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Coins are the most commonly ingested foreign body encountered in the pediatric population. Coins that are in the esophagus and are causing symptoms (cough, stridor, respiratory distress, drooling or pain) are managed with immediate removal via various methods. Asymptomatic coins have been a perplexing problem to the clinician for decades, with some advocating for immediate removal while others are proponents of ‘watchful waiting’.This article will provide a review of the current literature on management options for symptomatic and asymptomatic esophageal coins. The article will discuss clinical decision-making strategies for the diagnosis of the unwitnessed ingestion, as well as diagnostic studies, such as plain radiographs, as well as novel modalities, such as metal detectors. Discussion of the anatomic issues related to esophageal foreign bodies will be addressed. Treatment options for asymptomatic patients will be reviewed utilizing data from retrospective studies as well as a prospective randomized trial.In the symptomatic patient with an esophageal coin, immediate removal via endoscopy is recommended. For the asymptomatic patient with an esophageal coin, current data support expectant management for a period of 12–24 h with the hope of spontaneous passage and avoidance of general anesthesia and surgical procedure.