What are the next steps for a 4-year-old who swallowed a penny 4 days ago and now has a low-grade fever?

Immediate Endoscopic Removal Required

This 4-year-old requires urgent upper endoscopy for coin removal within 24 hours, as the combination of a retained esophageal foreign body for 4 days plus new-onset fever strongly suggests esophageal injury with possible perforation or mediastinitis. 1

Critical Assessment

The presence of fever in a child with a retained coin is a red flag that transforms this from a routine foreign body case into a potential surgical emergency:

• Fever after 4 days indicates tissue injury or infection - coins lodged in the esophagus can cause pressure necrosis, perforation, or mediastinitis, all of which present with fever 1
• Document the exact fever pattern - obtain a rectal temperature to confirm fever ≥38.0°C (100.4°F), as this is the most reliable method in young children 1, 2
• Assess for signs of serious complications immediately: difficulty swallowing, drooling, chest pain, respiratory distress, or signs of sepsis (poor perfusion, altered mental status, tachycardia out of proportion to fever) 1, 2

Immediate Diagnostic Workup

Before endoscopy, obtain:

• Chest X-ray (AP and lateral views) to confirm coin location, assess for mediastinal widening, pneumomediastinum, or pleural effusion suggesting perforation 3
• Complete blood count with differential - elevated WBC with left shift suggests bacterial infection/abscess formation 3
• Blood culture if the child appears ill or has high fever (≥39°C), as bacteremia can complicate esophageal perforation 3, 2
• C-reactive protein or procalcitonin may help risk-stratify for serious bacterial infection, though these should not delay definitive management 3

Management Algorithm

If the child appears well with low-grade fever only:

• Proceed to urgent endoscopy within 24 hours (not emergent, but cannot wait for routine scheduling) 1
• NPO status immediately to prepare for endoscopy and reduce aspiration risk 4
• IV access and hydration as the child has likely had reduced oral intake 4

If the child appears ill, toxic, or has high fever (≥39°C):

• Emergent endoscopy (within 2-6 hours) 1
• Broad-spectrum IV antibiotics before endoscopy to cover oral flora and potential mediastinitis: ampicillin-sulbactam or piperacillin-tazobactam 2
• Surgical consultation should be obtained simultaneously, as esophageal perforation may require surgical intervention 4
• Admit to hospital for monitoring even if endoscopy is successful, given the infection risk 2

Critical Pitfalls to Avoid

• Never assume the fever is unrelated to the coin - the temporal relationship (coin 4 days ago, fever now) is too significant to ignore 1
• Do not treat empirically with antibiotics and observe - the coin must be removed as it is the source of ongoing tissue injury 4
• Do not rely on the child's clinical appearance alone - well-appearing children can have serious complications including early perforation 1, 2
• Do not delay endoscopy for extensive infectious workup - the definitive treatment is foreign body removal, and cultures can be obtained during the procedure 4

Post-Removal Management

After successful endoscopic removal:

• Assess esophageal mucosa for ulceration, necrosis, or perforation during endoscopy 4
• If significant mucosal injury is present: continue IV antibiotics for 5-7 days, maintain NPO status initially, and obtain contrast esophagram if perforation is suspected 4
• If minimal injury: advance diet as tolerated and complete a short course of oral antibiotics if fever was present 1
• Hospital admission is warranted given the 4-day duration and presence of fever, even if endoscopy shows only mild injury 2