Foreign bodies of the esophagus are a common problem in children, with the majority of these foreign bodies being coins. Because there are various methods for managing esophageal coins, we retrospectively reviewed our experience of the past 4 years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990, 57 children were managed for esophageal coins in our institution. Nineteen children were managed endoscopically under general anesthesia, with a mean patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirty-eight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These were: (1) duration less than 24 hours; (2) no respiratory distress; and (3) no history of esophageal disease or surgery. Using these criteria, 16 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and cost-effective. A protocol for managing children with esophageal coins is presented, and the techniques of Foley balloon extraction and esophageal bougienage are reviewed.