Prevent Choking Hazards Incidences This Holiday Season

Amy Manning, MD, Erin Hamersley, DO, and Jenna Briddell, MD, on behalf of the Pediatric Otolaryngology Committee

The early phases of development are marked by an infant’s or child’s primitive exploration of his or her environment, leading to the “mouthing” of not only food but also non-food objects. As such, Sigmund Freud termed the first 18 months of childhood development the oral stage because infants primarily experience the world through oral stimulation.¹ This “mouthing” can lead to inadvertent swallowing or aspiration of foreign bodies (FB), leading to airway obstruction or esophageal impaction. The holidays are a time of many festivities, family gatherings, special culinary treats, decorations, and presents. As many are focused on all the fun and festivities, it is important to be aware of all the potential choking or ingestion hazards that may arise this time of year. By planning ahead to keep these things out of little hands and mouths, the whole family can safely enjoy the holidays.   

Toys 

Prevention of FB ingestion by the most vulnerable young children commenced 50 years ago. The Consumer Product Safety Commission (CPSC) introduced a legal standard that must be applied to toy products or other rigid objects manufactured and intended for children under three years of age. The proposed goal was to eliminate “tracheal obstruction,” which could lead to asphyxiation.²  In response to Federal regulation 16 CFR 1501, instituted to prevent aspiration and choking injuries by FBs, the Small Parts Test Fixture (SPTF) was created in 1973. The design of the SPTF was based on cadaveric estimates of the dimensions of the airway in young children.² The SPTF is a truncated cylinder that is 31.75 mm in diameter to eliminate small objects from entering the oral cavity, with a minimum length or depth of over 57.1 mm to eliminate longer and slender FBs, such as sewing needles. The diameter of the cylindrical opening (31.75 mm) was the more important measure and was designed to restrict penetration into the oropharynx that might lead to “tracheal obstruction.”  Toys are also tested for fatiguability, meaning it is likely that a component or piece may fracture and result in a piece that is smaller than the SPTF.² 

The SPTF regulation specifically applies to toys and products manufactured and intended for children under three years of age. All products intended for child use are subject to these regulations, so all toys should be clearly marked. Any toy labeled as three+ means it either failed component size testing or was intended for older children and thus may not have undergone this testing. The criteria for age appropriateness are also based on developmental abilities. This is an important point for consumers to understand. Even if they feel their child’s motor and cognitive development may have progressed to a point where they can enjoy interacting with a toy labeled three+, it may contain pieces small enough to fit in their airway.

Given the large variation that can be seen in the growth of toddlers and young children, many have advocated that the existing standards are insufficient. Subsequently, more detailed clinical and radiographic FB studies have suggested that this standard remains insufficient for solid objects and, therefore, does not provide adequate protection.^1,3-5  Many of these studies advocated for a diameter of closer to 40 mm. A useful “life hack” for parents trying to determine if a toy that is hand-made or out of its labeled packaging is safe for their child is to use the toilet paper roll rule. If any of the components or pieces can fit inside the cardboard tube of a typical toilet paper roll (approximately 4 cm in diameter), it should not be given to a child under the age of three. Furthermore, it is important to remind parents that aspiration of foreign bodies is more common in toddlers but can occur at any age. It is important to continue to watch older children and encourage them to avoid placing non-food items in their mouths. All ages should avoid running or playing with objects in their mouth that could accidentally be ingested if they trip, fall, or become distracted.   

Food

Choking events account for thousands of emergency room visits per year and greater than 150 pediatric deaths each year in the United States.⁶ Food is a common choking concern in children, comprising >90% of aspirated material in studies of pediatric airway foreign body, and the great majority of affected patients are under five years of age. Young children have underdeveloped dentition and chewing and swallowing skills, placing them at especially high risk for aspiration of food particles. Commonly aspirated food items include many things that are rather ubiquitous during the holiday season, including hard candy, other candy, meat, bone fragments, nuts, seeds, and legumes, a category that includes peanuts.⁷

The American Academy of Pediatrics (AAP) recommends the introduction of solid foods into a child’s diet no earlier than four to six months of age. The recent popularity of “baby-led weaning” raises concern for choking hazards as children are presented with a greater variety of foods from as young as six months of age, though this fear has not been corroborated in the literature.⁸ Regardless of feeding technique, it is recommended that children be supervised and seated while eating.

While federal legislation mandates labeling of toys and other items as potential choking hazards in young children, similar labeling requirements do not exist for food items. As such, the AAP recommends that children under five years of age not be provided with hard candies or gum and that raw fruits and vegetables be cut into manageable pieces. 

Decorations

Preparing for the holidays often involves decorating your home with festive, colorful decorations, twinkly lights, ornaments, and holiday trees or plants. Decorating your home is a fun family tradition for many households, though it may also introduce some safety hazards for young children. Below are some safety tips to keep in mind as you prepare to decorate for the holidays.

Holiday Décor Safety Considerations 

• Exposed electrical wires (including extension cords or holiday lights) may be a source of oral cavity burns or electrocution injuries. Additionally, if loose and a child becomes entangled in one, they can become a strangulation risk. Children may attempt to bite or chew the lights, resulting in ingestion or aspiration of fractured pieces of the tiny light bulbs.

• Keep electrical cords and string lights out of reach and sight, and place non-choking hazard plugs in all unused electrical outlets. Inspect lights and cords for frayed wires, loose connections, and broken sockets prior to use. 

• When decorating with ornaments, consider using shatterproof varieties and ensure smaller ornaments that may be choking hazards are placed out of reach. In homes with small children, avoid sharp and breakable decorations and those that resemble candy or food. Ensure any decorations with small removable pieces remain inaccessible to young children. 

• Mistletoe berries, Jerusalem cherry, and holiday berries are potentially poisonous plants. They are colorful and attract curious young children. These plants should either be avoided or kept out of reach to prevent accidental ingestion.

• Pushpins and tacks are convenient ways to hang temporary, seasonal decorations, but they can also become a hazard. In addition to finding their way into little hands and mouths, aspiration or ingestion of these items has occurred in older children and adults who may hold these in their mouths while reaching to hang décor. If one tries to talk, becomes startled, or falls from a step stool or stumbles, accidental aspiration can occur. The sharp nature of these foreign bodies can lead to significant trauma and make extraction more difficult.

• Button Batteries are found in many common household items: games/toys, watches, small light sources, flameless candles, greeting cards, ornaments, remote controls, key chains, clocks or timers, and music/video players.
• Patients’ families should know which items in the home
• Remind patients’ families that button batteries are an emergency and can lead to serious and life-threatening injury in as little as 2 hours. 
• If concerned about possible button battery ingestion, instruct parents to give children 12 months and older two teaspoons (10 ml) of honey by mouth every 10 minutes (up to six doses) while en route to the closest emergency department (ED). This should not delay transport to the ED and should only be given if readily available. 
• Call the National Battery Ingestion Hotline at 800-498-8665 for any questions.

References

1. Milkovich NM, Milkovich SM, Harty MP, Kecskemethy HH, Briddell JW, Levi JR, Reilly JS. Computerized Tomography Analysis of Young Children for Prevention of Aspiration Injuries. Laryngoscope. 2019 Jun;129(6):1468-1476. doi: 10.1002/lary.27354. Epub 2018 Oct 3. PMID: 30284274. 
2. Federal Register Notice: Banning of Toys and Other Children’s Articles Presenting Choking, Aspiration and/or Ingestion Hazards due to Small Parts: 38:14, 21 CFR, Pt. 191. 22 January 1973.  
3. Reilly JS, Walter MA. Consumer product aspiration and ingestion in children: analysis of emergency room reports to the National Electronic Injury Surveillance System. Ann Otol Rhinol Laryngol 1992;101(9):739-741.  
4. Reilly JS, Walter MA, Beste D, et al. Size/shape analysis of aerodigestive foreign bodies in children: a multi-institutional study. Am J Otolaryngol 1995;16(3):190-193.  
5. Reilly JS, Cook, SP, Stool D, Rider G. Prevention and management of aerodigestive foreign body injuries in childhood. Pediatr Clin North Am 1996;43(6):1403-1411.  
6. Sidell DR, Kim IA, Coker TR, Moreno C, Shapiro NL. Food choking hazards in children. Int J Pediatr Otorhinolaryngol. 2013 Dec;77(12):1940-6. doi: 10.1016/j.ijporl.2013.09.005. Epub 2013 Sep 12. PMID: 24113156. 
7. Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal choking on food among children 14 years or younger in the United States, 2001-2009. Pediatrics. 2013 Aug;132(2):275-81. doi: 10.1542/peds.2013-0260. Epub 2013 Jul 29. PMID: 23897916. 
8. D'Auria E, Bergamini M, Staiano A, Banderali G, Pendezza E, Penagini F, Zuccotti GV, Peroni DG; Italian Society of Pediatrics. Baby-led weaning: what a systematic review of the literature adds on. Ital J Pediatr. 2018 May 3;44(1):49. doi: 10.1186/s13052-018-0487-8. PMID: 29724233; PMCID: PMC5934812.