts of children's toys, including dolls, building sets, action figures, puzzles and games. These magnets are exponentially more powerful than the larger, rubbery variety used for decades in refrigerator magnets.
Once they fall out, these strong magnets tantalize youngsters. Some children who ingested them thought they were candy. When asked why he swallowed the Magnetix magnets at Grigsby's Indiana preschool, 5-year-old Kiegan Willis told his mom: "I was hungry."
Youngsters put just about everything in their mouths. It isn't aberrant behavior; it's how they explore the world. The tendency tapers off at age 3, but the CPSC's own studies have found that children of all ages put things in their mouths that they shouldn't.
Parents are petrified of small parts around young children because kids so easily can choke on them. When children swallow a choking hazard, a parent knows right away. The child gags and ultimately turns blue. If a child is sucking on candy or eating popcorn, caregivers often supervise them more closely.
But tiny, powerful magnets are a stealthy hazard. Parents aren't expecting them to come out of a toy, so they're not watching for them. Children can swallow them easily; because the kids don't choke, there is no immediate sign that anything is wrong. And youngsters who have been told not to put things in their mouths aren't likely to admit they've swallowed a piece of a toy.
To make matters worse, the magnets are so small that they blend in with carpet and stick to metal chair legs, harder to spot from a caregiver's vantage point but within easy reach of a child playing on the floor.
Even some doctors who saw the magnets on children's X-rays didn't understand the hazards. They sent children home, expecting the magnets to be discharged in a bowel movement. But often that doesn't happen.
Magnetic pieces can connect through layers of a child's intestines, strangling blood flow to that area of the bowels.
"Once the blood supply is cut off, the clock is ticking, and over the next several hours without blood supply, the bowel starts to die," said Dr. Mark McCollum, the attending pediatric surgeon at Akron Children's Hospital who last fall saved the life of a 6-year-old boy who had swallowed loose Magnetix magnets.
If magnets cut holes in intestinal walls, deadly bacteria can spill into the abdominal cavity. As McCollum said, "It's essentially a gunshot wound or a stab wound."
Even before Grigsby called with her warning, the CPSC had learned through two of its own investigations that powerful magnets could damage children's bowels. In 2000, an 8-year-old Atlanta boy had to undergo intestinal surgery after he swallowed small magnets that fell out of a broken fast-food meal toy. The child spent 10 days in the hospital.
Then in October 2003, a 6-year-old Muncie, Ind., girl suffered intestinal trauma after swallowing powerful magnetic jewelry she got at the state fair. The child put the jewelry in her mouth to mimic a pierced tongue.
The girl's surgeon alerted the CPSC a month later to expect more of these types of injuries if products with such magnets were marketed to children, according to CPSC records.
That same year, Rose Art Industries launched Magnetix, labeling the building sets safe for children as young as 3 years old.
Over the next four years, consumers complained to the CPSC that small magnets were falling out of the toys. As early as 2004, a Lewisville, N.C., grandmother warned the agency that "a small child could easily swallow" these loose magnets.
A Highlands Ranch, Colo., mother told a CPSC investigator in February 2005 that Magnetix toys were "particularly dangerous" because some magnets had fallen out and she worried that her 3-year-old son might use his teeth to try separating the loose magnets from each other.
Three different consumers were so concerned that such magnets could hurt children that they sent pieces of their defective Magnetix toys to the CPSC before Grigsby alerted the agency of Kiegan's intestinal injuries.
Parents shared their concerns with the toys' manufacturer as well. Consumers repeatedly told Rose Art that magnets were coming loose from Magnetix pieces. Before a rival company, Mega Brands, bought Rose Art in July 2005, Rose Art executives disclosed those complaints to its soon-to-be parent company, court records show.
Shortly after the sale closed, the CPSC sent Grigsby's complaint to Mega Brands' Rose Art division president. In a form letter accompanying the Grigsby report, the CPSC wrote that it forwards these types of complaints to manufacturers "because they often provide an early warning of potential safety problems."
In a written response to questions from the Tribune, Mega Brands said it was unaware of the extent of the problem and didn't know that swallowed magnets could injure children until it learned of Kenny's death.
Consumers told the CPSC that the company's Rose Art division downplayed the hazard.
In October 2005 parents in Highland, Ill., just east of St. Louis, told a Rose Art customer service representative that a magnet popped out of their 4-year-old son's Magnetix toy as he opened the box for the first time. They recounted the phone conversation in a complaint to the CPSC, recalling how the Rose Art representative reminded them "that if a child did swallow one, they are nontoxic."
"That did very little to reassure me," one of the boy's parents wrote.
If only she knew
Penny Sweet bought two boxes of Magnetix sets at her local supermarket in June 2005. She didn't know that parents around the country had warned the CPSC and Rose Art about magnets falling out of the toys.
She didn't know that by then, at least two children had been hospitalized for intestinal injuries they suffered after swallowing loose magnets from Magnetix. What Sweet did know was that her son Ben would like the toy.
During the time the Magnetix sets sat in storage in the Sweet home before Ben's 10th birthday, William Finley, a 4-year-old California boy, had emergency surgery to repair life-threatening intestinal damage linked to Magnetix.
Sweet was unaware of that, too, just as she didn't know that Sharon Grigsby had pleaded with the CPSC to recall Magnetix.
She couldn't have known, because neither the government nor Rose Art or its new owners, Mega Brands, told consumers there were any problems with Magnetix.
Ken and Penny Sweet are experienced parents who have surrounded themselves with children. A blended family with six kids living under one roof and another stepsister who would visit, the Sweets had children ranging in age from toddler to teenager. Penny ran a day-care service out of their home, typically caring for another five youngsters in addition to her two preschoolers.
The Sweets settled a lawsuit they filed against the maker of Magnetix and declined to be interviewed for this article. But CPSC files, medical records and online memorials provide a picture of their family and the actions that preceded Kenny's death.
When Penny gave the Magnetix toys to Ben on his birthday that November, she recognized the plastic pieces posed a choking hazard to young children. So Kenny -- at 20 months old, the baby of the family -- was not allowed near the Magnetix sets and, whenever possible, was moved to another room when his older siblings played with them.
In addition, the Sweets set family rules about Magnetix: You could play with them only in the family room. The pieces always had to go back in the plastic container with the lid shut tightly.
In the 10 days their children played with the Magnetix toys in November 2005, Ken and Penny Sweet didn't find any stray, brightly colored plastic pieces.
Not knowing the history of problems with Magnetix, the Sweets were looking for the wrong thing.
The tiny agency that shrank
Talk to people who work at the Consumer Product Safety Commission and at some point you're likely to hear the same refrain.
It goes like this: Apologetic sigh. Pause. "We're a small agency."
They're right. The U.S. government spends twice as much on the National Endowment for the Arts as it does on the agency charged with policing most consumer products. At just $62 million, the CPSC's budget is so small in Washington terms that one congressional aide described it as a "rounding error."
Last May, Hal Stratton, the CPSC chairman at the time, joked with manufacturers that the commission's 1950s-era laboratory in suburban Washington is so old that if the agency didn't get money to renovate it soon, "We're going to start putting Dr. Strangelove posters up."
Stratton resigned last summer. In March, President Bush nominated Michael Baroody, a top lobbyist for the National Association of Manufacturers, to head the commission. Consumer groups complained that Baroody has lobbied on behalf of the very manufacturers he would regulate.
Joan Claybrook, president of Public Citizen and a former head of the National Highway Traffic Safety Administration, charged that Baroody "has spent the past decade lobbying to undermine consumer rights."
Baroody's appointment awaits Senate confirmation. He declined to comment through the manufacturers' trade group spokesman, who said Baroody would be "an advocate for product safety."
The CPSC already has a cozy relationship with the companies it regulates. Agency staff and commissioners have taken work trips paid for by the industries they are charged with monitoring.
Reading CPSC travel records is like thumbing through a Who's Who of trade groups: associations for makers of electrical products, home appliances, gas appliances, juvenile products. All of them paid for CPSC staff or commissioners to travel to conferences and events around the country. In the past 3 1/2 years the Toy Industry Association alone sponsored numerous trips, including several to China, for nine different CPSC officials.
In defending such trips, the agency said it follows "strict rules" governing what it calls "gift travel" and that CPSC General Counsel Page Faulk's office evaluates all funding for them. Records show Faulk herself took a trip to China at the expense of a cigarette lighter trade group for a seminar and to tour factories.
"It is inaccurate and irresponsible to characterize the relationship the CPSC has with the industries it regulates as 'cozy,' " agency spokeswoman Julie Vallese said in a written statement.
The agency's woes date back decades. The Reagan administration tried to abolish the CPSC, settling instead for budgets cuts that trimmed its staff by more than a third over two years. The number of employees has dropped steadily since then under both Republican and Democratic presidents. The CPSC's current staff of about 400 is nearly 60 percent less than what it was in 1980.
"It's painful to watch," said Robert Adler, a management professor at the University of North Carolina at Chapel Hill who worked at the CPSC until the early 1980s and has studied the agency since then. "Most of the staff are extraordinarily committed and competent. They just get overwhelmed."
The agency said in a written statement that "in terms of lives saved, the CPSC delivers extraordinary value to the American people." Bush's budget office, the CPSC noted, gave the agency a top rating.
Even so, Kenny Sweet's death wasn't the first linked to a flawed response by the federal agency. The CPSC was so concerned about deadly playpens that it issued seven recall alerts in the 1990s. The top rails of the playpens collapsed, suffocating children who were trapped.
Beginning in 1996, consumers repeatedly told the CPSC that the top railing of a different style of playpen -- one that hadn't been recalled -- was collapsing, posing the same suffocation hazard.
The commission didn't recall those Cosco playpens until after a baby died in June 2001, more than five years after the first warning. An 11-month-old Ohio boy suffocated when his grandparents' Cosco playpen collapsed on him.
In addition, the CPSC failed to act promptly on years of warnings about a Rose Art soapmaking kit that severely burned children. An attorney implored the CPSC's top safety enforcer at a conference, sent him internal company documents and outlined the serious injuries of seven children. Still, the CPSC waited another 1 1/2 years to recall the toy -- allowing another two children to suffer severe burns.
One of the reasons the agency fails to spot such hazards quickly is that it doesn't investigate the vast majority of the complaints pouring in from consumers, retailers, coroners and media outlets. For instance, of the 360,374 injury reports that arrived in 2005 from hospital emergency rooms, the CPSC assigned less than 1 percent for a more in-depth investigation.
'We trust God took him quickly'
At 2 a.m. the day before Thanksgiving, 2005, Kenny Sweet woke up and whimpered to his parents, apparently suffering from a stomachache. They soothed him back to sleep several times.
Kenny refused to eat breakfast that morning, though he played with his friends at his mom's day care. When he ate a snack, he vomited.
His dad had a stomach bug the prior week, and Kenny's parents thought the toddler had caught it.
Kenny took a three-hour nap in the afternoon and threw up again. Later, though, his mom thought he seemed better, and he appeared to improve even more as the evening went on. The toddler was able to drink fluids without getting sick before he went to bed that night.
Very early the morning of Thanksgiving, Kenny vomited again, then fell back asleep. At bath time that morning, Kenny's parents noticed he had red blotchy patches on his arms that faded during the bath. He threw up more than once and ate only Jell-O and drank 7Up during the Thanksgiving meal that afternoon, resting in a beanbag chair next to the dining-room table.
His parents still thought he had the stomach bug and gave him some medicine for constipation. He never had a fever.
Later that afternoon, Kenny's mom worried he might be getting dehydrated, so she dashed to the drugstore to pick up some rehydrating drink. While Kenny's dad bathed him again, he noticed those red blotches on his son's arms returned, and his feet and hands had a bluish tint, all of which faded once Kenny was in the tub.
When Kenny's father offered him a drink of water, the toddler gulped down a third of the bottle. Immediately, Kenny's eyes rolled back in his head and his abdomen ballooned.
Ken Sweet Sr. quickly wrapped his son in towels, just as Penny returned from the drugstore. He told her something was seriously wrong. Kenny seemed to be moving in and out of consciousness. His breathing was shallow. Penny noticed that Kenny's fingernail beds were bluish, and the blotches on his arms returned.
They rushed their son to the emergency room, where doctors immediately began treating him. But several minutes after his arrival, Kenny lost consciousness.
For more than an hour, doctors worked to revive him with chest compressions, drugs and oxygen. At times they'd see a heart rhythm, but then they'd lose the pulse. "Finally after approximately 40 minutes of CPR, we realized that our efforts were futile," a doctor wrote on his chart.
Kenneth William Sweet Jr. was pronounced dead at 5:27 p.m. that Thanksgiving Day. "We had a few hours to hold our precious angel before the coroner came to take him," his parents would later write. "We trust God took him quickly to end his suffering."
Letter to a son
When the Sweets went home that night, they didn't know what killed their son.
Within days, the medical examiner found that approximately nine tiny magnets had pinched together loops of Kenny's small intestines. The magnets strangled the intestinal blood supply, causing a large section of his bowels to die. That triggered gangrene.
Ken and Penny Sweet ultimately found loose Magnetix magnets in the family room, camouflaged in the off-white, mottled pile of the carpet. They even discovered some stuck to the underside of the vacuum cleaner.
Not long after Kenny's death, a top executive at Rose Art's parent company called the Sweets to offer his condolences. Vic Bertrand, chief operating officer at Mega Brands, assured the Sweets that this was the first time in the company's history that a child had died or even suffered a serious injury from a Mega Brands toy, according to the company.
That wasn't true.
Before Kenny's death, at least three children had suffered life-threatening intestinal injuries from swallowing loose Magnetix magnets, and word of two of those injuries reached Mega Brands' Rose Art division before Kenny Sweet died.
In late July 2005 the agency sent to the division the complaint filed by Indiana preschool operator Sharon Grigsby, who detailed Kiegan Willis' serious injury from Magnetix. Mega Brands said its Rose Art division never forwarded the complaint to corporate headquarters.
Just three weeks before Kenny died, the division signed for a certified letter alerting the company that William Finley, the 4-year-old California boy, had been injured by a Magnetix toy. In a written statement, Mega Brands said that letter stated that William swallowed only one magnet and didn't describe the nature of the boy's injuries. "It is grossly inaccurate to suggest that this letter should have raised a flag," the company said.
Had Mega Brands investigated, it would have discovered that three loose Magnetix magnets cut a hole in William's bowels, allowing deadly bacteria to spill into the child's abdomen. Emergency surgery saved him.
A family friend of the Sweets wrote to the CPSC about two weeks after Kenny's death, pleading for action. "It is scary enough," read part of the friend's letter. "I want to make sure it is addressed."
Ken Sweet wrote a letter of a different sort. His was to Kenny Jr.
"Your days were spent teaching me how much joy existed in our world as every new experience was made more special because you were part of it," he wrote.
"We would walk the yard together and touch and smell the many beautiful flowers in the spring and summer. If I put my coat on to run an errand, you would quickly grab your shoes and meet me at the front door.
" ... Today for me the sun doesn't shine as bright and the future holds less excitement because you are not here to share it with."
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What to do if you have Magnetix in your home:
*1. Call Mega Brands to see if you qualify for a replacement toy: 800-779-7122.
*2. Don't allow children younger than 6 or those who tend to put things in their mouths to play with the toys.
*3. Check regularly to see if magnets have fallen out.
NOTE: Other products using strong magnets, including Polly Pocket play sets, also have caused injuries. To protect your children, regularly inspect the toys and check the Consumer Product Safety Commission Web site -- www.cpsc.gov -- to see if the toy has been recalled.Copyright © 2014, The Baltimore Sun