What is the evaluation and management for a child suspected of ingesting a coin?

Evaluation and Management of Suspected Coin Ingestion in Children

For a child suspected of ingesting a coin, immediate radiographic evaluation with biplanar (AP and lateral) views is essential to confirm the presence and location of the coin, followed by appropriate intervention based on symptoms and location.1

Initial Assessment

• Coin ingestions account for approximately 13% of all choking episodes in children, making them the most common non-food foreign bodies ingested2
• Children aged 3 years or younger account for more than three-fourths (77.1%) of choking episodes2, 1
• Coin-related choking episodes are usually transient, with the coin typically being swallowed rather than aspirated2
• Most coins that are swallowed will pass through the gastrointestinal tract without problems, but they may lodge in the esophagus2

Diagnostic Approach

• Obtain biplanar radiographs (AP and lateral views) to:
  • Confirm the presence of the coin1, 3
  • Distinguish between esophageal and tracheal location3
  • Identify the exact anatomical level of impaction1
• Common locations for coin impaction include:
  • Upper esophageal sphincter (cricopharyngeus muscle)1, 4
  • Thoracic esophagus at the level of the aortic arch2, 1
  • Gastroesophageal junction4

Management Algorithm

Symptomatic Patients

• For coins causing complete obstruction (inability to swallow saliva, drooling, respiratory distress):
  • Emergent endoscopic removal within 2-6 hours1, 4
  • Rigid endoscopy is preferred for coins in the upper esophagus1

Asymptomatic Patients

• For coins in the esophagus without symptoms:
  • Current data support expectant management for 12-24 hours to allow for possible spontaneous passage4
  • If the coin doesn't pass spontaneously within 24 hours, proceed with endoscopic removal1, 4

Special Considerations

• Button batteries require immediate removal (within 2 hours) due to risk of rapid tissue damage and perforation5
• Coins with diameter between 23.45-26.00 mm are most likely to become lodged in the esophagus6
• Children with developmental or neurologic impairment may be at higher risk for complications2

Potential Complications

• Prolonged retention of coins can lead to:
  • Pressure necrosis1
  • Esophageal perforation5, 7
  • Mediastinitis1
• Aspiration risk if the coin dislodges and enters the airway1
• Even asymptomatic perforations can occur and may present with delayed symptoms7

Prevention Strategies

• Pediatricians should provide choking-prevention counseling to parents as part of anticipatory guidance2
• Parents should be educated about age-appropriate toys and supervision2
• Cardiopulmonary resuscitation and choking first aid should be taught to parents and caregivers2

Follow-up

• After successful removal, observe for signs of esophageal injury1
• For coins that pass into the stomach, most will exit the body without complications2
• Consider follow-up radiographs if there are concerns about persistent symptoms7