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  Health Information Center  :  I  :  Infant Care

 Preventing Choking in Children

 


In what ways can objects get into a child's body?
Foreign objects can get into a child's body through three routes:

  • Inhaled: through the larynx (voice box), trachea (windpipe) and bronchi (main airways to the lungs)
  • Ingested: through the esophagus (food tube) and stomach
  • Inserted: through the nose and ear

The most serious situation occurs when a child inhales a foreign object. The object can completely block (obstruct) the larynx or trachea, which can lead to choking.

How common is choking?
About 3,000 people die per year from choking. This figure has remained unchanged in the last 20 years. However, there has been a progressive decline in the childhood deaths from choking. In 1968, 650 children died from choking; in 1990, the figure dropped to 261 children.

Why are children more susceptible to choking?
Children are at higher risk for choking for several reasons:

  • Toddlers have few teeth and cannot chew well.
  • Their swallowing mechanism, which helps them naturally swallow, is not fully mature.
  • Toddlers lack an understanding of what is edible and may mistake foreign objects for foods.
  • They often explore their environment by placing objects in the mouth that can be potential choking hazards.
  • Young children are often easily distracted or playful while eating. This activity can lead to poor chewing or the jarring of food back into the throat.

What types of objects are the most hazardous?
Small, globe-shaped objects are particularly hazardous, though any small object can cause choking. Materials that can conform to the shape of the throat, such as plastic bags and balloons also pose a risk. A partial list of potentially dangerous objects includes:

Foods

  • Hot dogs (cut into rounds)
  • Candies and nuts
  • Grapes
  • Raw peas, beans
  • Peanuts, popcorn, marshmallows

Household items

  • Balloons (broken and uninflated)
  • "Button" batteries (such as for watches and cameras)
  • Marbles
  • Small game or toy pieces
  • Buttons
  • Coins, tokens
  • Beads
  • Jewelry
  • Eraser caps
  • Foam packaging "peanuts"
  • Diaper foam

How can I keep my child safe from choking?

Prevention
The Consumer Product Safety Act (1979) bans objects that pose a choking risk. The small parts test fixture (SPTF) is used to gauge the safety of small objects. Objects that can fit into a cylinder that measures 3 centimeters (cms) in diameter by 2 to 5 cm deep fail this test.

Important ways that we can prevent choking include the following:

  • Educational outreach by physicians to parents, families, communities
  • Closer observation of infants
  • Greater attention to our children's eating habits and diet
  • Improved monitoring of the size, texture, and "chewability" of food

How can I know if my child is choking?
A child can choke to death within 2 to 5 minutes. Recognizing quickly that choking is occurring is critical. Signs of choking include:

  • Sudden respiratory distress (without crying or cough)
  • Clutching at the throat (older children)
  • Turning red in the face then ashen blue
  • Loss of consciousness from lack of oxygen (asphyxia)

If a child becomes unconscious, you can presume that he or she has a complete obstruction of the airway. If your child shows any of the signs listed above, begin first aid and call 911 immediately.

How do I begin first aid?
Recommendations for what to do in cases of choking are provided by The American Academy of Pediatrics, the American Heart Association, and the American Red Cross. Children of different ages require different procedures. The following guidelines reflect these recommendations.

Children under 1 year of age

1) Place the infant face down on your forearm.
2) Keep the baby's head down at 60 degrees and stabilized. (If the head bends too far back, the air passages can become blocked.)
3) Using the heel of your hand, deliver 4 blows to the back, between the shoulder blades.

If the infant is still not breathing:

4) Turn the infant onto his or her back on a firm surface.
5) Using two fingers, give four rapid chest thrusts over the lower breast bone (sternum).

If the infant is still not breathing:

6) Grasp both the tongue and lower jaw between the thumb and finger and lift (tongue-jaw lift).
7) Look inside the mouth for the foreign body. If you can see the object, remove it by a sweep of your finger. (Do not put your fingers in your child's mouth if you do not see the object.)
8) If your child is not breathing, begin mouth-to-mouth resuscitation. Place your mouth over your baby's nose and mouth and give 2 breaths.
9) Repeat all previous steps

Small Children (1 to 8 years)

1) Place your child on a firm surface.
2) Kneel at your child's feet.
3) Place the heel of your hand below your child's sternum.
4) Place your second hand on top of the first.
5) Press into the abdomen with an upward thrust. Repeat 6 to 10 times.

If your child is still not breathing:

6) Perform tongue-jaw lift.
7) Look into the mouth for the foreign body.
8) If you can see the object, remove it with a finger sweep.

If your child is still not breathing:

9) Give 2 breaths mouth to mouth.
10) Repeat all previous steps.

Older children (8 years and up)

1) Treat a child 8 years or older as an adult.
2) Perform the Heimlich maneuver: Grasping your child from behind (in a bear hug), place your hands just below the lower ribs and deliver upward thrusts at a 45-degree angle. The thrusts should force air out of the chest and into the narrow passageway, dislodging the object. The Heimlich maneuver can be performed with the child standing, sitting or lying flat on his or her back on a firm surface. Place both of your hands just below the ribs and thrust upwards.

When should I NOT give first aid?
You should not perform first aid if your child is:

  • Coughing
  • Gagging
  • Clearing his/her throat

These are signs that the object is only partially blocking the airway. In these cases, first aid can lead to complete obstruction.

When there is an incomplete obstruction:

  • DO NOT probe the throat with your fingers
  • DO NOT give mouth to mouth
  • DO NOT slap your child on the back
  • DO NOT do the Heimlich maneuver

What are the most common types of objects that cause obstructions?

  • Vegetable matter (55% to 95% of cases)
  • Peanuts (7% to 58%)
  • Carrot pieces, beans, sunflower seeds
  • Metal objects (5% to 15%)
  • Plastic toy parts (5% to 15%)
  • Stones, bones, glass

If the object gets past the throat, where does it go?
Most objects pass through larynx and trachea and lodge in the right, mainstream bronchus (a main airway of the lung). Many of these objects are large, irregular, or sharp. In 5 percent of cases, the object can open the voice box.

How can I know if my child has taken in a foreign body?
Physicians look for a number of signs and symptoms to determine if a foreign object has been inhaled or ingested. Inhaling (aspiration) that causes coughing, gagging, and choking is the first indication. However, the lining of larynx and trachea can adapt to the object. There may be no symptoms for a period of time, after which the child may have:

  • Fever
  • Cough
  • Asthma
  • Bronchitis
  • Pneumonia

How can a physician diagnose the problem?
First, the physician will ask about the child's medical history and perform a physical examination. Symptoms can vary depending on where the object lies. Some children may be quiet and comfortable, while others have symptoms of respiratory distress. A serial exam (12 to 24 hours) is often needed.

When are chest X-rays needed?
Chest X-rays sometimes can help the physician make the correct diagnosis. In up to 40 percent of the cases, the physical examination will not identify the problem. In addition, less than 50 percent of the cases show the hallmark signs of a foreign body in the airway.

However, most inhaled objects don't show up on X-ray. Signs on the X-ray are often subtle. Twenty-five to 50 percent of children have normal X-rays.

How are foreign bodies removed?
First, your physician will consider the severity of your child's condition to determine how to proceed. Foreign bodies are removed using endoscopic procedures. A number of steps are taken to prepare for this procedure.

1) Your physician may consult with a number of specialists, including an anesthesiologist (a physician who administers pain medication) and an endoscopist (a physician who specializes in using an endoscope). An endoscope is a slender tube that is fitted with a fiberoptic camera. It is passed through the mouth and down the throat and enables the physician to view the passageways.
2) Equipment including a laryngoscope, bronchoscope, and forceps are gathered

Anesthesia

3) The appropriate type of anesthesia is determined. (General anesthesia is preferred). Although a mask is placed over the child's face, the child still breathes.
4) The endoscopist performs laryngoscopy. A laryngoscope, a device similar to an endoscope, is passed through the mouth and can be used to view the area from the pharynx to the larynx.
5) The endoscopist then uses a rigid ventilating bronchoscope, a slender device similar to the endoscope, to view the larynx, trachea, and bronchi.
6) Anesthesia (pain killer) is given through the bronchoscope. (The child is continuously monitored.)

Extraction

7) Forceps are selected to fit the object and passed through the bronchoscope.
8) Removing the objects requires a light touch. The physician is careful not to break up the object or push it further back into the throat.
9) The physician may require several tries before extracting the object. Mask ventilation resumes after the object has been removed.
10) The endoscopist views the airways again. Additional objects are found in 5  to 20 percent of the cases.
11) Opening of the chest wall is rarely needed.

Can bronchoscopy cause any complications?
Complications are rare, but they can occur, and include:

  • Collapsed lung
  • Under-inflated lung
  • Pneumonia
  • Retained foreign body
  • Swelling of airway
  • Brain injury from lack of oxygen

Conclusion
Little children are prone to choking. Prevention is the best cure. It's important to recognize when your child inhales or ingests a foreign body so that prompt treatment can be given. Apply first aid only when your child's airway is completely obstructed. Keep in mind that the child's medical history, physical examination, and X-rays do not always prove that a foreign body is present. Endoscopy can help the physician locate and remove an object, but should be performed by an experienced team of physicians.





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