Choking in children

Dr B. J. C. Perera 
MBBS(Cey), DCH(Cey),
DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK),
Hony. FCGP(SL) 
Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

Choking in a little child is very definitely anyone’s worst nightmare. In medical terminology, the word ‘choking’ refers to the sudden onset of difficulty in breathing, produced by some sort of an acute obstruction to the airway, from within the lumen of the airway itself. Most commonly, it is due to some foreign material getting into the airway. Choking, as a medical problem, is more common in small children, mainly those under five years of age. However, it must be stressed that no age group is completely exempt from it. Most unfortunately, and quite sadly, some children have even lost their young lives due to choking.

Aspiration, which is the technical medical term for any kind of inhalation of foreign material into the airway, is the current day well-accepted cause of choking. It could be a toy, a piece of a toy, or various other small objects that young children habitually put in their mouths. It is not uncommon, especially in Western developed countries, for dire warnings to be issued forever about which household items and toys are choking hazards to small children. Some parents. and caregivers. carefully read the labels, listen to news reports, and do their best to be vigilant about what the little ones are sticking in their mouths. Yet, for all that, children being children, they are more than likely to put all kinds of things in their mouths, regularly.

However, many do not really appreciate that these potential hazards, that can lead to choking, could include some food articles as well. Since their airways are still small, the risk of choking on pieces of food are that much higher in young children. They are at risk because they do tend to swallow bits of food that are too large, and then those food articles might go the wrong way which can lead to choking. Accidents can easily happen even if the parents or caregivers are feeding the children or the children are eating by themselves. According to the American Academy of Pediatrics (AAP), food accounts for half of the choking incidents in small children.

To help prevent this, the AAP has highlighted which foods pose the biggest risk of choking to children under the age of four. In a very general sense, some of these food articles that have the potential to cause choking are as follows: –

Nuts

Children are more likely to choke on nuts as the nuts can easily get into little airways because of their size and shape. To add to this problem, tiny teeth might not be able to handle chewing whole nuts. The solution is to avoid giving them nuts altogether. Sometimes, the shells from the nuts can restrict airways, too. Before giving your child nuts, you should wait until they’re well over the age of four, can sit while eating, and have learned how to chew their food completely.

Candy and little sweets.

Hard candy, such as lollipops, apparently sends thousands of little ones to emergency medical facilities every year in the Western world. Even a small piece of a sweet or a small rounded sweet can get stuck in a child’s throat. The time-tested medical advice is not to give hard candy and even soft marshmallows to your child until they are over the age of five and can chew thoroughly.

Nice and rounded fruits like grapes

They are definitely a problem due to their size and slippery texture. They are a major choking hazard. Doctors suggest a no-grape policy for kids, under four, or cutting them into quarters before serving them to children. Similarly shaped foods, like cherries, should also be avoided at this age.

= Hot Dog type of food

These are notoriously bad from a choking point of view. Apparently, according to Johns Hopkins Medical facility in the USA, one of the biggest threats to children, under the age of three, is hot dogs; even if you cut them up. Choking on a small piece of hot dog can lead to hospitalization, if you are not careful. If you still want to give a small child a hot dog, make sure to cut it into very thin strips.

Meat and Cheese chunks

Like hot dogs, chunks of cheese and meat are difficult for growing toddlers to chew. Food should be carefully cut up so that it is no larger than half an inch or so, and the child should be supervised at all times while eating these foods.

Peanut Butter and all types of nut butter and seed butter

They can and do get stuck to the roof of the mouth and the throat. For kids under two, skip the globs of peanut butter and other types of nut butter. When serving to toddlers, spread a thin layer of it onto bread or crackers.

Chewing gum.

Chewing gum can cause dangerously sticky situations for small children. Many children are quite prone to try to swallow it or accidentally inhaling it while chewing. The standard advice is not to give chewing gum to small children at all.

 Vegetables and fruits.

Children run a higher chance of choking on pieces of fruits and vegetables. Vegetables should be cooked until soft, and cut into small pieces that are no larger than half an inch in size. It’s suggested to avoid stringy veggies, such as celery or string beans, altogether. Chunks of raw vegetables or fruits, such as carrots or apples, should be avoided until the children have learned to chew properly.

 Popcorn

Popcorn should not be given to children until they are at least four years old. Many toddlers have to visit the Emergency Departments of hospitals each year due to kernels getting lodged in their airways.

Bones in meat or fish

Even when covered by flesh in meat and fish, bones form a very important component of foods that can cause choking.The articles of food listed above have been formulated from a Western context. There must be a lot more articles that are important from a local perspective.

In the unfortunate scenario of a choking episode in a child, all of us must know what to do. One cardinally important principle is to realise that if the child is coughing, it is most important to encourage the child to keep on doing it. Coughing is a reflex mechanism of the human body, designed to propel extraneous elements out of the airway. It is most definitely a protective mechanism which is positively useful in cases of choking. We should never try to suppress the act of coughing in a choking child. A good and forceful cough might just about succeed in getting a foreign body out of the airway.

For a child, under one year of age, if there is a choking episode, the best way to dislodge the offending article is to administer some back blows. This is performed by giving up to five sharp back blows with the heel of one hand in the middle of the back between the shoulder blades, This has to be undertaken with the little baby being made to lie face down along the operator’s thigh or forearm.

For bigger children, a procedure called the Heimlich Manoeuvre or Abdominal Thrusts could be employed. It is done by standing behind the affected child. One has to make a fist with one hand and place it on the uppermost part of the abdomen above the navel and make a quick hard movement inwards and upward. It is thought to be successful in over 85 percent of cases. It can be repeated till the offending object is dislodged. This procedure increases the pressure within the chest and induces an artificial cough. However, Heimlich Manoeuvre is not recommended to be used in infants, under one year of age, because of the potential to cause some damage to the chest cage and some abdominal organs. Even in bigger children, some authorities advocate the use of back blows, followed by the Heimlich Manoeuvre.

In attending to a choking subject, time really matters. Very often it could be a matter of life and death. The quicker we intervene, the more likely it would be for us, to achieve a successful outcome.