Last reviewed 31 January 2022
Recent years have seen a number of cases where young children have tragically died in incidents where they have choked on food or other items in nurseries. Martin Hodgson, an early years Education writer, sets out what managers and staff can do to ensure that they reduce the risks of choking and keep children as safe as possible.
Choking — what is the risk?
Choking occurs when a foreign object becomes stuck in the airway and prevents breathing. Young children are particularly vulnerable because their trachea and bronchi which carry oxygen to the lungs are small and they have not yet developed full control of the muscles in their mouth and throat. Items of food or other objects put into the mouth can therefore easily become trapped.
In most cases, the item can be dislodged by coughing. However, sometimes this does not work and without immediate first aid the incident can quickly become life-threatening.
Risks may be greater for under-threes who often explore the world around them by putting things in their mouths. Older children can be taught about the dangers of such behaviour, but will still be at risk, particularly from food.
People of any age can choke while they are eating or drinking. However, children are more at risk than an adult because they do not chew as well, their swallowing may not be as co-ordinated and they get distracted during mealtimes.
In all cases, an early years service must complete appropriate risk assessments. Robust assessments should inform suitable policies and procedures designed to reduce risks to a minimum and to support contingency plans in case of an incident.
Risk assessments should be completed by a competent person and should be subject to regular review.
Choking on food
Most choking incidents involving pre-school children occur while they are eating.
Certain types of food have been identified as high risk because of their shape, texture or size. Round food such as grapes, nuts, cherry tomatoes and hard sweets can easily become trapped and form a perfect plug, effectively sealing the windpipe.
Evidence suggests that other high-risk foods include popcorn, chips, raw vegetables, raisins, peanut butter and chunks of meat or sausage such as hotdogs. Concerns have also been raised by the Child Accident Prevention Trust about raw jelly following the death of a child in a nursery who choked on a jelly cube in 2012.
Foods that might pose a risk should be either avoided or cut up into small pieces. Voluntary Food and Drink Guidelines for Early Years Settings in England — A Practical Guide, published by the Children’s Food Trust states that to reduce the risk of choking:
remove any stones and pips before serving
halve small fruit and vegetables like grapes and cherry tomatoes
cut large fruits, like melon, into slices instead of small chunks
do not give whole nuts to children under five years old.
The Child Accident Prevention Trust reinforces this advice, stressing the importance of chopping-up foods such as grapes. The Trust has produced a leaflet, Finger Food without the Fear, which early years providers can use as a display and in communications with parents.
Mealtimes should not be hurried. Trying to rush food will increase choking risks.
Young children should be properly supervised at mealtimes and should be given safe eating messages. Having an adult act as a role model is a useful approach.
Wherever possible children should be seated around a table to eat and taught to sit up straight. Large portions should be avoided and children should be encouraged to chew their food. Children who are not good at chewing should be identified and their food cut up into small pieces. Babies should not be fed from a bottle or cup when lying down.
Effective supervision applies both to organised mealtimes and to snacks provided during the day. The Children’s Food Trust advises providers to avoid cutting meal or snack times short to accommodate other activities. They warn that children may not eat well if they are distracted by more interesting things going on.
Children with swallowing difficulties
Risks can be increased if a child has a medical condition that compromises their ability to swallow.
All children should have their needs fully assessed when they start at an early years service. Nutrition should be discussed with their parents and a plan agreed of how to address any special needs. The plan should regularly be reviewed, especially where a child’s needs change.
Where necessary suitably prepared food, such as pureed meals, should be provided. In some cases the service will need to work with the child’s GP or a healthcare provider, such as a speech and language therapist.
Other causes of choking
While food is perhaps the highest risk area for choking, children can of course choke on other items as well. Small objects and toys that could be ingested and cause choking should therefore be kept out of the reach of very young children. This includes items such as button batteries, coins, beads, balloons, strings and cords.
Older children should be educated as far as possible about the dangers of putting toys in the mouth.
Toys should be carefully procured to ensure they are safe and do not contain parts that could come off and choke a child. They should be regularly inspected to ensure they are kept in good condition.
The Child Accident Prevention Trust advises that button batteries may be particularly hazardous if swallowed, potentially causing serious burns in the throat of a child as well as posing a choking risk.
In addition to preventing choking, an early years service must ensure that it has effective contingency plans in place in the event of an incident occurring.
A choking incident is a medical emergency and staff must be prepared if they are to respond effectively and potentially save a life.
The requirements for an effective response include:
awareness of what to do
robust policies and procedures
sufficient first-aid training and skills.
Staff and volunteers supervising children should be trained to always be alert to the dangers of choking. All new staff should be made aware of the risks during their induction training.
If a child is choking, staff should be trained to respond immediately by implementing a pre-agreed procedure. In all cases a first aider should be summoned and appropriate first-aid rendered which follows up-to-date best practice in care of a choking child.
An early years service should have an appropriate number of first-aid trained staff on duty at any time.
In England, guidance is provided in the most recent version of the Early Years Foundation Stage (EYFS) published in March 2021. Section 3.25 states that:
at least one person who has a current paediatric first-aid (PFA) certificate must be on the premises and available at all times when children are present, and must accompany children on outings
the certificate must be for a full course consistent with the criteria set out in Annex A of the guidance
PFA training must be renewed every three years and be relevant for workers caring for young children and where relevant, babies
providers should take into account the number of children, staff and layout of premises to ensure that a paediatric first aider is able to respond to emergencies quickly
all newly qualified entrants to the early years workforce who have completed a level 2 and/or level 3 qualification on or after June 2016, must also have either a full PFA or an emergency PFA certificate within three months of starting work in order to be included in the required staff:child ratios at level 2 or level 3 in an early years setting
providers should display (or make available to parents) staff PFA certificates or a list of staff who have a current PFA certificate.
The guidance states that early years providers are responsible for identifying and selecting a competent training provider to deliver their PFA training. All training should be obtained from a nationally approved and accredited provider.
In Scotland Good practice guidance: prevention and management of choking episodes in babies and children was published by the Care Inspectorate in December 2019.
Early years services in England are being encouraged by the Millie’s Mark campaign to go beyond these minimum standards and ensure that all their staff are trained in first aid and regularly updated, including in the care of choking incidents. The campaign is being led by Millie’s Trust who offer accreditation where 100% of employees are trained in paediatric first aid.
The award was developed by the parents of Millie Thompson who tragically passed away in a choking incident in a nursery in October 2012.
The effective management of a choke victim is a key element of first-aid training. In any incident a first aider should be called immediately and they should follow the basic life support training they have received on accredited courses from providers such as St John Ambulance or the British Red Cross. These are based on guidelines published by the Resuscitation Council (UK).
Choking often begins with small coughs or gasps as the child tries to draw in breath around the obstruction or clear it out. This may be followed by a struggling sound or by raspy, squeaking whispers as the child tries to communicate its distress. The child may thrash about, salivate, and the eyes may water. They may flush red and then turn blue. However, some children — particularly babies — can be remarkably silent.
In all cases, a conscious child should be encouraged to cough first in an effort to expel the obstruction.
If coughing is not effective, the Resuscitation Council (UK) advises initially giving a child up to five back blows between the shoulder blades to try to dislodge the object. If this does not work up to five abdominal thrusts should be administered by holding the child around the waist and pulling inwards and upwards above their belly button.
For an infant under one year old chest thrusts should be used instead of abdominal thrusts. Here two fingers are placed in the middle of the bottom half of the sternum to deliver up to five thrusts.
If the object still does not dislodge an ambulance should be called. If the child becomes unresponsive then cardiopulmonary resuscitation comprising rescue breaths and chest compressions should be initiated.
For a fuller description of what to do in the event of a choking incident refer to the latest guidelines for paediatric life support available from the Resuscitation Council (UK).
The Child Accident Prevention Trust leaflet, Finger Food without the Fear, can be obtained from their website at www.capt.org.uk.
Further details on Millie’s Mark accreditation are available through the Millie’s Trust website.