Coin Ingestion Research Articles

Symptoms and Spontaneous Passage of EsophagealCoins

Conners, Chamberlain, and Ochsenschlager 1 add a helpful article to the coin ingestion literature. For asymptomatic children, they propose the following two options: (1) immediate radiography for coin location or (2) delayed radiography up to 24 hours after ingestion (to increase convenience). A third option that was not mentioned is to order a radiograph for asymptomatic children only if they have not passed the coin per rectum by 72 hours following coin ingestion (obviously not acceptable for button batteries, sharp objects, etc). This approach is the most cost-effective. At least 60% of the authors' asymptomatic patients would probably have not needed a radiograph using this approach. I would appreciate the authors' thoughts about this variation on intervention. One concern about this study is sampling. It only includes children who were referred or walked into the emergency department. Asymptomatic children who were treated by telephone were not included. This may explain

Symptoms and Spontaneous Passage of Esophageal Coins

I found the article by Conners et al 1 in the January issue of theArchivesvery interesting. However, the data in their paper do not support one of their conclusions that coins lodged in the proximal or middle esophagus for more than 24 hours do not pass into the stomach and should be removed. If the authors had waited longer than 24 hours, it is certainly possible that more, most, or all the coins would have passed into the stomach. A 1985 telephone survey 2 in Salt Lake City, Utah, of 65 practicing pediatricians revealed that 77% would not obtain a radiograph of an asymtomatic child who swallowed a coin. It is also likely that a large number of coin ingestions never come to the attention of the parent or the physician. In spite of the large number of coin ingestions, many of which undoubtedly include coins lodged in

Swallowed Foreign Bodies in Children: Aspects of Management

Swallowed Foreign Bodies in Children: Aspects of Management

Esophageal perforation caused by coin ingestion: J.G. Tucker, H.H. Kim, and G.W. Lucas. South Med J 87:269–272, (February), 1994

Esophageal perforation caused by coin ingestion: J.G. Tucker, H.H. Kim, and G.W. Lucas. South Med J 87:269–272, (February), 1994

Management of coin ingestion: Any change?

Figure 1 summarizes the recommendations for treatment of coin ingestion. Serious complications from coin ingestion are extremely rare and are usually found in children who unknowingly ingest a coin. The recommendations from the literature concerning the treatment of children with a history of coin ingestion, such as obtaining radiographs on all such children, may not accurately reflect the current practices of emergency physicians. It would be of interest to survey emergency physicians to examine actual practices in the management of coin ingestion.

Ingestion of coins and batteries.

Witnessing the ingestion of a foreign body by a toddler is alarming and immediately raises several questions. What are the risks of aspiration and airway obstruction? Where do foreign bodies get stuck? Are investigations necessary in the absence of symptoms? How long can objects be watched at different locations? What complications can result? When should objects be removed and which procedure should be used? When can cathartics or enemas be given safely? Predisposing Factors The peak age range for foreign body ingestion is 6 months to 3 years. There are underlying social, developmental, or psychiatric risk factors in up to 30% of cases. Ingestions in older children usually are accidental. Symptoms occasionally can suggest an underlying abnormality such as an esophageal stricture or might be related to a previous surgical procedure such as the repair of an esophageal atresia or a pyloromyotomy for pyloric stenosis. Children who have had esophageal atresia repaired also have associated dysmotility of the distal segment. The Need For Radiologic Investigations The nature of the ingested foreign body obviously influences management. Directed questions or a search of the home for missing objects often will reveal the nature of the ingested object. The presence of symptoms such as choking, dysphagia, substernal discomfort, persistent cough, or of physical findings such as drooling mandates a radiologic search for foreign bodies from oropharynx to anus.

Esophageal Perforation Caused by Coin Ingestion

Esophageal perforation and acquired tracheoesophageal fistulae (ATEF) are rare sequelae of foreign body ingestion in the pediatric population. Here we discuss the cases of two patients with esophageal perforation caused by prolonged impaction of a coin; in one case, a tracheoesophageal fistula developed. The presence of aerodigestive symptoms and signs in infants and small children should prompt physicians to consider foreign body ingestion and the presence of an ATEF. Clinical presentation, diagnostic modalities, and technical considerations for surgical management are outlined.

Use of the transmitter-receiver metal detector in the evaluation of pediatric coin ingestions

Use of the transmitter-receiver metal detector in the evaluation of pediatric coin ingestions

Metal detectors: An alternative approach to the evaluation of coin ingestions in children?: Ros SP, Cetta F Pediatr Emerg Care 8: 134–136 Jun 1992

Metal detectors: An alternative approach to the evaluation of coin ingestions in children?: Ros SP, Cetta F Pediatr Emerg Care 8: 134–136 Jun 1992

Metal detectors: an alternative approach to the evaluation of coin ingestions in children?

Foreign body ingestions constitute a common problem in pediatric emergency medicine. Recent data indicate that, despite current recommendations, most children who ingest coins do not undergo radiologic evaluation. The purpose of this study was to determine the accuracy of a metal detector in locating coins in a model simulating coin ingestions in children. Initially, the distance between the anterior chest wall (ACW) and the esophagus was measured on 17 chest computed tomograms obtained on children between the ages of three months and six years. Subsequently, a distance equal to the mean ACW-to-gastroesophageal junction measurement was marked across the investigator's forearm. A second investigator then attempted to detect the presence of the coin through the forearm by using a Super Scanner (Garrett Security Systems, Inc, Garland, TX) metal detector. The study was conducted in a blinded manner and consisted of 50 attempts equally divided among pennies, nickels, dimes, quarters, and controls (no coin). The accuracy of the metal detector in identifying the presence or absence of coins in our model was 100%. We conclude that the metal detector evaluated by us is highly accurate in identifying coins through human tissues and that it should become a valuable and practical tool in the evaluation of children following a coin ingestion.

Management of Coin Ingestion-Reply

In Reply .—We would like to thank Dr Joseph for his comments and interest in our recently published article concerning coin ingestions. 1 It was our impression, and Dr Joseph's letter supports this, that the practice of not obtaining a roentgenogram of the asymptomatic child following a coin ingestion is common nationwide. Part of the impetus to do this study was this discrepancy between published recommendations and actual practice. Dr Fulginiti further examined the determinants of standard care and standard practice in the accompanying editorial. 2 We would like to address a few of the points mentioned by Dr Joseph. Though it is tempting to conclude that all asymptomatic patients with an esophageal coin who had a chance to be observed for spontaneous passage into the stomach actually did pass the coin, the number of patients that did so was only three. It is impractical to make a practice

Management of Coin Ingestion

Sir.—I read with interest the articles by Schunk et al1and Caravati et al2and Dr Fulginiti's editorial3in the May 1989 issue ofAJDCon the management of coin ingestion. Dr Fulginiti, the reviewers, and the editorial staff were startled to find that over 70% of the pediatricians surveyed in Salt Lake City, Utah, would not have obtained a roentgenogram of an asymptomatic child who had ingested a coin. I have been a practicing pediatrician for 23 years and I, too, would not have sent the asymptomatic child to the emergency department. I would like to comment on the Schunk et al article and on the literature on coin ingestion, and present a few of my own findings and observations. The editors have not served the readers of this journal well in publishing the part of the summary in the Schunk et al article

Pediatric Coin Ingestion-Reply

In Reply .—We appreciate Dr Foster's interest in our article. Although the authors of the two studies 1,2 in question may have faculty appointments at the same university, the studies were performed independently, without knowledge of one another, and on entirely different patient populations. Dr Schunk and associates 2 evaluated 52 patients presenting to an ED of a tertiary care children's hospital during a 12.5-month period. Some of their patients were referred to their institution specifically for coin removal. We prospectively studied 162 patients during a 28-month period who voluntarily called the Intermountain Regional Poison Control Center with a complaint of coin ingestion. There is evidence that children presenting to EDs are at a twofold to sixfold greater risk for symptoms, complications, and hospitalization from foreign-body ingestion than those presenting to an office practice with the same complaint. 3 This suggests that the ED population represents a higher-risk group and

Pediatric Coin Ingestion

Sir .—I read with interest, in the May 1989 issue of AJDC , the conflicting conclusions by different authors from the same university regarding the question of routine chest roentgenography in the evaluation of esophageal foreign bodies in children. 1,2 Schunk et al 1 recommended that all such children be evaluated, as previously suggested by Hodge et al. 3 Caravati et al, 2 however, concluded that evaluating asymptomatic children is unnecessary provided the enteral administration of liquids is tolerated and telephone follow-up is available. The latter conclusion is incredible considering the report of esophageal perforation by a coin in a 3½-year-old child who had been asymptomatic for 6 months following the ingestion. 4 The definitive thoracotomy would have been avoided if the parents had sought medical attention initially, a chest roentgenogram had been performed, and the coin had subsequently been removed. An 11-month-old male infant with a similar history was referred

Pediatric coin ingestion; A prospective study on the utility of routine roentgenograms

Pediatric coin ingestion; A prospective study on the utility of routine roentgenograms

Is Standard Practice 'Standard' In Community Pediatrics?

Sir .—The editorial by Fulginiti about of practice was thoughtful and provocative. Standards of practice are of particular importance to those of us in primary care as we do want to practice high-quality medicine. Standards also have their medicolegal implications. However, the means by which these standards come into being are of some importance. Dr Fulginiti correctly pointed out the central role of in establishing and further stated that practitioners might benefit by knowing that their practices might not conform to some standard held by experts. I would like to add that experts might benefit from a review of their standards when they do not conform to what is actually being done in primary care practice. The problem of coin ingestion is a good case in point. Forty-five of 65 pediatricians surveyed do not automatically obtain roentgenograms of an ingested coin. I suspect they would if the

Is Standard Practice 'Standard' In Community Pediatrics?

Sir .—After reading the editorial by Fulginiti 1 and the articles by Schunk et al 2 and Caravati et al 3 in the May issue of AJDC regarding pediatric coin ingestion, I telephoned 11 fellow pediatricians to learn how they would respond to an asymptomatic child who had swallowed a coin. I also decided to ask whether they would prescribe oral antibiotic therapy or administer an injection of benzathine penicillin to a nonallergic child weighing more than 18 kg whose throat culture results or rapid-strept test results were positive for streptococcal infection. Atlanta, Ga, is a medical school city with two tertiary care–level children's hospitals that strongly encourage continuing medical education for their physicians. All the pediatricians I questioned are members of the active staffs of at least one of the children's hospitals. My questions were the same to each pediatrician: If you have a totally asymptomatic child in no

Pediatric coin ingestions—A prospective study of coin location and symptoms

Pediatric coin ingestions—A prospective study of coin location and symptoms

Pediatric Coin Ingestion

It has been recommended that all children with a history of coin ingestion immediately undergo roentgenography to locate the coin, regardless of symptoms. We performed a prospective evaluation of these ingestions to determine the risk of asymptomatic esophageal impaction and the need for routine roentgenography. One hundred sixty-two children (mean +/- SD age, 3.6 +/- 2.1 years) were evaluated. All were referred for immediate roentgenography after ingestion and followed up daily by telephone for 5 days. Sixty-six patients (41%) did comply and 96 (59%) did not comply with the roentgenogram recommendation. A coin was visualized in the esophagus of 13 patients (20%); 11 were symptomatic and 2 were asymptomatic at the time of ingestion. Symptomatic patients had a 42% risk of a coin later being located in the esophagus compared with a 5% risk for asymptomatic patients. The asymptomatic patients with lodged coins passed them without difficulty after the administration of oral fluids. Nineteen percent of the patients who did not undergo roentgenography were symptomatic and all became asymptomatic within 24 hours of ingestion. There was no difference in morbidity between the group that underwent roentgenography and the group that did not undergo roentgenography at 5 days after ingestion. Children who are asymptomatic at the time of coin ingestion may not need routine roentgenography if they can tolerate oral fluids and telephone follow-up is available.

Pediatric Coin Ingestions

Coins are the most common esophageal foreign body in children. We prospectively evaluated 52 consecutive children who had swallowed coins to determine the incidence of asymptomatic esophageal coins and the rate of spontaneous passage. All patients had a roentgenogram; coins were removed from the esophagus if the patient was symptomatic. children with asymptomatic esophageal coins were allowed less than 24 hours to pass the coin to the stomach. Thirty children had esophageal coins; of these, 9 (30%) were asymptomatic. The presence of symptoms was significantly associated with esophageal coins, but the absence of symptoms did not reliably exclude the possibility of an esophageal coin. All children who swallow coins should undergo roentgenographic evaluation.