A randomized clinical trial of the management of esophageal coins in children

Context. Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously. Objectives. (1) To compare relatively immediate endoscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relationship between select clinical features and spontaneous passage. Design/ Setting. Randomized, prospective study of children < 21 years old who presented to an emergency department with esophageal coins in the esophagus. Exclusion criteria were (1) history of tracheal or esophageal surgery, (2) showing symptoms, or (3) swallowing the coin > 24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for observation, with repeat radiographs similar to 16 hours after the initial image. Outcome Measures. Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed. Results. Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligible. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized- to- observation group compared with the randomized- to- surgery group (mean: 19.4 [ SD: +/- 8.0] hours vs 10.7 [SD: +/- 7.1] hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98 - 13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% [ 95% confidence interval: 1.07 - 5.57]). Conclusions. Because 25% to 30% of esophageal coins in children will pass spontaneously without complications, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins.