Posts for Parents

Choking prevention and management — A Critical Care Paramedic’s tips

Posted on by Carmen Myler

A guest blog by Amy Gomes

When I heard about the recent choking death of a dear little boy, I reached out to a wonderful paramedic and mum in my community to ask if she could please write a blog to help us raise awareness about choking and what parents can do if faced with this awful situation. My intention in sharing this is not to scare parents, but simply to educate and inform. Here is Amy’s very sage advice…

Firstly, I would like to acknowledge the absolutely devastating loss of young Zaire, also known as ZaZa.  I would also like to recognise his amazing father Brian who not only tried so desperately to save his son, but also has turned his unimaginable grief into advocacy in the hope that no other family suffer the same loss that they have.

For those unfamiliar with ZaZa, he was a 22-month-old boy who was given a whole grape by another child, while playing at a park. The innocence of children sharing led to the total occlusion of ZaZa’s airway and devastatingly he passed away. Brian had recently conducted first aid training, but unfortunately, sometimes there is nothing that can be done. No one would have fought harder to save ZaZa than Brian and my thoughts are with Zaire’s family and loved ones.

I wholeheartedly agree with Brian’s petition for ZaZa’s Law, which demands better labelling on grapes. The research clearly supports that foods such as grapes are high-risk choking items, yet we miss the crucial opportunity to provide the awareness and education when these items are purchased.

No parent would ever have left their child with a whole grape thinking that it could risk their life or another child’s life, ever. And while this may seem like common sense to some, it is sadly still not well-known enough to prevent these terrible tragedies from continuing to occur. It does raise the question of whether we are doing enough to educate about the risks of choking in children. According to the Australian Institute of Health and Welfare, older people have the highest rates of death by choking, while young children have the highest rates of hospitalisation. Children under the age of three are most at risk of choking, accounting for two-thirds of choking deaths.

On average across the nation, ambulances take approximately 8-10 minutes to arrive at code 1A (highest priority) cases. Parents need to be empowered to intervene as waiting for the Paramedics is simply not enough. Thankfully in most instances, the obstruction is cleared prior to our arrival thanks to rapid, life-saving first aid intervention from bystanders.

I commenced my career in the ambulance field in 2008, more recently as a Critical Care Paramedic attending to the highest acuity cases. I now also have the added bonus lens of the world as a new (ish) Mum. I know first-hand the challenges of young children learning to eat, their desire to explore their world and how quickly things can happen. Here are my top 5 tips for prevention and management of choking.

  1. Prevention is the key

Ensure food products are always cut in a manner that is suitable for your child’s age. There are so many free online resources these days that highlight food preparation recommendations for different age groups. I highly recommend Solid Starts as a reliable source of up-to-date information. Solid Starts highlights that there are four main features of food that increase the risk of choking:

  • Small
  • Round
  • Firm
  • Slippery

All of these characteristics relate to a whole grape sadly. It is so important to remember though that ANYTHING can be a choking hazard. While food preparation reduces the risk, it doesn’t completely eliminate the risk of choking or a partial obstruction. Which leads to tip 2.

  1. Supervision

The scary thing about true choking is that it is silent. It is important to know that gagging is usually normal in children learning to eat and trying new foods – gagging is not choking. Never assume a child is safe while eating. Kids put so many things in their mouths as a way of navigating their world and the things around them. While grapes are a common risk item, there are so many other general items and foods such as blueberries, deflated balloons, hard lollies, hot dogs, raw vegetables, apple skins, whole nuts, etc that also pose a significant risk. Some other items like popcorn may not necessarily completely obstruct an airway but there is a risk that they are inhaled more deeply into the lungs, requiring medical intervention for extraction in hospital. It is not uncommon for Paramedics to attend to a child in cardiac arrest from an unknown cause who is then found on examination to have a foreign body obstruction.

As a busy parent myself, I appreciate that it is not always realistic to have eyes on both of my children 100% of the time.

I am often verbally interacting with my 3-year-old son if I don’t have eyes on him while I’m doing something with my 1-year-old. I find this is helpful in many circumstances. Have them sing to you or tell you a story about their day – this is not foolproof, but it gives me some reassurance that my son is ok for those times when I am unavoidably preoccupied with my daughter and I can rapidly divert to my son if he becomes silent.

  1. Chewing education

As a Paramedic, I have attended to countless adults who have had complete airway obstructions from not chewing food properly. I have been astounded by the size of unchewed food that I have removed from the airways of people in cardiac arrest, in patients who otherwise normally have no problem swallowing or eating safely. Because of this, I always discuss the importance of chewing with my children, making exaggerated chomping movements. Remember, children younger than three years may not have a full set of teeth yet which can make chewing challenging for them and put them at a higher risk of choking. Grapes are actually a food my three-year-old practices loudly chomping, with close supervision and never while playing. Educating children about how to chew challenging foods (in a safe and supervised manner) may prepare them for times when they are given food that is not suitably cut for them.

This seems like common sense, but if adults are still incapable of chewing food properly, then we can hardly expect children to always understand the importance of chewing their food properly, especially when there are competing tasks – kids are busy beings.

  1. Assess the Environment

While I highlighted chewing education in tip 3, it is important to note that even children who are normally safe eaters are at risk in certain environments. The highest risk times for children to choke are when they are eating, coupled with playing, laughing or running around. It is tempting to leave food for children to graze on while they are playing to allow them the autonomy of deciding when they want to eat, but this also presents a significant risk. Children are more likely to inhale food and objects during playtime and less likely to allow themselves the time needed to properly chew the food.

High-risk environments for choking are places where the competing excitement to play or engage with others is a higher priority of focus than safely and slowly eating their food.

If your child is in a higher-risk environment (playground, kids’ party, school) where supervision may not be one-on-one, or there is a risk that they will be tempted to run around, then don’t prepare risky food, even if they are usually ok. If you allow your child to have food at a park or somewhere that other children may have access to it, you also need to appreciate that children share and you do not know the other child’s capabilities. Just as you shouldn’t blindly give a non-allergic child a potentially allergen risky item that another child make be exposed to, you should not risk other children having access to food without their parent’s supervision or approval.

An additional risk is when children are startled. If your child puts something in their mouth that they shouldn’t, it is important to try to remain calm, rather than alarmingly leaping for the child and item. The startle reflex may result in the unintentional inhalation of that item.

  1. Know what to do in an emergency

Know your parameters for calling for help and learn first aid – I cannot stress this enough. If your child is choking or having trouble breathing, call 000 immediately. There is never any harm in calling 000 for what you assess to be an emergency situation and then either cancelling if the obstruction clears or having an assessment with Paramedics. The risk of not calling, or delaying help in an instance where the obstruction does not pass could be a matter of life or death. You need to get the Paramedics heading towards you as soon as possible. While waiting for the Paramedics, you need to know what to do and how to intervene. There are some excellent online resources available these days.

Additionally, an in-person first aid course is invaluable. Learning and going through the motions while physically practising back blows, chest thrusts and CPR is essential to ensure you can respond effectively in an emergency. If this is not possible, at the very least, familiarise yourself with choking first aid via online sources.

Some of the current recommendations include the following:

  1. If your child is able to breath, encourage them to cough in an attempt to clear their own airway. Young children will usually instinctively try to cough. Children’s airway reflexes however are not as well developed as an adult’s and their accessory muscles are not as strong. This may mean that they are unable to effectively clear the obstruction, or it may result in them tiring quickly if they cannot clear the obstruction. These are dynamic situations and, in most cases thankfully, the child will be able to cough the item out themselves. I have had multiple patients with significant partial airway obstructions who were still able to ventilate and even as a Paramedic it can be confronting.Do not commence more advanced interventions (such as back blows) if the child is still breathing or making noises indicating air movement. Patting the child on the back is a natural instinct, but this can worsen the situation as it may cause the obstruction to migrate to a point that completely occludes the airway.

    Remember, choking is silent. As confronting as noise is, it indicates air movement.

    Do not put your fingers in their mouth, you may cause further obstruction by pushing the object down further. Trust me, in most cases, you will not even be able to see the obstruction anymore due to the location and you certainly will not be able to effectively grip the object.

    Do not do the Heimlich manoeuvre – this is not recommended and can cause internal injuries in children.

  1. If your child deteriorates further or is not able to effectively ventilate (silent, unable to make noises), you need to intervene immediately – this is a time-critical situation. If you haven’t already, you need to call 000 straight away. Supported by many current guidelines, the best practice at this stage is to commence 5x sharp back blows (use the heel of your hand, between the shoulder blades), checking for dislodgement between each blow. Back blows can be performed on children in a seated position (with a slight forward lean), whereas babies (less than 12 months) can be laid across your lap, with their head slightly down. If after 5x back blows, the obstruction is still present, commence 5x chest thrusts, again assessing for dislodgement between each blow. Chest thrusts can be performed in a similar location to CPR (lower part of the sternum) but with slower, sharper thrusts. This can be done by placing one hand in the middle of the patient’s back for support and the heel of the other on the lower half of the sternum, thrusting in a backwards, upwards motion. For babies, you can use your middle and pointer finger to perform the thrusts. Continue performing back blows and chest thrusts in alternation until the obstruction is dislodged or the child is able to ventilate again. If the child becomes limp or unconscious, progress to step 3.
  1. If your child is limp or unconscious, call 000 (if you haven’t already) and immediately commence CPR. The remarkable call-takers are experts and will provide you with life-saving advice and instructions while getting Paramedics to you as quickly as possible. Put the phone on loudspeaker and commence interventions.

A lot of my focus outside of my normal role of a Paramedic is how to educate and empower not just parents, but kids to be future life savers. Kids are highly motivated to learn basic life-saving skills and are more than capable of learning what to do in a choking emergency, even if the initial focus is on alerting an adult in the primary instance. We certainly cannot expect children to always understand or recognise what choking is, however it is an important scenario to discuss with them.

Research suggests that a four-year-old who can recognise when to call 000 in an emergency becomes a 10-year-old who may begin to perform effect chest compressions (ILCOR, AHA, EHC, 2023).

These are life skills that are helpful not just in the event of a choking emergency but are important life-long lessons.

Button battery danger

It is also necessary to highlight the absolute risk of button batteries. While choking is an obvious risk, button batteries are also extremely dangerous if ingested. If you suspect that your child has ingested a button battery, you must seek medical intervention immediately.

Unfortunately, like in the case of little ZaZa, sometimes it doesn’t matter what first aid is done by those on the scene if the item is firmly lodged. In these instances, paramedics use specific equipment known as a Laryngoscope and Magill’s forceps that require intense specialised training for the management of airway obstructions – these are strictly not first aid devices.

I also highly recommend parents visit online sites such as the Tiny Hearts Education page and download their free choking first aid fridge memo. There are so many great videos and clear educational instructions to help parents respond in a range of emergencies, with a large volume of content on choking. The education they provide has undoubtedly saved hundreds of lives.

So remember, prevention is key, supervise children, provide chewing education, assess the environment and know what to do in an emergency. If you are ever concerned that your child is choking or has inhaled a foreign body, seek medical help immediately and commence first aid interventions.

Amy Gomes is a Critical Care Paramedic with a special interest in paediatrics. Amy is the founder of One Little Heart which aims to help empower children with the knowledge to know how and when to call 000, through educational content such as her children’s picture book, What Paramedics Do. Amy is also the Director of PARA PEM which provides education to Paramedics in Paediatric Emergency Medicine. Find out more at: onelittleheart.com.au