Eating safety and choking prevention in children

When starting solids at six months (we even raise the possibility of starting solids at an earlier age in certain circumstances, see the following link), children will normally try to grab foods and try putting them in their mouths. Babies explore through touching, feeling & tasting, meaning they use their hands and mouth to learn their world. They tend to put everything in their mouths, which is part of a normal development, and usually, it should be encouraged. Sometimes, they will even get mad at us when we prevent them from putting certain things in their mouths.

That said, there are foods that are a major safety hazard for children. As a pediatrician, I have seen too many tragedies that could have been prevented if only parents knew what was considered safe at what age. So simple, yet so dramatic.

Even if it sometimes seems that a child is capable of chewing a certain food or maybe you say ‘I make sure to only serve it to him when he is nearby’, all these assumptions still do not keep the child out of danger. It is important to keep these foods out of reach and of course avoid serving them any food that is not age suitable.

We will now try to clarify what foods are allowed at what age and why, and who will do so is our wonderful Pediatric nutritionist, Lauren Ben-Yehuda.

Note that this article will discuss two main subjects:
A. Eating safety, mainly during transitioning to solids.
B. Prohibited foods or foods that should be served in a certain way to children up to the age of five.
This is a lifesaving article so please concentrate.

What is choking and why are we so afraid of it?

We apologize for starting with the most stressful issue. Suffocation is a condition in which there is no oxygen supplied to the brain. In this case, due to a large foreign body (food), blocking the air way.
Choking is the third most common cause of child death due to a hazard, with most cases being caused by food.
Baby’s and toddler’s trachea is narrow compared to adults and so, food of the wrong size, which is inhaled into the trachea, can more easily block the airway and quickly cause suffocation. Also, children’s cough reflex is not always fully developed and therefore they do not have the ability to effectively expel inhaled food. That’s why, safe eating can prevent choking and therefore save lives.

What should be considered when starting solids?

It is clear to us all that every child develops at his own pace, and it is always important to suit the texture served to the child’s abilities, especially when starting solids. In general, the recommendation is to start with purees and gradually progress to grated/squished foods. Then, on to finger foods which the child can hold on his own.
Transitioning should be gradual. Just as learning to walk takes time and practice, so does learning to handle, chew and swallow different textures.
Many parents worry, as taking the first step is sometimes a little scary and advancing to more challenging foods raises fear of suffocation, even when the child seems to be very ready and interested.
Therefore, sit baby down at the family table and offer purees first, then advance to finely grated/mashed foods, then soft finger foods (that is, foods you can squish between two fingers, for example soft avocados, steamed or baked vegetables, etc.). Children should never be left unattended and while you are around, it is important to stay calm and make them feel secure about the situation. If a caregiver is stressed at mealtime, the child will sense it.

Remember that a gag reflex might appear during this phase when a new texture is presented. We will elaborate on this shortly.

What is the difference between gagging and choking?

I will start by saying that most children transition easily between textures and at 6 months of age, we can already recognize that baby can chew. Babies are gradually and safely exposed to foods and advance to eat nearly everything we adults eat by the age of 1 or so. Over time they practice and improve their abilities and it is important to help them to do so.
When challenging the palate with a new texture, a gag reflex may appear, and it is important to understand that this is a normal phenomenon and that this reflex is not anything like choking. Gagging indicates proper functioning of the swallowing system.
As opposed to gagging, suffocation is a life-threatening condition where the airway is blocked. This situation obviously requires immediate medical intervention.
Coughing also sometimes appears during feeding and can also indicate a feeding skill that is still not fully developed.
If you are having any doubt or thought regarding feeding problems, I advise you to seek for a healthcare evaluation, meaning a pediatrician/nutritionist.

What foods should be offered when starting solids (in terms of texture)?

Most babies should start with purees i.e., with a smooth texture (a bit like the fruit and vegetables pouches you can buy, but of course we recommend serving fresh & homemade food). This texture should be served for a short period of time only, as an intermediate step to eating more solid foods.
The next step will usually be grated/mashed foods (such as sweet potato or banana mashed with a fork).
By then they are probably eating 1-2 solid meals a day and should be able to handle lumpy food. That’s when you can start offering soft finger foods i.e., foods that we can squish between two fingers).
Gradually, eating skills will improve over time to the point where they can eat all the foods suitable for their age.
Note that the child must be an active participant during mealtime at all ages. In the puree stage, give then their own spoon dipped in a spread/puree and later on, they should freely touch and explore foods that are served on their plates.
There is the Baby Led Weaning method that offers finger foods from the start, but this method is not suitable for every child and family (read more about Baby Led Weaning here).

What foods are considered choking hazards and are prohibited up to 5 years of age?

These recommendations are according to the one national association for children’s safety.
• All types of nuts, almonds, and peanuts – prohibited except if served as a smooth spreads (such as peanut butter).
• Dried fruit – must be peeled and cut into small pieces due to their tendency to stick to the trachea.
• Hard vegetables and fruits – when starting solids, it is recommended to cook and mash. Up to the age of 5, cut into pieces according to the child’s chewing abilities. Meaning a salad probably won’t be suitable to start with.
• Grapes – should be cut lengthwise.
• Cherry tomatoes, carrots, cucumbers (and any other hard and round vegetable or fruit) – should be cut lengthwise.
• Olives – pit and cut lengthwise.
• Peas, corn, chickpeas, and legumes – dried grains are prohibited. They can be served if cooked well to a soft texture.
• Sausages – not that as a nutritionist I would ever understand why children should eat sausages… but if you chose to serve them, then they should be cut lengthwise until the age of 5.
• Popcorn – forbidden.
• Chewing gum, hard candy, lollipops – prohibited.
• Marshmallows, hard candy, jellybeans, chocolate covered candy (such as M&M or smarties) – prohibited.
Of course, there are many other foods not mentioned, but these are the main ones.

Which eating behaviors should be adapted to help maintain safe eating?

• Food texture must be suitable to the child’s abilities and age.
• Try focusing on feeding with no distractions or movement (i.e., sitting at the family table without any toys, tv…).
• Be sure they chew their food.
• Small children should never eat unattended.
• Be sure to properly cut problematic foods.
• Never offer foods that are not age-appropriate or feed while asleep.

In conclusion, food and eating are a fun and inseparable part of our and our children’s lives. Therefore, it is important to ensure a safe eating environment and the serving of safe foods at every age and to every child. Just as boundaries at home are very clear regarding knives/fire/electricity, so should it be regarding what is safe and allowed to eat.

Stay safe & healthy.