Accepted Manuscript

Predictive Factors Associated With Spontaenous Passage Of Coins: A Ten-Year

Analysis Of Paediatric Coin Ingestion In Australia

Dr Narinder Singh, Dr Jessica Chong, Dr Joyce Ho, Dr Shruti Jayachandra, Dr Daron

Cope, Dr Fred Azimi, Guy D. Eslick, Dr Eugene Wong

PII: S0165-5876(18)30390-2
DOI: 10.1016/j.ijporl.2018.08.010
Reference: PEDOT 9135

To appear in: International Journal of Pediatric Otorhinolaryngology

Received Date: 19 May 2018

Revised Date: 7 August 2018
Accepted Date: 8 August 2018

Please cite this article as: D.N. Singh, D.J. Chong, D.J. Ho, D.S. Jayachandra, D.D. Cope, D.F. Azimi,
G.D Eslick, D.E. Wong, Predictive Factors Associated With Spontaenous Passage Of Coins: A Ten-Year
Analysis Of Paediatric Coin Ingestion In Australia, International Journal of Pediatric Otorhinolaryngology
(2018), doi: 10.1016/j.ijporl.2018.08.010.

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 ACCEPTED MANUSCRIPT
PREDICTIVE FACTORS ASSOCIATED WITH SPONTAENOUS
PASSAGE OF COINS: A TEN-YEAR ANALYSIS OF PAEDIATRIC
COIN INGESTION IN AUSTRALIA
Dr Narinder Singh1,2
Dr Jessica Chong1
Dr Joyce Ho1
Dr Shruti Jayachandra2,3
Dr Daron Cope1

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Dr Fred Azimi1
Professor Guy D. Eslick3
Dr Eugene Wong1,2

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1. Department of Otolaryngology, Westmead Hospital, Mons Road, Westmead, Sydney,

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Australia
2. Sydney Medical School, University of Sydney, Australia
3. Department of Cancer Epidemiology and Medical Statistics, Nepean Hospital, Derby

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Street, Kingswood, Sydney, Australia
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Corresponding Author
Dr Eugene Wong
Department of Otolaryngology
Westmead Hospital
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Sydney
Australia
Email: eugene.hl.wong@gmail.com
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Keywords: coin; foreign body; ingestion; paediatric, size, age

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Conflict of Interest Statement: The authors declare no conflicts of interest.

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 To be considered for publication in:
ACCEPTED
International Journal of Paediatric Otorhinolaryngology MANUSCRIPT

ABSTRACT

Objectives: Coins are the commonest foreign body ingested in paediatric populations. Although

most ingested coins are either spontaneously passed or retrieved with medical intervention without

serious consequence, there is potential for serious morbidity and mortality related to paediatric coin

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ingestion. We performed a 10-year retrospective review of Australian denomination coin ingestion

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at a tertiary paediatric hospital in Sydney, Australia. We attempted to determine whether a

relationship exists between coin size, patient age, coin ingestion and spontaneous passage.

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Methods: Hospital records of all children presenting in a 10-year period to a paediatric tertiary

care centre for coin ingestion were reviewed. Demographic information, coin denomination,

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previous history, symptoms, investigations, management, outcome and complications were
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recorded.
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Results: 241 cases were identified. The majority (55%) of cases occurred in children ≤3 years of

age (range 7 months to 11 years, mean 3.39 years). The most common location where coins were
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identified was in the proximal third of the oesophagus or at the cricopharyngeus (65%).
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Spontaneous passage occurred in 84 cases (34.9%) while 167 cases (69.3%) required intervention.

Children ≤3 years were more likely to ingest small coins (<22mm) (OR: 2.44; 1.39-4.17) and
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children >3 years were more likely to ingest larger coins (22-26mm) (OR: 2.17; 1.39-4.35).
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Conclusions: Coin size, coin weight and age of the child appear to be predictors for both likelihood
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of ingestion and spontaneous passage in paediatric coin ingestion cases. A child with minimal

symptoms, witnessed ingestion and radiographic identification of the coin in the lower oesophagus

or more distal can often be safety observed for up to 24 hours in anticipation of spontaneous

passage.
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1. INTRODUCTION

Coins are the most commonly ingested foreign body among paediatric populations [1,2].

Although most ingested coins are either passed spontaneously or retrieved with medical

intervention, without serious consequence, there is potential for serious morbidity and

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mortality to occur if the coins remain in the gastrointestinal tract [3, 4-7]. Complications can

include stricture formation, oesophageal perforation, tracheo-esophageal fistula and aorto-

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oesophageal fistula [8]. Furthermore, coins can often mimic button batteries, which have

significant potential for harm if not removed urgently.

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Traditional management of known or suspected coin ingestion includes plain radiography

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with emergent intervention to retrieve any identified coins. However, some authors have
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suggested that, in certain cases, where coin ingestion has been witnessed or reliably

confirmed, particularly where the child is asymptomatic, a watch-and-wait approach with

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careful overnight observation and serial imaging may be safe in both an emergency
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department or outpatient setting [9]. They suggest that where spontaneous passage does not
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occur overnight, surgical removal is then considered the following day. This approach

confers several potential benefits – a period of conservative, expectant management can be

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trialled; and potentially dangerous overnight emergency surgery and its risks and logistical

issues may be avoided. Therefore, there is a need to determine the reliability and clinical
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safety of such an approach.

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Accordingly, there is a need to define the child and coin characteristics that predict the

likelihood of spontaneous passage, such that clinicians can make well-informed, evidence-

based decisions on whether to take a child to the operating theatre emergently or if overnight

conservative management may be trialled. Furthermore, coin characteristics that are found to
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be associated with ingestion, spontaneous passage or a need for surgical intervention can be

fed back to industrial mints to aid in future coin designs and production.

A retrospective review was performed to assess the clinical features, investigations, management

and outcomes of paediatric patients presenting following coin ingestion. Our aim was to determine

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risk factors for coin ingestion in the paediatric population, factors associated with spontaneous

passage and to establish whether an association exists between patient demographics and various

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coin characteristics with coin ingestion and impaction.

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2. METHODS AN
2.1 Study design

This study is a retrospective analysis of prospectively collected data. A case note review was
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undertaken of patients who presented to The Children’s Hospital Westmead in Sydney,

Australia with a history of foreign body (coin) ingestion between January 1994 and
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December 2004. International Coding of Diseases (ICD) Nine codes 933, 935.1, 935.2, 936,
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938 and ICD Ten codes T17.2, T18.1 T18.2, T18.3, T18.4, and T18.9 were used to identify

cases of foreign body ingestion. ICD-10 was implemented from 1994 onwards. Cases
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involving foreign bodies other than coins were excluded.

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2.2 Data Collection

Prior to data collection, ethics approval was obtained from the Western Sydney Local Health

District Human Research Ethics Committee (WSLHD HREC; approval number MR-2004-

12-02) governing The Children’s Hospital at Westmead. For each case, patient age, sex,

presenting symptoms, time from ingestion and coin denomination ingested was collected. All

investigations, treatments, complications and outcomes were also recorded.

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2.3 Definitions

The Royal Australian mint produces six Australian coins that vary in size, shape, edge,

composition and mass based on their denomination. A table describing each coin

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denomination’s diameter, weight, shape and volume in circulation (at the time of data

collection) is listed in Table 1.

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Separation of coin size into three distinct categorical variables was performed for statistical

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analysis. We defined small coins as those with a diameter of under 22mm (i.e 5c and $2

denominations); medium coins as those between 22mm and 26mm (i.e 10c and $1

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denominations); and large coins as those greater than 26mm (20c and 50c denominations).
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Separation of coin weight into two categorical variables was also performed. Light coins

were those that weighed less than 8g (i.e 5c, 10c and $2 denominations) while heavy coins
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were those that weighed more than 8g ($1, 20c and 50c denominations).
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Separation of the cohort into those either ≤ 3 years old or >3 years old was performed based
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on previous literature suggesting that children ≤ 3 most frequently ingest foreign bodies [10-
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12].
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2.4 Statistical Analysis

Patient demographic and clinical characteristics were reported as medians and ranges for

numeric-scaled features and percentages for discrete characteristics. Factors associated with

coin ingestion were identified using unconditional logistic regression. All P-values calculated

were two-tailed; the alpha level of significance was set at 0.05. All data was analysed using

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STATA version 12.0 (StataCorp. 2011. Stata Statistical Software: Release 12. College

Station, TX, USA).

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RESULTS

A total of 530 paediatric cases were identified as having presented with foreign body

ingestion at Westmead Children’s Hospital between January 1994 and December 2004. Of

these, 241 (45.5%) were found to have ingested a coin.

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3.1 Demographics

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Of the 241 cases of coin ingestion, 118 (49.0%) were male and 123 (51.0%) were female.

The mean age was 3.39 years (range 7 months to 11 years). More than half of patients were 3

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years or under (54.8%, n=132)

3.2 Time to presentation

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Of the total 241 cases, the median time from coin ingestion to hospital presentation was 2
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hours (range 15 minutes to 42 days). The vast majority of cases (91.7%, n=221) presented to

hospital within 24 hours of suspected or known foreign body ingestion. In the majority
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(70.1%, n=169) of cases, the coin ingestion was witnessed by a parent or sibling or the child
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provided a history of foreign body ingestion.

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Delayed presentation to hospital or delayed diagnosis (defined as >4 hours following coin
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ingestion) was noted in 20 out of the 241 cases. Of these, the majority (75%, n=15) were
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under 2 years of age. Many of these children were symptomatic, most commonly with

vomiting (35.0%, n=7) and coughing (25.0%, n=5).

3.3 Symptoms associated with coin ingestion

A variety of symptoms were associated with coin ingestion among our study subjects.

Gastrointestinal symptoms were present in 161 (66.8%) of the subjects, respiratory

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symptoms were present in 52 cases (21.6%) and pain was the presenting symptom in 48

(19.9%) cases in the cohort. Vomiting was the most common gastrointestinal symptom,

present in 92 children (38.2%), followed by drooling in 78 children (32.6%), gagging in 35

cases (14.5%), foreign body sensation in 31 cases (12.9%), dysphagia in 28 cases (11.6%),

refusal to eat in 17 cases (7.1%), odynophagia in 8 cases (3.3%) and blood stained saliva in 3

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cases (1.2%). Coughing was the most prominent respiratory symptom noted in 48 cases

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(19.9%), 5 children (2.1%) had dyspnoea and 5 children (2.1%) had stridor, 3 (1.2%) had a

wheeze and in 1 child accessory muscle use was noted.

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Pain was the presenting symptom in 48 children with the neck (22 cases or 9.1%) and chest

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(18 cases or 7.5%) being the most common sites of pain and epigastric, abdominal and oral
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pain being less common with 8, 4 and 1 cases noted, respectively. Systemic symptoms were
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present in 10 children, of which 6 cases were irritable and 4 had fevers. Vocal symptoms

were very rare with only 1 child presenting with dysphonia. Of note, 37 children (15%) did
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not have any symptoms on presentation.

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3.4 Investigations
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Plain radiographs were the most common investigation used, being ordered in 97.1% (n=234)
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of cases. In the vast majority of patients (92.9%, n=224), a radio-opaque foreign body was
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identified.

When an initial radiograph demonstrated a lodged coin, the most common location was in the

upper oesophagus (66.1%, n=148). In the remaining cases with positive initial radiograph, the

coin was in the mid (10.3%, n=23) or lower (12.9%, n=29) oesophagus, stomach (9.8%,

n=22) or bowel (0.9%, n=2).

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Of all cases that underwent initial radiograph, 27.4% (n=64) of cases underwent a subsequent

radiograph, mainly due to clinical suspicion of spontaneous passage, secondary to diminution

of symptoms. In this group, spontaneous progression of the coin to a more distal segment of

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the gastrointestinal tract was noted in most cases (59.4%, n=38).

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Progression of the coin was seen to occur more commonly when the site of visualisation on

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initial radiograph was the lower oesophagus (88% progression rate), than the mid (60%

progression rate) or upper (39% progression rate) third of the oesophagus. Overall, coins in

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the lower third of the oesophagus were much more likely to spontaneously pass through the
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gastrointestinal tract than coins in any other location in the oesophagus (RR=11.5, 95%CI
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5.70-23.16, p<0.001).
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3.5 Management
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A decision to manage the patient conservatively was made in 30.7% (n=74) of cases, with the

expectation of subsequent spontaneous passage of the coin. In the vast majority of these cases
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(91.9%, n=68) the coin location on plain radiograph, either on initial or subsequent film, was
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either within the stomach or distal. The remaining coins were either within the lower
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oesophagus (6.8%, n=5) or within the mid-oesophagus (1.4%, n=1).

All other cases (69.3%, n=167) proceeded to the operating theatre. In a few (6.0%, n=10) of

these patients, no foreign body was visualised intra-operatively and subsequent radiographs

indicated that the coin had passed spontaneously. All these patients were discharged without

consequence.

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In the remaining cases (94.0%, n=157) where an ingested coin was visualised, all were

successfully removed intra-operatively. Rigid oesophagoscopy with endoscopic forcep

retrieval was used in most cases (91.1%, n=143). In the small proportion (8.3%, n=13) of

patients where the coin was located at the cricopharyngeus muscle, a Miller anaesthetic

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laryngoscope with McGill offset forcep retrieval was used. In the one case where a flexible

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gastroscope was used, flexible through-the-scope forceps were used. The Foley catheter,

oesophageal bougienage and magnetised catheter techniques were not employed in any of the

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cases in our study.

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The site of visualisation of the coin in the oesophagus was documented in 95.5% (n=150) of
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the cases requiring retrieval. The coin was located in the upper oesophagus in the
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overwhelming majority of cases (82.7%, n=124), compared to the mid-oesophagus (6.7%,

n=10) or lower oesophagus (10.7%, n=16.)

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3.6 Ingested coin denominations

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Various denominations of coins were ingested. The 5c coin was the most commonly ingested
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denomination in our study (33.2%, n=80.) This was followed by the 10c coin (23.2%, n=56),

$1 coin (13.7%, n=33), $2 coin (10.8%, n=26) and finally the 20c coin (4.1%, n=10.). No
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patients ingested a 50c coin, which is quite large at 31.5mm.

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In addition, 15 patients ingested non-standard coins. This included the out-of-circulation

Australian 1c (1.2%, n=3) and 2c (2.5%, n=6) coins, the United States penny (0.8%, n=2) and

the United Kingdom 1 pence (1.2%, n=3) and 50 pence (0.4%, n=1) coins. Five children

swallowed more than one coin. The denomination of the ingested coin was not documented

in 16 children (6.6%).

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3.7 Coin denomination versus age and weight

There was an increased likelihood of ingestion of small size coins in children ≤3 (OR: 2.44,

95%CI: 1.39-4.17, P<0.01) and vice-versa in children >3 years old (OR: 0.41, 0.24- 0.72,

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p<0.01). Medium sized coins were more likely (OR=3.17, 95%CI 1.8-5.5, p=0.02) to be

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ingested by children over 3 years compared to those under 3 years (OR 0.31; 0.18- 0.55,

p=0.02). Finally, large coins trended to be more likely (OR=1.23, p=n.s/) to be ingested by

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children over 3 years, however this did not reach statistical significance.

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With respect to segregation by coin weight (Table 2), low weight coins were more likely (OR
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2.17, 95%CI 1.2-4.0, p=0.01) to be ingested by children ≤3 years compared to those >3 years
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old. However children >3 years more often ingested the heavy coins compared to those ≤3

years old (OR=3.15, 95%CI 1.62-6.14, p<0.01).

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3.8 Coin denomination and retrieval in theatre

Event rate (ER) analysis of surgical intervention based on ingested coin denomination was
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performed (Figure 1). It found a statistically significant increased event rate in children who
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swallowed a 5c coin (ER=0.70, 95%CI 0.60-0.79, p<0.01) or a $1 coin (ER 0.77, 95%CI
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0.61-0.88, p<0.01.)

3.9 Coin denomination and spontaneous passage

ER analysis (Figure 2) of our data showed that one third of children (n=27/81) (ER: 0.33

[0.24-0.44]; p<0.01) who swallowed a 5c coin spontaneously passed the coin. Of note, most

children (ER: 0.74[0.5-0.89]; p= 0.05) who swallowed a 10c coin and almost half of the 35

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children (ER: 0.48[0.3-0.67]; p<0.01) who swallowed a $2 coin spontaneously passed them.

The 20c and $1 coins were spontaneously passed by very few children (ER: 0.20[0.05-0.54];

p <0.08 and ER: 0.23[0.12-0.39]; p<0.01 respectively).

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DISCUSSION

Coin ingestion is reported to occur in approximately 4% of all children [13]. Chen &

colleagues [14] estimated an annual incidence of nearly 30,000 cases of paediatric coin

ingestion in the United States in 2000. The actual incidence of coin ingestion may in fact be

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higher than estimates based on hospital presentations, especially when considering that many

children may pass them asymptomatically in the community and never present to hospital.

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Several authors [15-16] have found that observing asymptomatic children at home is a safe

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strategy.

3.1 Coin denomination and ingestion

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Regarding coin denomination, our results demonstrated that younger (≤3 years of age)

children were more likely to present to hospital having ingested coins of smaller diameter or
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lighter weight (<22mm and <8g), a finding that is consistent with previous studies such as

that by Chen et al [14.] However, Chen’s population-based study examined only paediatric
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ingestion admissions and hospitalisations, and did not examine which coin characteristics
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correlated with spontaneous passage or whether surgical intervention was required while an
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inpatient.

As younger children have a smaller diameter oropharynx and oesophagus, we postulate that
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they may be unable to ingest larger diameter coins such as the 20c and 50c denominations
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[14,17-18]. Any larger diameter coins that do eventually reach the oropharynx may cause the

child to initiate a strong gag reflex and prevent ingestion.

As older children have a larger diameter oropharynx and oesophagus, they can ingest coins of

all sizes from the 5c to the 20c. The 50c coin, at 31.5mm still potentially represents a

challenge, even to the older child and may explain why it was rarely ingested. Our results

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confirm that children older than 3 years were more likely to present to hospital having

ingested coins of a medium or large diameter (>22mm). We speculate that fewer older

children presented to hospital with small coin ingestion primarily because in the older age

group small coins may pass through the gastrointestinal tract spontaneously and

asymptomatically in the community.

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Previous studies [19,20] assessing US coin ingestion suggest that the smaller dime (17.9mm

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diameter) and larger dollar (26.5mm) and half-dollar (30.6mm) are significantly under-
represented in ED presentations when compared to the moderately sized penny (19.1mm),

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nickel (21.2mm) and quarter (24.3mm.). Studies [21] relating to button battery ingestions also
demonstrated that batteries retained in the oesophagus were significantly larger on average
than those that passed spontaneously and battery diameter greater than 20 mm was

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significantly associated with oesophageal impaction (P<0.0001).
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Combined with our ingestion data, these findings suggest that that a "danger zone" may exist
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for coins between the diameters of 19mm (Australian 5c) to 25mm (Australian $1). Coins
greater than 25mm (Australian 20c and 50c, US dollar and half dollar) tend not to be ingested
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in younger children due to the mismatch between coin and oropharyngeal/ oesophageal
diameter. Coins less than 19mm (US dime) may tend to pass spontaneously once ingested,
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without requiring presentation.

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Coins within the postulated 19 to 25 mm “danger zone” (Australian 5c, 10c, $1, $2, US
penny, nickel quarter) may have a higher risk of ingestion and impaction, leading to
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presentation and need for surgical removal. Based on this observation, it could be
recommended that, where possible, new coins should not be produced within this danger
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zone. Instead, new coins larger than 25 mm or smaller than 19 mm could be recommended.
Very small coins may theoretically risk airway aspiration, but data on this is lacking.

3.2 Spontaneous passage and coin location

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In our study, spontaneous progression of the ingested coin occurred regularly when impacted

in the distal oesophagus and beyond. Approximately a third of all children were managed

conservatively and all of them spontaneously passed the ingested coin. The decision to

manage cases conservatively was largely based on clinical symptoms and coin location on

plain radiographs. However, caution must be exercised in determining the nature of the

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foreign body visualised on a radiograph. Soccorso and colleagues [22] describe a case where

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a 20mm button battery was mistaken for a coin on a radiograph and managed conservatively,

leading to oesophageal perforation. They suggest treating coin-like foreign bodies as button

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batteries until proven otherwise. This typically requires witnessed ingestion or a very reliable

history.

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Most children managed conservatively had coins identified in the distal gastrointestinal

system (stomach and distal). However, the time from ingestion to spontaneous passage was
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not recorded. In addition, a small number of children managed non-conservatively

spontaneously passed the coin by the time they reached the operating theatre. The literature
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supports the finding that coins in the distal gastrointestinal tract usually pass spontaneously
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and that, within the oesophagus, coins in the lower third have a higher likelihood of passing
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spontaneously in comparison to those in the upper and mid thirds [23].

A randomised controlled trial by Waltzman et al [24] that compared outcomes in children

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who underwent immediate endoscopic removal with conservative management in hospital

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demonstrated similar findings. In this study, they were unable to demonstrate a statistically

significant difference in spontaneous passage between the two groups, although it may have

been underpowered as only a small cohort size was recruited. They also demonstrated that

distal coin location was a strong predictor for spontaneous passage.

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Several authors have suggested a watchful waiting period in children who are known to have

a distal oesophageal coin. Conners et al [23] recommended that in children with oesophageal

coins, particularly in the distal oesophagus, a 24-hour observation period should be

considered, with intervention after this period if the coin has not spontaneously passed.

Stringer suggested an observation period of 12 hours prior to intervention [25]. Based on our

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findings with coin location and conservative management, we recommend that, in a child

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with witnessed ingestion and minimal symptoms, when the coin is in the distal oesophagus or

beyond, an observation period overnight and of up to 24 hours from time of coin ingestion

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can be trialled in anticipation of spontaneous passage. In cases where there are significant

symptoms or uncertainty about the foreign body (eg possibility of button battery), we

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recommend endoscopic retrieval in the operating theatre at the earliest opportunity.
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3.3 Spontaneous passage and denomination
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We studied coin size and weight as predictors of spontaneous passage of ingested coins. The
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current literature on coin denomination as a predictor of likelihood of spontaneous passage is

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limited. We anticipated that likelihood of spontaneous passage would decrease with

increasing coin size and weight. Similarly, Amin et al [26] suggested that smaller coins are
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less likely to become lodged in the gastrointestinal tract while on the other end of the

spectrum, larger coins were found to be impacted more often and require retrieval due to their
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large size.
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However, detailed analysis of our spontaneous passage data demonstrates a more

sophisticated association. While we did find that the larger 20c and $1 denominations had

decreased rates of spontaneous passage compared to the smaller 10c coins, as expected, a

clear majority of the smallest 5c coins also failed to pass spontaneously, representing a bi-

modal distribution for requirement for surgical intervention. The contradictory findings in our

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study may be explained by the observation that the children presenting after ingesting the

smaller 5c coin were more likely to be younger. Tander [27] noted that smaller coins became

impacted in younger children and vice-versa. This may be due to narrower oesophageal

lumens in younger versus older children.

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In our study, the Australian 10 cent coin, which has a diameter of 23.6mm, carries the
greatest likelihood of spontaneous passage once ingested. This appears to be due to the

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observation that the cohort presenting after ingesting the 10c coin was typically older than the
cohort presenting after ingesting the 5c coin. It is likely the older cohort’s larger diameter

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oesophageal lumen was more likely to pass the larger 10c coin than the younger cohort’s
smaller lumen with its impacted 5c coin. Other factors, such as coin thickness or the reeded

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edge may be at play but were not assessed.
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To date there have only been a few studies specifically focused on coin ingestion and as such,
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this study adds to the literature on coin ingestion in children, with one of the largest study
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samples to date. Uniquely, our study presents data from an experience with Australian

currency, which provides a previously unpublished and interesting alternative perspective

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when compared to the other studies which describe US denominations. Furthermore, most
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prior studies were published over one decade ago, and an update to our knowledge is

warranted given coins remain the most commonly ingested paediatric foreign body.
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Nevertheless, there are some limitations of the study. One inherent limitation is that it only
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assesses patients presenting to hospital – it is likely that many ingested coins pass

spontaneously in the community, thus skewing the observed ingestion and spontaneous

passage rates, and is a potential source of selection bias. Also, the data was collected

retrospectively from a single institution, thus there may be some missing data due to

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incomplete medical records if ICD codes were entered incorrectly. A prospective study

design as a part of future research could help alleviate this limitation.

Another limitation of this study is that other coin characteristics that may play a role in

ingestion or impaction, such as thickness or type of coin edge, were not assessed. All

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Australian coin denominations, apart from the 50 cent piece, have reeded edges. The fact that

no child ingested the 50c and that the coin has many other unique characteristics made it

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impossible to assess the impact of reeded edges in this cohort. The authors suggest that future

studies on the topic take these characteristics into consideration.

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3. CONCLUSIONS

Coin size, coin weight and age of the child appear to be significant predictors for likelihood

of ingestion and the probability of spontaneous passage in paediatric coin ingestion cases.

Smaller denominations were more likely to be ingested by younger children, and larger

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denominations by older children. Furthermore, spontaneous passage of impacted coins

appears to be associated with radiographic localisation of the coin within the lower

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oesophagus or beyond and the Australian 10c denomination (23.6mm diameter). Witnessed

coin ingestion in patients with minimal symptoms and radiographic localisation within the

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lower oesophagus and beyond can often be safety observed overnight and for up to 24 hours

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from the time of ingestion in anticipation of likely spontaneous passage.
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ACKNOWLEDGEMENTS

Nil

FUNDING

This research did not receive any specific grant from funding agencies in the public,

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commercial or not-for-profit sectors.

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References

1. Hur K, Angajala V, Maceri D, Hochstim C. Geographic health disparities in the Los

Angeles paediatric esophageal foreign body population. Int J Pediatr Otorhinol. 2018;

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FIGURES AND FIGURE LEGENDS

Figure 1: Event rate analysis of coin denomination and need for surgical

intervention. All coin sizes were found to be associated with high rates of the

requirement for surgical intervention, except for the 10 cent denomination. *CI:

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Confidence Interval

Figure 2: Event rate analysis of coin denomination and spontaneous passage. All coin

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sizes were found to have low rates of spontaneous passage except for the 10 cent

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denomination. *CI: Confidence Interval

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TABLES AND TABLE LEGENDS

Denomination Diameter Weight (in Shape Volume in circulation (in billion coins) Composition

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(in mm) g)
5 cent 19.41 2.83 Circular 3.088 75% Cu, 25% Ni

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2 dollar 20.5 6.6 Circular 0.415 92% Cu, 6% Al, 2% Ni

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10 cent 23.6 5.65 Circular 1.469 75% Cu, 25% Ni

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1 dollar 25 9 Circular 0.531 92% Cu, 6% Al, 2% Ni

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20 cent 28.52 11.3 Circular 1.051 75% Cu, 25% Ni

50 cent 31.51 15.55 TE

Dodecagon 0.604 75% Cu, 25% Ni
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Table 1: Specifications of current Australian coins in circulation, by diameter

*Cu- copper ; *Al- aluminium ; *Ni- Nickel.

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Coin Likelihood of Confidence P- Likelihood Confidence P-value

ingestion in interval value of interval
children ≤ 3 [lower- ingestion [lower-
years old upper limit] in upper
children limit]
>3 years

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old
Separated by coin diameter
Small 2.44 1.39-4.17 <0.01 0.41 0.24-0.72 <0.01

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(<22mm)
Medium 0.31 0.18-0.55 0.02 3.17 1.83-5.55 0.02
(22mm-

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26mm)
Large 0.81 0.22-2.94 0.76 1.23 0.34-4.47 0.76
(>26mm)

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Separated by coin weight
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Light 2.17 1.2-4.00 0.01 0.46 0.25-0.84 0.01
(<8g)
Heavy 0.32 0.16-0.62 0.01 3.15 1.62-6.14 0.01
(>8g)
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Table 2: Likelihood of ingestion of coins based on their diameter and weight versus
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age of child (under or over 3 years old).

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