Published online August 31, 2005
PEDIATRICS Vol. 116 No. 3 September 2005, pp. 752-753 (doi:10.1542/peds.2005-0062)
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COMMENTARY

Management of Asymptomatic Coin Ingestion

Gregory P. Conners, MD, MPH, MBA, FAAP

Departments of Emergency Medicine and Pediatrics,
University of Rochester Medical Center,
Rochester, NY 14642

Although the evidence-based management of pediatric coin ingestion has evolved over the past 20 years, several important questions remain. Among the most important of these questions is: Can previously healthy children who are asymptomatic after coin ingestion be safely managed with home observation, or should they have radiographs to rule out retained esophageal coins?1–3 Because a tremendous number of children swallow coins each year,4 many of whom are asymptomatic, this is an important public health question. The prospective comparison of immediate versus delayed endoscopic esophageal coin removal by Waltzman et al5 in this issue of Pediatrics provides important additional information toward answering this question. Their work is especially useful because it focuses on the clinical dilemma of the radiographically positive but asymptomatic child.

In the past, hospital-based studies, typically retrospective case series, have suggested that although most children with coins lodged in the esophagus have suggestive signs or symptoms (eg, drooling, dysphagia, pain, foreign-body sensation), a substantial minority of children with esophageal coins are asymptomatic.1,6–7 Because unrecognized esophageal coins may lead to important, even life-threatening complications over time, these studies suggested that all children who swallow a coin, regardless of whether they are symptomatic, should undergo imaging to rule out the presence of an esophageal coin. In contrast, several non–hospital-based studies have painted a different picture, suggesting that home observation of children who are asymptomatic after coin ingestion is safe and effective, with radiographs taken of only those who develop symptoms.2–4,8–9 This apparent contradiction is likely caused mostly by an incomplete understanding of the "natural history" of asymptomatic esophageal coins in otherwise healthy children.9

In their study, Waltzman et al5 prospectively randomly assigned 60 asymptomatic pediatric emergency department patients with recently swallowed, radiographically proven esophageal coins and without previous esophageal or tracheal abnormalities; half of the patients were assigned to endoscopic removal at the next available time, and half were assigned to inpatient observation for ~16 hours before scheduled endoscopy. All patients had repeat radiographs before endoscopy to identify those who had spontaneously passed their coins into the stomach and therefore did not require a removal procedure (once they are in the stomach, coins generally traverse the remainder of the gastrointestinal tract of children with normal anatomy without difficulty). All of the children were kept non per os. Spontaneous passage occurred in 16 (27%) of the 60 patients and, interestingly, was about equally frequent in both groups. Two thirds of all spontaneous passage occurred in the first 8 hours after coin ingestion. The authors conclude that an 8- to 16-hour observation period of children meeting their entry criteria, rather than immediate endoscopy, is reasonable, because it would allow many children to avoid unnecessary endoscopic procedures.

By prospectively studying asymptomatic children rather than the symptomatically mixed group found in most previous studies, the authors contribute to a better understanding of the natural history of the children whose outcomes are at the heart of the management uncertainty. The authors had 2 key findings that, taken together, suggest that children with asymptomatic esophageal coins are far likelier to pass their coins spontaneously into the stomach than are children with symptoms. First, only 33% had coins in the upper portion of the esophagus, although several earlier studies have shown that 60% to 75% of all esophageal coins in children are in the upper esophagus.1,6–7,10–11 This result suggests that asymptomatic esophageal coins are far likelier to be located lower in the esophagus than are those in children who are symptomatic. Second, spontaneous passage of asymptomatic coins in the lower portions of the esophagus was much likelier than it was of coins in the upper esophagus. Only 8% of the 13 children in the study's observation group who had upper-esophageal coins had spontaneous coin passage, whereas 47% of the 17 corresponding children with middle- or distal-esophageal coins had spontaneous passage. Both of these points support findings from earlier studies7,8,11–13 and suggest that management recommendations based on outcomes of symptomatic children may lead to overtesting and overtreatment of children without symptoms.

These findings should be reassuring to advocates of home observation, who now have evidence that asymptomatic children with coins acutely lodged in the esophagus, particularly older children and boys, are far likelier to pass them spontaneously than are children with symptoms. Does this imply that asymptomatic children, therefore, do not need radiographs? In particular, would any of the 44 asymptomatic children in the Waltzman et al study who underwent endoscopy have had avoidable complications resulting from missed esophageal coins had they been managed by home observation? In considering this question, it is worth noting that it took the investigators 2 years to gather even this modest number of patients despite being based at one of the nation's leading pediatric referral centers. Nearly half of this group were in the study's "relatively immediate endoscopy" group; some of these patients may have passed their coins into the stomach had they been allowed a longer observation period. Additionally, study patients were kept non per os, whereas at home they would likely have eaten and drunk. Previous evidence suggests that at least some of them would have passed their coins as they swallowed their meals.8,14 Those whose coins remained may have developed the sorts of symptoms that parents should be advised to watch for during home observation, triggering radiography. Clearly, unanswered questions remain. A prospective study of home observation for management of asymptomatic children who have swallowed coins, including a cost-effectiveness comparison versus obtaining automatic radiographs, is an important next step in obtaining the answers.3 Until data from such a study are available, an ionizing-radiation-free scan with a metal detector (with radiographic follow-up of those suggestive of esophageal coins) remains a reasonable middle-ground alternative to automatic radiography.13,15


   FOOTNOTES
 
Accepted Jan 12, 2005.

Address correspondence to Gregory P. Conners, MD, MPH, MBA, FAAP, Departments of Emergency Medicine and Pediatrics, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY 14642. E-mail: gregory_conners{at}urmc.rochester.edu

No conflict of interest declared.


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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics




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