Need to review guidelines for prevention of choking on food in children

Food has been found to account for more than half the foreign bodies aspirated by children under the age of five years.’ There is a need to give clear and consistent advice for parents and carers to prevent choking on food and still ensure children’s nutritional and developmental needs are met. At present, there does not appear to be guidelines that satisfactorily meet this need.‘.’ In endeavouring to provide guidance to carers on food safety, particularly in child care centres, we need to approach the issue carefully to avoid creating ever growing lists of foods to be excluded from young children’s diets. In addition we need to be clear and consistent with regard to the age at which certain foods pose a risk to children. American research has identified children most at risk of hospitalisation due to aspirating foreign bodies are aged between 6 months and 2 years.’ Children younger than 3 years accounted for 65% of deaths from aspirated foreign bodies over a 20 year p e r i ~ d . ~ A Welsh study identified the median age for deaths due to choking on foreign bodies (including food) as 2.3 years, and 3.3 years for deaths due to choking on food.5 Another American study identified the peak incidence for ingestion and aspiration of all foreign bodies is between the age of 9 and 24 months.h An Australian case study recommends that vegetables are steamed to the point of softness or diced and mashed so that no firm or hard foods are given to children under the age of five.7 Other published work by the same author applies this rule to all children under four years of age.s It is essential that we link the ages that children have been found to be at greatest risk of choking on food to the recommendations we make. We need to consider also, the developmental ability of individual children. It has been postulated that child care centres are places of risk for children to choke on food because of reduced supervision7. It is unclear as to how this risk was measured or compared to the risk of choking in children cared for at home.’ Fatalities from choking on food have remained constant from 1989 to 1993 a period when the number of children attending child care has increased.* If child care centres are a possible risk we should have, in theory, seen an increase in hospitalisations due to choking to correspond with the increase in the number of children attending child care. In America deaths from choking accidents occurred in the home environment in more than 95% of cases.6 Therefore, we need to be clear as to when and where children are at risk. Paediatricians have proposed an injury formula that states “risk is the result of the hazard multiplied by exposure”.6 Apples have been listed as a high risk food7 and feature prominently in preschool fruit bowls. If we applied the injury formula to child care centres and preschools, we would anticipate an increase in choking episodes in children eating apples. The lack of documented change in choking episodes in children attending preschool and eating apples could be attributed to apples being mistakenly labelled “high risk” or due to the vigilance of the carers. The injury formula accounts for reduced risk when a parent or carer is particularly vigilant when a hazardous food is placed with the child.6 Vigilance reduces exposure to a potential risk and so the overall risk of injury is reduced. Guidelines developed to prevent choking on food in child care centres suggest modifications to foods to prevent their exclusion from a child’s diet. This in itself raises some issues. From experience in having worked with child care centres, the response to potentially dangerous foods has been to ban rather than modify them. With the current resource constraints placed on child care centres it may be simpler to ban or eliminate rather than modify potentially hazardous foods. With modification such as grating, cooking and mashing foods, there will be consequent vitamin and mineral losses. This will be heightened when there are invariable delays between food preparation and the actual service of foods. As many parents and nutritionists are aware, many children are happy to accept fresh vegetables after previously rejecting the cooked version. Will cooking all vegetables reduce the appeal and subsequent intake of vegetables in children? If we follow the above mentioned guideline that we need to modify firm or hard foods for children under the age of five will we inadvertently reduce the ability of children to develop their chewing skills through the removal foods that may offer a crisp or crunchy texture? Will this action encourage a preference in children for softer and more highly processed foods? It is clear in the research that there are particular foods that pose a risk to children, particularly those 3 years and under.’.4 However, research has also identified that a child can choke on anything from banana bread and bacon to peanuts’. This has been attributed to the fact that there are many factors that contribute to a choking episode separate to the nature of the food being consumed. Preventing choking episodes does not solely rely on removing foods that children have been found to choke on. It involves in part identifying (through sound research) the foods children are most likely to choke on, the role of supervision and vigilance when new foods are offered, and developmental stages where a child is at greatest risk. Of all the research reviewed, prevention involves a number of steps one of which involves being aware of foods that are potentially hazardous to children at specific ages and developmental stages. Strategies to prevent children choking on food need to be balanced with promoting healthy eating patterns and oral development. Guidelines on choking which do not clearly state when and where a child is likely to be at risk, which provide endless lists of “problem” foods, and do not identify carer behaviours which can reduce risks of aspiration will impede the ability for us to achieve this balance.