by Heidi Green
March 25, 2010

Two-and-a-half-year-old Sam wants to do everything his older siblings do. He wants to play with the toys they play with. He wants to eat the foods they eat. He wants to handle the coins they do. As a parent, I know that is not always the best (or safest) decision. After all, choking caused by food, coins or toys is a common form of injury and death among children. It is the fourth most common cause of accidental death in children and, for those under one year, it is the most common cause. Approximately every five days, a child in the U.S. chokes to death while eating, and more than 10,000 emergency visits are due to choking on food by children 14 and younger. The risk of choking is highest among young children, with nearly 75 percent of choking episodes occurring in children under the age of 3.

In a new policy statement, Prevention of Choking Among Children, the American Academy of Pediatrics (AAP) highlights the risks and provides recommendations for parents, health care providers, and regulatory agencies.

Parents
To a large extent, children’s environments are created by their parents and other caregivers. It should come as no surprise that the AAP emphasizes the responsibility of parents to recognize and reduce risks.

• Parents should be especially wary of hot dogs, which, according to a widespread study, accounted for nearly one in five food-related choking fatalities among children under 10 years of age. Generally, it is good practice to cut food into small pieces for children.

• Parents should choose developmentally appropriate foods. For example, young children lack the necessary grinding motion for hard, smooth foods (such as raw vegetables) until about age four. (For more specifics, check out Dr. Sears’ list of risky foods.)

• Parents should always supervise their children when they are eating and encourage them to chew completely before swallowing.

• Parents should never allow their children to run and play while eating.

• Parents should avoid latex balloons, which have been associated with more than a quarter of choking deaths among children younger than 14 years old. Uninflated balloons and pieces of broken balloons can conform to the child’s airway and form an airtight seal.

• Parents should check for small parts when selecting toys for their children. Choose toys with parts larger than one-and-three-quarters inches in size, about the diameter of a toilet paper roll.

• Parents should keep their home clean, since young children explore their environments by putting even non-food items in their mouths. Coins, paper clips, and other small objects may cause choking.

• Because accidents and emergencies do happen, parents and other caregivers should take an infant/child CPR class that includes instructions about what to do if their child is choking.

Health care providers
Too many parents never think about choking prevention. Many do not understand the full scope of their children’s physical development (e.g., the anatomical development, gagging reflex, chewing and swallowing abilities) and how it relates to choking. Health care providers, coming into contact with infants/children and their parents on a regular basis, are in the perfect position to educate parents on this important topic. The AAP urges health care providers to include discussions of choking prevention in health care visits.

• Infant and child health care providers (including pediatricians, dentists, nurses and others) should provide choking prevention guidance to parents regularly, addressing foods, toys and the home environment.

• Health care providers should discuss which foods children are able to handle at different ages and developmental stages.

• Health care providers should address parents’ questions about toy selection and remind parents to be cautious about small toy parts, particularly those their young child may access because of an older sibling (e.g., advanced Lego blocks, Barbie doll shoes).

Regulatory agencies
The AAP details specific recommendations for the federal agencies charged with regulating toys and foods, namely the Consumer Product Safety Commission (CPSC), the Food and Drug Administration (FDA) and the Department of Agriculture (USDA). These recommendations aim to reduce children’s exposure to risky products. Several emphasize assessment and surveillance, since choking-related incidents have been poorly recorded. Many choking events, while dangerous, are transient and do not result in health care visits. Even when they do result in an emergency room visit, the specific cause may not be logged; for almost 10 percent of the choking incidents found in the national injury surveillance system, the cause is unknown. As a result, our understanding of the scope of the problem has been limited.

• The FDA should establish a process for assessing and addressing food-related choking risks, including enhanced surveillance and public education, including warning labels on foods that pose a high risk.

• The FDA’s authority should extend to choking risks of all foods, including meat (currently under USDA jurisdiction).

• The CPSC’s national injury surveillance system (NEISS) should collect more information about food-related choking.

• The CPSC should increase efforts to identify toys that pose choking risks and ensure they have appropriate warning labels.

• The CPSC should work with manufacturers to improve recalls of products that pose choking hazards.

• The CPSC should increase efforts to prevent the resale of recalled items via online auction sites, such as eBay.

Keep kids safe
Regulatory changes may be a long time coming; it’s hard to imagine the all-American hot dog being reintroduced in a new shape. Even if such changes do pass, toys and foods that pose risks to our children may still make their way into our stores. It is a relief to know that there are many steps that parents and caregivers can take to reduce children’s risk of choking. Many are common sense, and all take relatively little effort. Parents can check age-recommendation labels when shopping and be aware of small pieces when selecting toys. Recognizing that food can pose at least as great a choking risk as toys, parents can start by educating themselves on the risks, preparing and cutting up foods as needed, and keeping a watchful eye during dinnertime and playtime alike.

To encourage the support of the AAP’s recommendations for additional surveillance and assessment of risky products, parents can contact state and federal legislators or regulatory agencies—CPSC, FDA, and USDA—directly. Go for it!

Heidi Green has been researching and writing about women’s and children health since she moved to Pittsburgh more than 10 years ago. She is also a children’s book reviewer in her spare time. She is mom to Ben, Katie, Sam, and Max.