As we begin our pediatric series, I thought it best to build on the previous article “Dysphagia in Children and Young Adults with Neuromuscular Disorders” by Lenie van den Engel-Hoek, PhD who in her opening paragraph introduces us to dysphagia and a relationship to choking.

Eating is a learned skill incorporating a myriad of complex neurophysiological processes that are impacted by a multitude of variables in the meal time environment, in the presentation by and expectations of the feeder, and in the inherent uniqueness of the pediatric patient, family and culture that we serve. Over this series we will delve into various aspects of typical/atypical feeding and swallowing.

For decades professionals have explored use of clinical techniques and research endeavors to provide improved oral feeding for children and thus optimize safety, growth, development, maturation and enhancement of mealtimes with family. Our ultimate goal has been optimization of feeding skills, enhancement of nutrition/hydration for growth and development, family interactions during meal times and support of cultural traditions.

Despite our diligence and understanding of feeding and swallowing disorders, our awareness of choking risk in pediatrics is often misaligned with current data. In 2010 the American Academy of Pediatrics (AAP) put forth a report, based on CDC data analysis, informing professionals that every 5 days a child in the United States does not survive a choking episode directly related to food. (Reference: American Academy of Pediatrics; The Committee on Injury Violence and Poison Prevention. (2010). Prevention of choking among children. Pediatrics, 125(3), 601-607. ) According to the CDC (Goetsch et al 2002) one of the many concerns associated with this alarming statistic is the realization that for every choking-related death in children ≤ the age of 14, an estimated 110 children were also treated in the emergency department for choking-related events. Choking events may be associated with complications such as pharyngeal irritation, respiratory tract infection, anoxia resulting from airway compromise, permanent neurological insult and death. These statistics do not include data regarding children treated by emergency medical personnel in which 55% of patients were not transported to the Emergency Department (ED), children treated in physician offices or pediatric deaths upon arrival to or during the visit to the emergency room.

As we analyze the data, we can determine that children under 1 year of age were identified at greatest risk for unintentional choking events. Children explore their world orally with toys, fingers, toes and toys, while growing experience with tolerance of texture, shape, temperature and experience while inhibiting gag response. As clinicians we can incorporate the additional consideration of feeding skill development with eruption of dental incisors around 6 to 7 months allowing for development of volitional biting, lingual lateralization and emerging jaw gradation (Stolovitz & Gisel, 1991). Anecdotally we understand that oft times foods are offered to children that are unintentionally above current chewing skill level.

Photo credit: Nongbri Family Pix / Foter / CC BY-NC-ND
Photo credit: Nongbri Family Pix / Foter / CC BY-NC-ND

Non-intentional choking risks persist even as the first molars for grinding erupt at approximately 14 months of age. By 9 months, an emerging inefficient chewing pattern emerges yet continues to become more efficient and coordinated between 12-48 months of age (Steeve, Moore, Green, Reilly, & Ruark McMurtrey, 2008). Dental eruption for biting and grinding, development of rotary chewing, and the transition from immature sucking patterns should guide the introduction of foods requiring grinding and increased effort (Carruth & Skinner, 2002; Delaney & Arvedson, 2008). As we better understand growth and development, we come to realize that by age 4 chewing skills are more similar to mature feeders, but continue to increase in efficiency with the eruption of teeth, growth of bony structures and learned experience.

Knowing the impact of neurophysiology and sensorineural complications (such as hypotonia and reduced postural stability) often inherent in special needs children, it would be logical for children with special needs to be at an increased choking risk. We must always be aware that chewing skills for managing different textures, different widths and different levels of cohesion develop at different rates for typically developing children as well as for those with special needs (Gisel, 1988). Physiological and behavioral feeding issues characteristic of meal times may differ for each child. This topic is quite extensive and should be explored in future articles.

The literature fluctuates with regard to recommended timelines for introducing different textures to children (Carruth & Skinner, 2002; Evans Morris & Dunn Klein, 2000; Stevenson & Allaire, 1991); however, general guidelines can be found through research. Confounding the issue is the lack of standardization in terminology. Physicians may recommend ‘table foods’, meaning pureed foods, at approximately one year of age. This term may be misunderstood by caregivers to mean all foods from the family table. Perhaps use of familiar foods would be beneficial. For example, as children transition from smooth pureed baby food to table food puree recommendations may be given as, ‘Pureed table food similar to mashed potatoes, guacamole, applesauce, or cream of wheat.’ In addition, as children are developing chewing skills they often overfill their mouths, are unable to determine appropriate bite size or how many pieces they can safely manage orally without increasing choking risk. To reduce choking risk, caregivers must actively supervise children during mealtimes while continuing to follow choking precautions and physician recommendations.

Role of the Feeding Specialist

Feeding and swallowing specialists use clinical experience, the available limited normative data, research review and caregiver input to strive to incorporate choking-prevention as a part of best evidence-based practice. As specialists we must take an active role in educating parents and care providers regarding the relationship between oral feeding skills and other facets of development (Delaney & Arvedson, 2008).

Direct therapeutic interventions provided by feeding therapists can further reduce a child’s risk of choking:

  • Utilizing oral-motor/sensory pathways to help the child be more aware of the location of the food in the mouth
  • Enhancing emerging skills to develop more efficient chewing may promote the child’s ability to handle different textures.
  • Making physician- approved diet modifications or changes to food presentation may increase safety while chewing skills develop.
  • Recommending modifications to mealtime routines:
    • decreasing distractions and movement during feeding
    • increasing caregiver supervision
    • optimizing seating and positioning
    • determining appropriate bite size
    • determining appropriate portion size to avoid overfilling the mouth
    • observing for sufficient chewing
    • avoiding foods that increase aspiration or choking risk especially for children under 4 years of age (hot dog, sausage link, grapes, bananas, popcorn, hard candy, gum, seeds, raisins, raw fruits or vegetables, spoonful of peanut butter)
    • reminding older children to take small bites and chew sufficiently
  • In conjunction with the medical team, reducing choking risk associated with medical conditions such as dysphagia, gastrointestinal, and pulmonary complications

Feeding therapists may also be involved in the recovery following a choking event. After negative experiences with foods offered prematurely or a spontaneous choking event, a child may develop negative behavioral responses, causing avoidance of similar foods. Once the underlying cause for the difficulty has been addressed to reduce choking risk, such as modification to food appropriate for chewing skill level, a full assessment of oromotor function is necessary to best define plan of care. As physiological supports are enhanced, behavioral feeding approaches may then need to be employed to increase acceptance of appropriate foods and reduction of learned negative behavioral responses.

Future insights into data collection on choking events with children may be gained with consideration of outcomes following ED visits, state and local data collection, exposure to high risk choking foods by age group, identification of any medical diagnoses or associated special needs, and mortality statistics.

Advocacy Efforts

In 2003 the Center for Science in the Public Interest, an advocacy group, and Representatives Mike Honda (D-CA) and Mike Ferguson (R-NJ) lobbied unsuccessfully for the bipartisan Food Choking Prevention Act requiring the Food and Drug Administration to develop food-labeling regulations. The regulations urged the food industry to place safety labels on such foods as hot dogs, grapes, candies and other common foods noted to be choking hazards for children. There have been some food companies that have volunteered to label foods, but the labels may be inconspicuous on the packaging.

Standardization of terminology would be beneficial for communication between physicians, affiliated professionals, caregivers, children and families. Consistent use of terms and common examples of food to be introduced may promote increased safety at meal times as well as consistency in plan of care with caregivers across settings including daycare, shared home environments, community outreach and school settings.

Educating ourselves and encouraging our caregivers be educated on CPR increases safety at meal times for children. The American Red Cross provides local chapters that offer education for professionals and families. Emergency preparedness supplements alternative modifications at mealtime to increase safety.

As part of the effort to educate caregivers and reduce choking risk in children, a coloring book entitled “Chewing Can Be Tricky” is available for free download:
Chewing Can Be Tricky-English Version

Chewing Can Be Tricky-Spanish Version

As feeding and swallowing specialists it is imperative that we remain cognizant of choking risks to children developing feeding skills, especially those with dysphagia. Along with health-care providers we can play a vital role in increasing educational opportunities during evaluations and therapy sessions through instruction on normal development and anticipatory guidance to reduce choking risks.



  1. American Academy of Pediatrics
  2. American Academy of Pediatrics
  3. American Academy of Pediatrics; The Committee on Injury Violence and Poison Prevention. (2010). Prevention of choking among children. Pediatrics, 125(3), 601-607.
  4. American Board of Swallowing and Swallowing Disorders
  5. Burklow, K. A., Phelps, A. N., Schultz, J. R., McConnell, K., & Rudolph, K. (1998). Classifying complex pediatric feeding disorders. Journal of Pediatric Gastroenterology & Nutrition, 27(2), 143-147.
  6. Carruth, B., & Skinner, J. (2002). Feeding behaviors and other motor development in healthy children (2- 24 months). Journal of the American College of Nutrition, 21(2), 88-96.
  7. Centers for Disease Control
  8. Choking prevention for children
  9. Delaney, A., & Arvedson, J. (2008). Development of swallowing and feeding: Prenatal through first year of life. Developmental Disabilities Research Reviews, 14, 105-117.
  10. Edwards, D & Martin Sara. (2011) Protecting Children as Feeding Skills Develop. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), October 2011, Vol. 20, 88-93. doi:10.1044/sasd20.3.88
  11. Evans Morris, S., & Dunn Klein, M. (2000). Pre-feeding skills: a comprehensive resource for mealtime development (2nd ed.). Austin, TX: PRO-ED.
  12. Gisel, E. (1988). Chewing cycles in 2- to 8-year-old normal children: A developmental profile. The American Journal of Occupational Therapy, 42(1), 40-46.
  13. Gotsch, K., Annest, J., Holmgreen, P., & Gilchrist, J. (2002). Nonfatal choking-related episodes among children-United States, 2001. Morb Mortal Wkly Rep, 51(42), 945–8. Retrieved from
  14. Hayes, N., & Chidekel, A. (2004). Pediatric choking. Delaware Medical Journal, 76(9), 335-340.
  15. Labels Urged for Food That Can Choke
  16. Pediatric Dysphagia   (professionals)
  17. Red Cross
  18. Steeve, R., Moore, C., Green, J., Reilly, K., & Ruark McMurtrey, J. (2008). Babbling, chewing, and sucking: Oromandibular coordination at 9 months. Journal of Speech Language and Hearing Research, 51(6), 1390-1404.
  19. Stevenson, R., & Allaire, J. (1991). The development of normal feeding and swallowing. Pediatric Clinics of North America, 38(6), 1439-1453.
  20. Stolovitz, P., & Gisel, E. (1991). Circumoral movements in response to three different food textures in children 6 months to 2 years of age. Dysphagia, 6, 17-2
  21. 2015 ACSLPA Conference on October 22-23 the Edmonton Marriott at River Cree Resort in Edmonton, Alberta.
    “Feeding and Swallowing in Preschool and School-aged Children: Building Capacity in the Community”
    ACSLPA Conference in Edmonton on October 22
    Alberta College of Speech-Language Pathologists and Audiologists
    Edmonton, Alberta.