What are the recommended next steps for a 4-year-old otherwise healthy child with no known past medical history who swallowed a dime one week ago and has been asymptomatic since, but the dime has not been seen in the stool?

Management of Ingested Coin in an Asymptomatic 4-Year-Old After One Week

Obtain an abdominal radiograph (anteroposterior and lateral views) to localize the coin; if it remains in the esophagus, proceed with urgent endoscopic removal within 24 hours, but if it has passed into the stomach or intestines, continue observation with repeat radiograph in 3-4 weeks if not passed in stool. 1

Initial Radiographic Assessment

• Obtain two-view abdominal radiographs immediately to determine the current location of the coin, as coins that remain in the esophagus for more than 24 hours require endoscopic removal even in asymptomatic patients 1

• The coin's orientation on radiograph helps determine location: coins in the esophagus typically appear en face (circular) on anteroposterior view and edge-on (linear) on lateral view, while coins in the trachea show the opposite pattern 1

• After one week, if the coin is still present, it is most likely either lodged in the esophagus (requiring intervention) or has passed into the gastrointestinal tract (can be observed) 1

Management Based on Coin Location

If Coin is in the Esophagus

• Urgent endoscopic removal is indicated for any coin that has been in the esophagus for more than 24 hours, regardless of symptoms, due to risk of pressure necrosis, perforation, and fistula formation 1

• Esophageal coins in asymptomatic children still require removal because prolonged contact can cause mucosal injury even without symptoms 1

If Coin is in the Stomach or Intestines

• Continue expectant management with observation if the coin has passed beyond the pylorus and the child remains asymptomatic 1

• Most coins that reach the stomach will pass spontaneously through the gastrointestinal tract within 2-4 weeks without intervention 1

• Obtain repeat radiograph in 3-4 weeks if the coin has not been visualized in the stool to confirm passage 1

• Coins larger than 23-25 mm in diameter may have difficulty passing through the pylorus in young children and may require endoscopic removal if they remain in the stomach beyond 3-4 weeks 1

Indications for Intervention

• Immediate endoscopy is required if the child develops any symptoms including dysphagia, drooling, chest pain, abdominal pain, vomiting, or respiratory symptoms, as these suggest complications 1

• Surgical consultation is needed if there are signs of perforation (fever, severe pain, peritoneal signs) or if the coin fails to progress despite appropriate observation period 1

Common Pitfalls to Avoid

• Do not assume the coin has passed simply because the child is asymptomatic—esophageal foreign bodies can be present for extended periods without symptoms, particularly in young children who may not communicate discomfort effectively 1

• Do not delay radiographic evaluation—waiting longer without imaging risks missing an esophageal coin that requires urgent removal 1

• Do not rely solely on parental observation of stool—coins can be missed in stool, and radiographic confirmation is more reliable after one week 1

• Avoid using cathartics, meat tenderizers, or other home remedies to facilitate passage, as these are ineffective and potentially harmful 1

Follow-Up Protocol

• Instruct parents to monitor for warning signs including refusal to eat, drooling, vomiting, abdominal pain, or respiratory symptoms that would require immediate medical attention 1

• If the coin is in the gastrointestinal tract, parents should continue to observe stools but understand that visualization may be difficult 1

• Schedule follow-up radiograph at 3-4 weeks if coin not seen in stool to document passage 1