What is the appropriate evaluation and management for a healthy 6‑year‑old who ingested a single coin?

Management of Coin Ingestion in a 6-Year-Old Child

Obtain biplanar radiographs (AP and lateral views) immediately to confirm the coin's location, and if the coin is in the esophagus and the child is asymptomatic, proceed with urgent flexible endoscopic removal within 24 hours. 1, 2

Initial Diagnostic Evaluation

Radiographic Assessment

• Biplanar imaging is mandatory to confirm the coin's presence, distinguish between esophageal versus tracheal location, and identify the exact anatomical level of impaction 1, 2, 3
• Both anteroposterior and lateral neck/chest views are essential, as coin orientation alone can be misleading 4
• Do not perform contrast swallow studies—they increase aspiration risk and impair subsequent endoscopic visualization 2

Clinical Assessment

• Assess for symptoms including drooling, inability to swallow saliva, respiratory distress, stridor, cough, or chest/neck pain 2, 5
• Important caveat: 30% of children with esophageal coins are completely asymptomatic, so the absence of symptoms does not exclude esophageal impaction 6
• All children who swallow coins require radiographic evaluation regardless of symptoms 6

Management Algorithm Based on Location and Symptoms

If Coin is in the Esophagus

Symptomatic Patient (drooling, respiratory distress, pain, stridor)

• Emergent flexible endoscopic removal within 2-6 hours to prevent aspiration and perforation 1, 2, 3
• Rigid endoscopy should be considered as second-line if flexible endoscopy fails, particularly for coins in the upper esophagus 1, 2

Asymptomatic Patient

• Urgent flexible endoscopic removal within 24 hours according to American Academy of Pediatrics guidelines 1, 2
• Alternative approach supported by research: observation for 8-16 hours may be reasonable, as 25-30% of esophageal coins pass spontaneously without complications 5, 7
• Spontaneous passage is more likely in older children, males, and when the coin is in the distal third of the esophagus 7
• However, the guideline-based approach prioritizes removal within 24 hours to minimize risk of complications 1, 2

If Coin is in the Stomach

• Most coins that reach the stomach will pass through the gastrointestinal tract without problems 1
• Expectant management with observation is appropriate 1

Endoscopic Technique

• Flexible endoscopy is first-line for most esophageal foreign bodies 2, 3
• During the procedure, attempt gentle pushing of the coin into the stomach using air insufflation first 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 2
• Obtain diagnostic biopsies during the index endoscopy to assess for underlying esophageal disorders, which are found in up to 25% of pediatric patients with foreign body impaction 2

Common Impaction Sites

• Upper esophageal sphincter at the cricopharyngeus muscle (C4-C7 vertebral level) 1, 3
• Thoracic esophagus at the aortic arch level 1, 3
• These anatomical narrowings are where coins most frequently lodge in children 3

Post-Procedure Monitoring

• Keep the patient nil by mouth if there are concerns about laryngeal competence 2
• Monitor for warning signs of complications: stridor, obstructed breathing, agitation, fever, deep cervical or chest pain 2
• Watch for signs of mediastinitis, which can occur after esophageal perforation 2

Complications to Avoid

• Prolonged retention (>24 hours) leads to pressure necrosis, perforation, and mediastinitis 1, 2, 3
• Critical timing: Coins lodged for fewer than 24 hours do not cause significant esophageal mucosal compromise 8
• Surgical intervention is required in only 1-3% of cases for complications such as irretrievable foreign body, perforation, or mediastinitis 2

Key Clinical Pitfalls

• Never assume tracheal versus esophageal location based on coin orientation alone—always obtain both AP and lateral views 4
• Never rely on absence of symptoms to rule out esophageal impaction—30% of esophageal coins are asymptomatic 6
• Avoid prolonged observation beyond 24 hours, as this significantly increases complication risk 1, 2, 8