Choking: An under-acknowledged & leading cause of accidental death in kids under 3.

My little human is almost two now.  I’ve spent the past year trying very hard to live and let live when it comes to other peoples parenting styles (the first year I was admittedly all knowing and too judgy).  But there are some things, as a nurse and a CPR/first aid instructor, that I have a really hard time biting my tongue about.  The big one, lately, has been choking hazards.  I’m having an especially hard time with this topic because toddlers want what other toddlers have.  So when another parent doesn’t see the harm in letting their toddler play with a certain toy, or eat a certain food, I’m in a hell of a pickle trying to pry what I perceive as a threat to my child’s safety from her greedy little hands, while explaining my rationale to the parent without sounding arrogant or judgmental.  It usually just turns into a battle with my own kid that results in having to move away from the area or engage in a constant game of distraction (which takes all the fun out of getting to hang out with other moms), because a two year old doesn’t understand why her friend gets to do something that she doesn’t.   I’m sure those of you who have kids with allergies smell what I’m stepping in here.

Reflecting on the past year and a half as a mom, I’ve realized that we’ve received virtually zero education about preventing choking; be it toys to avoid, ways to prepare certain foods or the pathology of what makes one item/food more of a hazard than another.  I’ve also found, that when I’m with friends of toddlers, they seem surprised when I tell them a specific thing is a big risk (i.e. hot dogs, grapes, latex balloons).  I can account for my family not receiving education from our pediatricians – the assumption on the doctors end being, “mom’s a nurse, she knows this already”.  But it doesn’t account for the lack of education being delivered to my friends who are not medical.  Aside from maybe the handouts we’re given at every well visit (that most people leave on the floor of their car for eternity and are NOT reading), it seems no one is seriously talking about choking.

I get it.  No one likes to talk about babies dying.  It’s a really shitty topic.  But it does happen, and it’s probably one of the most devastating and traumatic topics on the planet.  But I’m going to do it, because addressing uncomfortable topics can sometimes help avoid said topics from happening.

Disclaimer:  The resources for the following data are abundant.  If you’d like citations, I’m not providing them.  This is a blog, not an academic journal article.  Please familiarize yourself with Google search.

So here goes…

Choking accounts for about 30% of accidental deaths in children under 3.  The following are items/foods are some of the most common culprits, as well as what I, as a parent have encountered the most often in the past 24 months.

Let’s start with latex balloons.

1/3 of choking deaths are caused by the inhalation of a latex balloon or a piece of a latex balloon.  I regularly witness people allowing their infants and toddlers to play with balloons, and my heart races with anxiety the entire time (birthday parties have become terrifying).  When the other parent is a stranger, I try to bite my tongue.  I try to play it cool.  But they look at me like a crazy person when I repeatedly take balloons away from my own child.  My child is not allowed to hold a balloon anywhere near her face, nor is she allowed any aggressive play that may cause one to pop.  Since mouthing, squeezing and poking at a balloon pretty much defines “playing” with a balloon for most 2 year olds,  my kid just isn’t allowed to play with latex balloons period.  That’s my rule.  When she is old enough to be compliant with the rules that balloons are only to be looked at and dragged along by a ribbon, she can have a balloon.   But even then, there will be rules.

Unlike toys with small parts whose choking risk decreases dramatically after a child’s age of 3, the risk of choking death related to inhalation of a latex balloon remains high all the way up until the age of 8.  Small kids tend to choke on popped balloon pieces, where as older children tend to accidentally inhale entire balloons when attempting to inflate them.

Balloons are dangerous because when inhaled, the flexible and stretchy properties of the material conform to the shape of the airway and become virtually impossible remove.  No number of back thrusts or Heimlich maneuvers can dislodge it.  In conforming to the shape of the airway, it also can easily turn into a complete obstruction, which equates to rapid suffocation, and makes rescue breathing fruitless.  Your window for rescue in this scenario is disturbingly small.   I try to explain this to people rationally, without trying to scare them, and without lecturing.   A lot of people seem surprised, because they never thought of a balloon as something dangerous.  Other people still don’t seem concerned after I explain the risk.  That’s where my live and let live mantra comes in.  It’s tough to manage my toddlers expectations in those instances, but it is what it is.  Hopefully with this article, more people will look at balloons less innocuously.   But at the end of the day, every parent will make their own choices.  I just hope those choices are well informed.

Next up on Mother Ernestine’s list of “Items that Fill Me with Terror” are hot dogs, grapes and coins.

Hot dogs and grapes share similar properties in that they’re sort of firm and sort of squishy at the same time, wrapped in a sort of tough skin.  They’re also approximately 1-1.5″ in diameter when left whole or cut in rounds.  The squishiness lends to the risk of conforming to the shape of the airway.  And the physics behind back thrusts and Heimlich Maneuvers don’t help much in removing squishy things from the airway.  The diameter of these two foods is similar to the size and shape of a child’s airway, again, creating the risk of a complete obstruction.  The airway tends to swell with the irritation of an obstruction, so the tough skin assures that the item gets thoroughly lodged.

Now I am NOT a proponent of completely disallowing my kid to eat hot dogs and grapes  the way I am about not letting her play with balloons.  Both food items are a staple of toddlerdom.  But I am diligent about how I prepare these foods.  I slice her grapes like I would a lemon, lengthwise, into small wedges.  Hot dogs, I cut into rounds first, then cut the rounds into fourths so they look like pie slices.  The goal is that if your child accidentally swallows a piece whole, it is narrow enough to clear his/her throat and airway without getting stuck or causing an obstruction if it does.

Oh I get looks.  I get looks from strangers, I get looks from friends and family.  I get told, “your kid DOES have teeth”.  My husband has argued that our child is capable of chewing her food, and doesn’t need me to cut it into such small pieces.  But it really isn’t about whether or not she is capable of chewing certain foods.  It’s about the danger associated with said food when/if she accidentally does NOT chew her food before swallowing it (which definitely happens, as evidenced by some shockingly undigested food bits in her poop from time to time).  He didn’t take me seriously until a friend of his sister’s lost their toddler from choking on a hot dog round.  This principle goes for any food with semi firm, semi squishy properties; cheese cubes, bananas, marshmallows, raw vegetables etc.  And although not remotely firm, large globs of peanut butter are worthy of adding to this list because its sticky and very very squishy.  I’m not saying to avoid feeding these foods to your toddler, I’m just suggesting that they are prepared in a way that reduces the risk of choking.  I personally was devastated to learn that whole bananas were on the list of big no no’s.  They are literally the ONLY food my kid was eating 100% independently.  But back to the chopping board the banana has gone.

On to the next item of concern; coins.  Here we are again with a 1-1.5″ diameter.  With a round shape and that dangerous diameter, we come across the complete obstruction scenario once more.  Coins are especially scary because many of us think nothing of tossing a handful of change onto our night stand or cup holder in our cars.  We let it clink around the bottom of our purses, then allow our kids to fish through our purse in an attempt to entertain them long enough to finish our sentence or our meal.  We don’t check under our couch cushions regularly.  But toddler hands always seem to be digging through those cracks, looking for treasures or snacks.  Coins roll under furniture forever forgotten, until a little human is on rug patrol.  This is an item that is pretty hard to control, because you honestly cant ask your guest to empty his pockets before he sits on your couch.  But you can try to be diligent about where you dump your change, as well as inspect places the childless you would never think to clean on a regular basis.

In the name of saving time, I’ve only discussed the items I personally have encountered on a very regular basis.  There are quite a few more items that pediatricians around the world have added to their lists of high risk for choking related injury and death. I’ve provided them below if you’re interested in researching further:

  • Button batteries
  • Magnets (if they clear the airway, they can stick together in the gut causing tissue death)
  • Nuts & seeds
  • Popcorn
  • Hard candy (even when it’s attached to a stick)
  • Dried fruits
  • Food with skin (sausages and many types of fruits – plums, apples, nectarines etc)


Aside from WHAT foods/items I associate with being a high choking risk, there are also certain practices I implement to hopefully prevent choking.

First, in our house, all eating and snacking happens in a stationary position and is always supervised.  Be it sitting at the table, standing in a toddler tower at the kitchen counter, or sitting on a park bench.  I do not allow my toddler to walk around and eat at the same time.  The dogs don’t really appreciate this rule, but aside from reducing the risk of choking, it also helps contain my toddlers dietary debris from being littered across every surface of my house.  I understand that toddlers are perpetual motion machines, and some of us rely on letting them play and eat at the same time to guarantee ANY caloric intake.  I just urge you to supervise them closely.

Second, we don’t allow any eating while the car is in motion.  At least for now.  When our little human is older, I’ll re-evaluate this.  I know, I know….I can literally HEAR YOU rolling your eyes right now.  Snacking and dining on the go has become more American than the flag itself.  But hear me out.  Choking is silent.  It is nothing like what you see on TV, which is typically a scene filled with dramatic coughing, labored breathing and the universal hands to throat motion.  I’ll also add, that many of our kiddos under the age of 3 are rear facing, so we can’t really see them from the drivers seat (hence the sharp increase in kids being left in hot cars)….

Here’s my rationale on the no eating in the car rule: So you’re in a rush to go pick up Kid A from preschool.  You strap Kid B into his super expensive and super safe rear facing up to 120lb car seat, hand him a donut, and off you go.  You’re in the far left lane on the highway passing everyone because you’re going to be late.  Then, you glance up to your rear view and see there is something wrong with Kid B.  He’s not talking, his mouth is wide open, and you cant really tell from the double reflection off his headrest mirror, but his color doesn’t seem right.  “Holy shit, is he choking!!?”.  You speed back across the right lanes, into the breakdown lane.  Put the car in park, unbuckle your seat belt, lean into the back seat to find YES, your kid is choking.  Now you need to get out of the car, open his door, remove him from his car seat and start to perform back thrusts and potentially CPR….on the side of the road.  First, you don’t really know how long he was choking before you noticed.  If he was still conscious, you caught it early.  But how many times have you thrown the tablet on with cartoons in the car and then spaced out on autopilot heading to your destination?  Second, a choking incident can unravel into devastation in the matter of minutes.  Like 2-4 minutes.  By allowing your child to eat, unsupervised, in a moving vehicle, where everyone is restrained, you’re shaving at least a whole a minute off your rescue window…..never mind the sheer panic and shock you’re probably experiencing.  It’s just a heck of a lot easier to make kids wait.

I’m not trying to scare you.  I’m just breaking down what these scenarios actually look like in real life.  Choking, how it happens and what it looks like, is something a lot of people have never had to think about because its never happened to them or someone they know.  I unfortunately have more real life stories and tragedies to refer to than I’d like to admit.

The bottom line is this….We all have a certain level of risk we’re comfortable living with.  And for the most part, our kids are doing fine with whatever that level is.  So I continue to live and let live.   I just want every parent to make good decisions for their children, and hope to provide them with the knowledge that allows them to do so.



Mother bird, who pre-chews her kids food

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