In 2017, approximately 130 children younger than age 15 years died as the result of a choking episode; most of them were younger than age 3 years.1 It is much more problematic to estimate nonfatal choking episodes, as most self-resolve and do not come to medical attention. Those that do come to medical attention are likely to be the most serious. The US Consumer Product Safety Commission (CPSC), through its National Electronic Injury Surveillance System, conducts studies of incidents presenting to emergency departments across the country.2 In 2001, there where an estimated 17,537 children age 14 years and younger who presented to an emergency department for a choking episode.3 More than one-half were treated for a choking episode related to food, one-third for nonfood items, and the remainder unknown.3 Two large categories of offending objects are coins (13%) and candy/chewing gum (19%). Coin-related choking is well known to general pediatrics and emergency medicine physicians, and the majority of incidents result in coins being swallowed and passed through the gastrointestinal (GI) tract, although lodging in the esophagus and airway does sometimes occur.
Children who are younger than age 3 years are generally more at risk of choking than older children, with highest rates of choking among infants.3 Infants and young children are vulnerable based on several developmental factors, including immature approach to eating and chewing. They are learning how to eat, which means developing skill in knowing the amount of food to put in the mouth, thorough chewing, and speed of eating. A young child's exploratory nature leads them to place objects in their mouths frequently. An additional anatomic risk is the relative small size of a child's airway compared to an adult's. If an airway obstruction does occur, a child is less able to generate the kind of forces necessary to unblock the airway; their coughs are less effective than older children and adults.4 Lastly, behavioral factors put children at risk, including the fact that they are distractible and not as likely to concentrate on their eating as adults do. Children with neuromuscular disorders or developmental delay who have altered swallowing mechanisms are at even greater risk of aspiration.
The size and shape of objects a child may access are also risk factors. Certain types of food present more of a choking risk than others. Hot dogs account for the largest category of fatal food-related choking events (about 17%).5 Hot dog slices are a perfect shape and size to conform to, and therefore block, the airway. They are cylindrical and compressible and, therefore, can become wedged tightly into a child's hypopharynx. Other high-risk edible items include grapes, chewing gun, popcorn, nuts, and hard candy.6
What To Do if a Child Is Choking
All parents should be trained in infant and child cardiopulmonary resuscitation (CPR), including basic response to choking. An infant (a child younger than age 1 year) is choking when they are struggling to take a breath and making no crying sounds. They may become weak or cyanotic. The rescuer(s) should immediately summon the emergency response team (ie, call 911) and look in the mouth for an object that, if visually present, should be removed manually. If there is no removable object, then the rescuer should position the infant's face and torso prone with the body at a 30° angle, supporting the chest by the palm and arm and supporting the head with their hand. Five rapid and forceful blows to the back between the shoulder blades should be delivered, and then the infant turned face up and given five rapid chest compressions in the center of the sternum immediately below the nipple line. These cycles should be repeated until the object is dislodged or until consciousness is lost. A blind sweep of the mouth with one's fingers should not be attempted.
If there is loss of consciousness, CPR should be initiated.7 Older children who choke and have no cough and are unable to talk or make noise should receive abdominal thrusts (ie, Heimlich maneuver) to remove the obstruction. This requires standing directly behind the child and placing both arms around the patient's waist. The rescuer should make a fist with one hand grab the fist with the opposite hand, positioning the hands immediately above the child's umbilicus. Fast upward and inward abdominal thrust should be performed until the obstruction is removed or the child becomes unconscious. If loss of consciousness occurs, then CPR should be initiated.7
Children and infants who present with a concern of a choking event who are not in extremis (as described above) raise the primary diagnostic question of whether the foreign body was aspirated into the airway or was swallowed and present in the GI tract. Aspirated foreign bodies usually cause respiratory symptoms, but esophageal foreign bodies can also result in such symptoms due to compression on the trachea. Symptoms vary depending on the location of the foreign body within the airway. There may be stridor and hoarseness with laryngeal foreign bodies, and coughing, wheezing, and diminished breath sounds with lower airway (bronchi) foreign bodies. With any degree and type of symptomatology, radiographic imaging is key in diagnosis. Traditional imaging approach involves obtaining a chest radiograph to include inspiratory and expiratory films, as many aspirated objects will be radiolucent.8 Findings consistent with an aspirated foreign body are air trapping due to partial or complete bronchial obstruction. On the side with the obstruction, there will be hyperexpansion of the lung field and the possibility of a mediastinal shift to the contralateral side.9 Because infants and toddlers are not often able to cooperate well enough to obtain inspiratory/expiratory radiographs, right and left decubitus views can be utilized. There is currently a movement towards use of computed tomographty (CT) as the primary imaging modality in the diagnosis of aspirated foreign bodies. CT is reported to be 100% sensitive in this situation and has the advantage of determining the exact location of the foreign body as well as visualizing any complications such as bronchiectasis or atelectasis.10 Known details such as these can decrease operative time spent for removal by rigid bronchoscopy, which is the definitive treatment for an aspirated foreign body.
Pediatricians should give appropriate anticipatory guidance to parents about not giving children solid foods prior to age 6 months and that children should be given foods appropriate to their age and developmental stage after that. Before a child's molars erupt (age 3 or 4 years) children are able to use their incisors to bite off a piece of food but they will not be able to adequately chew it. When the molars start to erupt in children, they will be at risk for a time of choking on food as they are learning to chew.
The American Academy of Pediatrics has long advocated for public education through required warnings on packages, regulatory interventions, and voluntary recalls on products revealing a choking risk.6 The Child Safety Protection Act and Consumer Product Safety Improvement Act require warning labels on packaging for products that contain small parts and bans any toy made for use of children younger than age 3 years if it poses a risk of aspiration or choking.11 A small part is defined as any object that will fit into a test cylinder that is 2.25 inches long and 1.25 inches wide. This dimension approximates the size of fully expanded throat of a child younger than age 3 years. A part can be a whole object, such as a toy, a part of a toy or game, or a piece of an object that breaks off during testing. The CPSC issues recalls routinely for toys and other objects that present a choking risk to children. A review of the CPSC website ( https://www.cpsc.gov) reveals that hundreds of products are recalled every year. More comprehensive national legislation aimed at preventing choking has been introduced for several years but has never been enacted.
- National Safety Council. Preventable injuries and injury-related deaths in homes and communities. https://injuryfacts.nsc.org/home-and-community/home-and-community-overview/introduction/. Accessed August 16, 2019.
- United States Consumer Product Safety Commission. Research and statistics. https://www.cpsc.gov/Research--Statistics/NEISS-Injury-Data. Accessed August 16, 2019.
- Centers for Disease Control and Prevention. Nonfatal choking-related episodes among children: United States, 2001. MMWR Morb Mortal Wkly Rep. 2002;51(42):945–948.12437033
- Foltin GL, Tunik M, Cooper A, (eds). Teaching Resources for Instructors in Prehospital Pediatrics (TRIPP): Respiratory Emergencies. Vol. 2. New York, NY: Center for Pediatric Emergency Medicine; 1988.
- Harris CS, Baker SP, Smith GA, Harris RM. Childhood asphyxiation by food: a national analysis and overview. JAMA. 1984;251(17);2231–2235. doi:10.1001/jama.1984.03340410039029 [CrossRef]6708272
- American Academy of Pediatrics. Committee on Injury, Violence and Poison Prevention. Policy statement-prevention of choking among children. Pediatrics. 2010;125(3):601–607. doi:.20176668
- United Medical Education. BLS algorithms and training 2019 (basic life support). https://www.acls-pals-bls.com/algorithms/bls/. Accessed August 16, 2019.
- Maraynes M, Agoritsas K. Inhaled foreign bodies in pediatric patients: proven management techniques in the emergency department. Pediatr Emerg Med Prac. 2015;12(10):1–16.
- Heyer CM, Bollmeier ME, Rossler L, et al. Evaluation of clinical, radiologic, and laboratory prebronchoscopy findings in children with suspected foreign body aspiration. J Pediatr Surg. 2006;41(11):1882–1888. doi:. doi:10.1016/j.jpedsurg.2006.06.016 [CrossRef]17101364
- Bai W, Zhou X, Gao X, et al. Value of chest CT in the diagnosis and management of tracheobronchial foreign bodies. Pediatr Int. 2011;53(4):515–518. doi:. doi:10.1111/j.1442-200X.2010.03299.x [CrossRef]
- US Consumer Product Safety Commission. Child safety protection act fact sheet: CPSC document #282. https://childsafetycentral.com/Child-Safety-Protection-Act-Fact-Sheet.htm. Accessed August 16, 2019.
- Child Safety Central. Avoiding choking hazards in children's toys. https://childsafetycentral.com/toy-choking-hazards.html. Accessed August 19, 2019.