Choking Prevention for Infants and Young Children

Choking prevention guidelines to share with parents and caregivers

popcorn with choking warning label

Choking on food causes the death of approximately 1 child every 5 days in the United States.

American Academy of Pediatrics (2020)

Pediatricians, dentists and other health-care providers should increase their efforts to provide parents and caregivers of young children with “choking-prevention counseling as an integral part of anticipatory guidance activities” (AAP, 2020). Texas Health Steps also promotes anticipatory guidance about ways to prevent a child from choking on a foreign object. Following are general guidelines to share as part of anticipatory guidance.

The following high-risk foods should be kept away from children 3 years and younger:

  • Hot dogs
  • Nuts and seeds
  • Chewing gum
  • Hard candy
  • Gooey or sticky candy such as a caramel
  • Chunks of meat or cheese
  • Whole grapes, cherries and cherry tomatoes
  • Hard fruit with peels, like apples
  • Popcorn
  • Chunks of peanut butter
  • Chunks of raw vegetables like carrot sticks
  • Chips (potato, corn and tortilla) and pretzels
  • Marshmallows

Such foods should not be introduced into a child’s diet until the 4th birthday or later.

Breastfeeding and introducing complementary foods

All major health organizations recommend:

  • Breastmilk as the sole source of nourishment through 6 months of age, with continued breastfeeding for at least one year to two years of life.
  • Breastfeeding to begin immediately after birth, with the introduction of appropriate complementary foods at about 6 months of age.

Those organizations include:

  • Academy of Nutrition and Dietetics
  • American Academy of Pediatrics (AAP)
  • American Academy of Family Physicians (AAFP)
  • American College of Nurse-Midwives (ACNM)
  • American College of Obstetricians and Gynecologists (ACOG)
  • American Public Health Association

The World Health Organization (WHO) recommends continued breastfeeding through the child’s second year and beyond.

The following mealtime supervision guidelines are recommended for parents and caregivers of children 3 years and younger:

  • Always supervise mealtimes. Never leave a young child alone with food.
  • Young infants should eat pureed foods.
  • Once older infants can sit up on their own, then soft foods can be cut into small pieces no larger than one-half inch.
  • Encourage children to chew food well. Insist that children sit down while eating.
  • Children should never run, walk, play or lie down with food in their mouths.

The following high-risk nonfood items should be kept away from children 4 years and younger:

  • Coins
  • Buttons
  • Toys with small parts
  • Toys that can fit entirely in a child’s mouth
  • Small balls, marbles
  • Small hair bows, barrettes, rubber bands
  • Pen or marker caps
  • Small button-type batteries
  • Refrigerator magnets
  • Pieces of dog and cat food
  • Balloons, including those that are uninflated or broken (a hazard for children through 8 years of age)

Paper tube as measuring guide

If a toy part or other item fits inside of a paper towel tube, it is too small to be given to a child 3 years old or younger. Such a small object can cause choking if it gets stuck in the airway.

The following counseling guidelines are recommended for parents of children 3 years and younger:

  • Check under furniture and between cushions for small items that children could find and put in their mouths.
  • Remove loose parts from toys, such as eyes and buttons from dolls, wheels from cars and loose screws.
  • Toys are designed to be used by children within a certain age range. Age guidelines take into account the safety of a toy based on possible choking hazard. Don’t allow young children to play with toys designed for older children.
  • Be aware of older children’s actions. Many choking incidents are caused when an older child gives a dangerous toy or food to a younger child.
  • Keep purses, toolkits, craft baskets and other catchall containers out of reach of young children.

Refer parents and caregivers to the Texas Department of State Health Services (DSHS) for more information about toy safety. The DSHS Hazardous Products Program works with the U.S. Consumer Product Safety Commission (CPSC). DSHS offers a web page with safety suggestions for buying toys. Find links in this course’s Appendix of Resources for Health-Care Providers.

Case Example

portrait of toddler boy
Owen 30 months

Anticipatory guidance about choking

Owen is in your office with his father for his 30-month Texas Health Steps preventive medical checkup. Owen is happy as he chews a snack and sits on his father’s lap. You notice he is eating whole grapes from a small bag his father holds for him.

Whole grapes should not be fed to children ages 3 years and younger, even when they are supervised. You begin the checkup with anticipatory guidance about choking hazards for very young children.

Physician: I see that Owen is having a snack.

Father: Yes, he loves fruit, especially grapes.

Physician: I’m glad to know that Owen likes healthy food. Unfortunately, grapes and other foods like apples and carrots that are not cut into small pieces could cause him to choke.

Father: Oh really? I thought as long as he eats fruit and vegetables he will be healthy.

Physician: Let me show you why whole grapes and other small objects are dangerous for young children like Owen.

You take from a drawer a see-through bag that contains a small plastic construction toy, buttons and coins, a hearing aid battery, a broken crayon, a marble, a pen cap, a torn balloon, and magazine photos of carrot sticks, grapes, apple slices and bowls of dog and cat food. You also bring out an empty paper towel tube.

Physician: Do you see how all of these objects are small enough to fit inside this paper tube? That means they are too small to be around babies and young children because they can get stuck in their throats and cause them to choke by blocking their airway. You’re a parent so you know how much babies and toddlers like to put things in their mouth.

Father: I knew that tiny toys and things like buttons were not safe but I guess I didn’t realize so many food items can be dangerous. I thought Owen could chew them.

Physician: I can give you a list of foods and other objects that could cause Owen to choke. It’s easy to lose track around a busy toddler, and we all need reminders. I can write down a few tips to help you keep Owen safe.

Father: Thank you. I sure don’t want Owen to choke.