Clinical Guideline

USING A METAL DETECTOR FOR CHILDREN WHO

SWALLOW COINS
SETTING Paediatric Emergency Department (CED)
FOR STAFF All medical and nursing staff

PATIENTS Paediatric patients presenting with a suspicion of having ingested metal coins

_____________________________________________________________________________

GUIDANCE
Foreign body ingestion is a common way for children to present to the CED, with the most
commonly swallowed objects being made of metal (namely coins)1.

Most metallic foreign bodies (MFBs) are inert and once in the stomach, pass through the
alimentary tract without any adverse effects. Complications may arise however, when the MFB
impacts in the oesophagus. Such reported complications include perforation, mediastinitis and
trachea-bronchial fistulas2.

Various studies have shown that being asymptomatic does not preclude the presence of
impaction. The percentage of children with an impacted MFB, who were asymptomatic at
presentation, can range from 7 – 64%3. Common practice has therefore been to use further
investigations to try and rule this out, such as solitary or serial radiographs of the chest or
abdomen.

A reliable hand held metal detector (HHMD) scan could negate the need for further
investigations and reduce unnecessary radiographs, with the associated exposure to potentially
harmful ionising radiation. See Appendix 1 for HHMD technique. HHMDs are an accurate
screening tool for children who have swallowed or are suspected to have swallowed metal coins.
Their use, as part of a departmental guideline (for algorithm see Appendix 2) and along with staff
training, can effectively rule out or accurately localise swallowed metal coins 4.

Caution should be exercised when using HHMDs with smaller MFBs (such as pins or wires) and
in these instances; HHMDs cannot be used reliably exclude or localise a MFB, though if positive
a MFB is likely to be present. For button batteries and magnets, a chest x-ray is required as
these are more likely to have complications if missed.
REFERENCES 1. Crysdale WS, Sendi KS, Yoo J. Esophageal foreign bodies in children:
15 year review of 484 cases. Ann Otol Rhinol Laryngol 1991; 100:320-
324.
2. Tucker JG, Kim HH, Lucas GW. Esophageal perforation caused by
coin ingestion. South Med J 1994; 87:269-272.
3. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and
spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med
1995; 149:36-9.
4. Lee J, Ahmad S, Gale C. Detection of coins ingested by children using
a handheld metal detector: a systematic review. Emerg Med J 2005;
22:839–844.

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RELATED None
DOCUMENTS
AND PAGES
AUTHORISING Children’s Emergency Department Governance
BODY

SAFETY Be aware that metal detectors cannot reliably exclude small non-coin metallic
foreign bodies such as wires or pins. High-risk objects such as batteries and
magnets require further imaging.
QUERIES AND ED consultant/middle grade
CONTACT

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Appendix 1 - Metal Detector Technique
All metallic objects, for example jewellery, are removed. Non-removable metal, for example
fillings and sternal wires, are noted. Children stand upright or are held by their parents with their
trunk extended (fig 1).

Figure 1.

The metal detector is checked on a metallic object and then passed from the level of the
nasopharynx, moving caudally down the chest and abdomen, to the symphysis pubis in the
midline. Scan again in two more vertical lines to the left and right of the midline, so that all 9
regions of the abdomen are scanned. Finally, this is repeated posteriorly from the level of the
nasopharynx to the sacrum, again in three vertical lines.

A positive signal gives a visual and auditory alarm. An oesophageal metallic foreign body is
indicated by a positive signal when any part of the metal detector is above the xiphisternum,
with a positive signal below this level considered indicative of location in or distal to the
stomach. An equivocal signal is reported where the examiner is unable to definitely allocate the
positive signal as above or below this level.

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Appendix 2 - Algorithm

Child with suspected

metal coin ingestion

Scan with HHMD

Ensure metal sources

Reassure and are removed**
discharge Coin is in the
Scan anterior neck, Neck:
To return if HHMD chest and abdomen
symptomatic* -ve Refer to ENT
Scan posteriorly down
to sacrum

HHMD +ve Coin is below

the Neck:
Coin is in the Attempt to
abdomen Refer to
Below localise coin surgeons
xiphisternum

Above
xiphisternum or
unsure

Request X-Ray
Coin is below the Coin is above the
diaphragm Note position on diaphragm
request form if able
Coin not seen

Reassure and Ensure metal Consider

discharge with sources are Aluminium foreign
advice to come removed** body – discuss with
back if ENT/surgeons
Re-scan Re-scan
symptomatic* Negative Re-Scan with Positive

HHMD Discharge ED clinic

review 5/7

*Symptomatic Children: **Metal sources:

• SOB; • Jewellery/piercing;
• Severe abdominal • Metal on parents if
pain or distension; being held;
• Drooling or vomiting. • Buckle, belts;
• Wall fixtures.

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