For parents, the prospect of a truly choking infant or toddler is very distressing indeed. Those of us who have such an experience never forget it. All babies “swallow wrong” from time to time and sometimes appear to be choking but quickly clear their airway by coughing. The truly choking child cannot breathe or cough. This situation requires quick thinking and decisive action.  All parents and other caregivers should prepare themselves for this possibility by learning what steps to take.

In the case of a choking infant, the caregiver should not attempt to clear the throat with a finger, as this may push the food or object further into the airway. Instead, one should get into a sitting position and hold the child face down on one arm, supporting the baby’s head in the palm of the hand. The caregiver’s arm should be rested on the thigh, with the baby’s head positioned lower than the torso. With the baby in this position, one should strike a quick, firm blow to the center of the back, just below the bottom of the shoulder blades. If the baby coughs, the airway is clearing and no further action is required. If not, the blow should be repeated. If the baby is still not breathing or coughing after 5 blows to the back, one should call 911 and start CPR.

As babies grow, their bodies become too large for this process. The first step in such a case is to strike a firm back blow to the child in the sitting or standing position, supporting the upper body with the other arm. If, after 5 such blows, the airway is not clear, a slightly modified Heimlich maneuver is called for. Instead of standing, the caregiver should kneel on the floor with the child held standing and facing away from the caregiver. One’s arms should be wrapped around the child’s midsection just below the rib cage with one hand in a fist and the other wrapped tightly around it. The next move is a quick, firm upward and inward thrust of the fist. If the child is still not breathing or coughing, the thrust should be repeated until the food or other object is dislodged.  The National Institutes of Health suggests a “5 plus 5” approach, in which up to 5 back blows are followed by 5 abdominal thrusts. In any case, if the object is not cleared from the airway or only partially cleared so that the child is breathing with difficulty, 911 should be called immediately. The same is true if at any time the child loses consciousness. In the latter case, CPR should be initiated.

Parents can take simple steps to minimize the risk of choking.  In infants, pureed solid foods should not be given until at least 4 months of age.  Younger babies have not matured their swallowing sufficiently to accommodate even pureed solids. The American Academy of Pediatrics recommends that the following foods be kept away from children under 4:  hot dogs, nuts and seeds, chunks of meat or cheese, whole grapes, hard or sticky candy, popcorn, chunks of peanut butter, chunks of raw vegetables, and chewing gum.

There are also a number of choking hazard items that should be carefully kept away from babies and young children. These include coins, buttons, any toy or part of a toy small enough to fit entirely in a child’s mouth, small hair bows, barrettes, rubber bands, pen or marker caps, small button-type batteries, refrigerator magnets, and pieces of dog food. Latex balloons are especially hazardous. In the “popped” or uninflated state, they can go very quickly into a child’s mouth and be inhaled into the airway.

Taking these steps will prevent the vast majority of choking episodes. Doing so is an especially big challenge when there are older children around. These children should be taught as early as possible to keep small objects away from their younger siblings.

The American Academy of Pediatrics choking prevention document is on a single page and can be printed and posted as a reminder for parents. It can be easily accessed at healthychildren.org.