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To the Editor.—
We read with interest the case report of a child with a penny lodged in the esophagus by Bothwell et al.1 In our pediatric otolaryngology and anesthesia practice, we see a number of such patients annually. Before diagnosis of chronic esophageal foreign bodies, it is not unusual for some of these children to have been treated for new-onset asthma for several weeks to months. Most often, the "asthma" resolves following removal of the foreign body. Although reactions as severe as that described by the authors in their case report have not been seen, almost all have some esophageal mucosal and/or muscular reaction to the presence of the penny, especially if it has been present for more than a few days.
Our concern with this report and discussion is the emphasis on zinc toxicity in this patient despite neither a documented zinc blood level measurement nor explicit, distinct signs of toxicity. It is only in conclusion that the authors suggest careful evaluation of small children who present with marked respiratory symptoms suggestive of asthma or stridor, who do not improve as expected with proper medical therapy.
We believe that the important message to be learned from the presentation of this case report is that a foreign body ingestion/aspiration needs to be an early consideration for any child who fails to respond to appropriate medical treatment of their respiratory symptoms. This would help to reduce severe esophageal injuries associated with zinc-containing pennies as described in the report.
REFERENCE
In Reply.—
Coin ingestion with esophageal impaction is not a new or rare problem. Four percent of children have swallowed a coin (the most commonly swallowed foreign body in the United States).1 Small children use their mouths to explore the world. They specifically like to put coins in their mouths because they are shiny, plentiful, and relatively easy to pick up. Children also see adults "play with them" all the time. Although esophageal coins may spontaneously pass in up to 28% of children,2 we routinely endoscopically remove them in the majority of cases without sequelae. Rarely, long-term esophageal coin impaction may lead to untoward complications including death.3,4
Our goal in presenting a child with long-term esophageal penny impaction was to alert pediatricians to the specific problem associated with post-1982 penny ingestion.5 Since 1982, to reduce minting costs the United States has produced a penny composed primarily of zinc with only a very thin layer of copper coating. Zinc is highly reactive with gastric acid and causes local corrosion leading to potential mucosal erosion, abrasion, and perforation. Systemic toxicity may present with signs of lethargy, severe gastroenteritis, and even multisystem organ failure. We clearly stated that our child had normal zinc lab values without systemic toxicity yet sustained severe local ulceration and scarring of the esophagus. Since publication of our article we treated another case of long-term penny esophageal impaction in a small child presenting with a chronic cough of unclear etiology. Again, local zinc reactivity led to extensive ulcerative esophagitis and granulation.
Systemic zinc toxicity from penny ingestion is well-described in the veterinary literature.6–8 On a recent visit to our local zoo, the corresponding author noted a sign near an animal cage admonishing visitors not to toss coins into the fountain inside the cage. The zookeeper explained that animals (like children) will swallow the shiny coins (especially pennies), leading to either esophageal obstruction and airway ramifications or zinc toxicity.
Prior to 1982, the United States minted coins that were 
95% copper and <5% zinc. Beginning in 1982, the proportion of each metal was reversed because the value of the copper in a penny was becoming more valuable than a penny. Since 1982, the United States has minted pennies as copper-coated zinc wafers. Canada also changed to the primarily zinc penny in 1997. However, in 2001, Canada switched to a copper-plated steel penny (95% steel and 5% copper), which is potentially less toxic from long-term local exposure. Perhaps the United States should follow Canada’s lead.
We emphasized two practical conclusions from our case report. First and foremost, any child with a chronic cough or wheeze without a clear cause must undergo a detailed evaluation to include a workup for foreign-body ingestion. This workup commonly includes a chest radiograph and may include endoscopy. Second, zinc-based pennies are common and, if ingested, have the potential to create acute and chronic inflammatory responses more than other similar types of coinage. Early detection is stressed. We agree wholeheartedly with the comments from our colleagues at Arkansas Children’s Hospital as stated in this letter to the editor and a similar one.9 We echo these concerns in our article and in our pediatric otolaryngology practice.
REFERENCES
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