Everyone who has spent any time around an infant, toddler, or preschool-aged child knows that the number one job two little hands have is to pick things up and put items in the mouth. The important events in a child’s life and normal childhood development is summarized in the Erikson’s psychosocial stages summary chart. The first stage is the oral-sensory stage describing from birth to 12 months, where for the first 6 life is pretty much about eating and sleeping, while the second 6 months the most prominent activity is teething and biting. As a pediatric ENT specialists, we have the skills and privilege of taking care of one of the most concerning problem in children, the removal of foreign bodies and/or food items from the windpipe (trachea) or the large branch on either side (main bronchus) when they choke and aspirate or inhale these things into the airway.  Another common problem ENT specialists see  is foreign bodies, like coins, being swallowed by young children and then it’s “stuck” in the most upper part of the esophagus right below the natural upper esophageal sphincter (so it “holds” the item there”.

If you are lucky enough to sit next to me on a plane ride, and we strike up a conversation (almost always unless you slept the entire flight and clearly do not want to talk), I will likely have shared with you what the top food and nonfood choking items are for children from my line of work.  If you are holding an infant in your lap during this flight, I am afraid you will get this chat sometime between my telling you how cute your baby is, then how cute my Claire is, and before we land.

Before I list the major choking hazards, here is why babies choke/cough and may aspirate. The first molars (large teeth in the back of the jaw) do not even come in until age 3, so imagine your child eating a peanut, and since he/she does not have molars to chew such a hard item, it’s not well chewed and “mushed up”. Then, the sharp edges from nut chunks even after initial chewing will likely be difficult for he/she to handle during swallowing, leading to choking, coughing, and then risk of aspiration.  In order to cough, humans close their vocal cords, build up lots of pressure from the diaphragm muscle, and then the sudden opening of the vocal cords and violent push of the diaphragm upward rushes the air out of the windpipe at up to 25-35 miles per hour. This was a great design for human survival and safety so that whatever is trying to get into the windpipe other than air gets removed and “coughed” out, avoiding stuff getting into a one way system with no outlet. Anytime a person coughs, right after the big violent expelling of air, the body immediately follows that with a huge inspiration (sucking in of air) so the vocal cords or gateway/doors of the windpipe is wide open, and air is moving quickly into the airway to fill up our lungs again. By the way, whatever piece of objects/foods small enough to be carried by that force of airflow can then get “sucked” into the windpipe.

Top Choking Hazards -Food Items, for Children

  1. Mixed nuts

    Mixed nuts (Photo credit: Wikipedia)

    NUTS – Never offer any peanuts, tree nuts, cashews, hazelnuts, whatever the “nut” to a child under the age of 5 or 6.  Nuts require good and thorough chewing, and toddler and preschool aged children can’t do a good enough job of this. Also, in this day and age of so many kids with peanut and tree nut allergies, it’s simply better to avoid it all together. By the way, once aspirated into the airway, nuts are perhaps the worst items for us to remove because every minute it’s in the airway, it absorbs the natural secretions from the body and the oils from the nuts are released, causing more inflammation. By the time we get to the operating room and I am trying to get it out, the nut half crumbles and it’s a nightmare to get out every tiny piece. If we don’t remove it all, pneumonia is very likely.

  2. 2/365

    2/365 (Photo credit: @bastique)

    Popcorn – This is especially hazardous for children who have older siblings. It’s seems harmless and definitely is easy to microwave a bag of popcorn, and as everyone is enjoying this, so is the youngest child.  Unpopped corn kernels are round and hard, and just perfect to be aspirated into the airway.  The hard and irregular edges and texture of popcorn, before being thoroughly chewed, is definitely a hazard. I did not give Claire any popcorn until about age 5, and remember calling her preschool to discuss this concern when she came home with “popcorn art’.  If you must give a child popcorn, then be diligent and pick out every unpopped kernel before serving it. If anyone has a method or microwave recommendations to get every kernel popped without burning some of the popcorn, let me know please. 

  3.  Hotdog – likely the most common cause of choking related death in children.  I had a case during fellowship training in Chicago, of a 5 year old whose grandmother was
    English: A hot dog. Français : Un hot-dog.

    English: A hot dog. Français : Un hot-dog. (Photo credit: Wikipedia)

    serving him his favorite lunch, except he was holding it bunless and eating it whole.  One large chunk was then stuck behind his huge tonsils against the back wall of the throat, and then he could not spit it out nor swallow it (it was not even chewed yet). What a scary case, thank goodness he was able to breathe, get to the children’s hospital, we had him go to sleep with anesthesia, and as soon as I opened his mouth I shoved it up towards the center of the head away from his voice box/airway, intubated him (put a tube into the trachea through the vocal cords) to protect his airway, then wrestled the chunk of hotdog out of the center of his head.  You MUST cut the hotdog length wise, even quartered lengthwise, and then into tiny chunk. We try not to serve hotdog more than once every week, it’s considered an emergency food item in our house when I am not available and daddy needs to make something quick.  I will go ahead and confess I love the 1.50 Costco hotdog/drink combo, so this has nothing to do with my dislike for the item. But it is so unhealthy so that’s another issue altogether.

  4.  Hard candies of any kinds – M&M’s with peanuts/almonds/any nuts, lemonheads, gumballs, and pretty much ANY hard candy.  If it does not dissolve quickly once it

    Gumballs (Photo credit: grandmasandy+chuck)

    hits saliva, don’t’ give it. Children love “gummy” candy of any kind, and now there are all these fruit snacks. Again, I don’t have a magic age so you must use your best judgement. Same problem with lack of molars and coordination, let alone running around playing and yelling at siblings while with these items in their mouths. So many reasons why it sets them up for choking and coughing and risk of aspirating.  Oh, also bad for their teeth anyways.

  5.  Raw vegetables – I share in A Healthier Wei that growing up in Taiwan, we never ate raw vegetables. Asians believe in warm foods helping with digestion, while cold
    080410 carrots

    080410 carrots (Photo credit: Dan4th)

    foods decrease blood flow to the digestive track since blood vessels constrict so I never ate a raw cucumber slice, carrot, broccoli, or knew the word crudité until many years arriving immigrating to the U.S. and well into my college years away from home. I have removed chunks of raw carrots from the windpipe of a toddler. I am not trying to change the well accepted Western culture and love of salads and raw vegetables, except to tell you that for the same reasons discussed above, chunks of hard carrots, and bits of broccoli are simply too hard for toddlers to handle. I even tell mom’s to make sure apple slices are thin, else your kid may choke on them all the same due to the harder texture. I am a huge fan of cooked vegetables so that they are soft. Look, you don’t see Gerber making small containers of raw vegetable and selling them as Stage 2 or 3 foods for a reason. Remember that ranch dressing is not good enough reason to serve your toddlers hard crunchy veggies (Claire could probably drink ranch dressing from a bottle ….)

  6. Round spherical foods – most moms now know to cut grapes into at least halves if not quartered for obvious reasons. Small blueberries are probably okay for toddlers since they’re usually pretty soft upon the first chew.
  7. CDC edamame

    CDC edamame (Photo credit: Wikipedia)

    Edamame/soybean.  My fellowship director showed me pictures and shared with me a story from years again in Chicago, when he saved a child who fell into the soybean silo on the farm, and “drowned” in soybeans. He had to remove several soybeans from the airway. Imagine these soybeans expanding as they absorbed the natural moisture in the windpipe, and again, suffocating the child by blocking his/her airway. While we all love edamame, again due to its texture/shape, not as good to give to younger children despite its great nutrition profile.

I have a “story” or case for just about anything, so the key is that even if a food item is not on this list, you must use your judgement. Last year, a 10 months old baby came into our emergency department with history of noisy breathing for almost a week and decreased eating/drinking. When I took him to the operating room and did a bronchoscopy (rigid tube/camera) to look into his airway, there was nothing there but a weird bulge from the back wall of the trachea (the muscular parting wall that separates the trachea from the esophagus), so I did an esophagoscopy and wow, I spent the next 30 minutes removing ground beef, pieces of chicken with cartilage on it, popcorn pieces, and all that had been stuck in the esophagus since this baby can’t possibly handle these foods.  I have learned through my career that even though I may assume it’s common sense not to feed a child or a certain age certain items, real life is such that caretakers may offer all kinds of foods without realizing the risk or hazards. Of course the kids may feed themselves these items as they are able to reach them. I can imagine that when a family has multiple children, it is hard to deny the youngest any of the items everyone else is enjoying.

Next blog will be the top non-food items, stay tuned.

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Dr. Julie Wei is a pediatric ear, nose, and throat specialist and the author of A Healthier Wei. As a mother herself, Dr. Wei is a passionate advocate for improving children's health through better diet and dietary habits. She has been committed to helping parents learn how to eliminate their child's ear, nose, and throat problems simply by reducing excessive sugar and dairy intake, as well as minimizing habitual late night snacking. She hopes to raise awareness for the need for accountability by both medical professionals and parents to ensure that children are not prescribed or take unnecessary medications long term.

When she is not in the clinic, operating room, or conducting research, you will find her in the kitchen preparing food with love along with her daughter Claire. If you sit next to her on the plane, she will likely share with you information about how to minimize choking hazards in young children, and many other tips for improving your child's health.