Gagging, and why it is left alone
Gagging is a reflex that sits well forward in the mouth in a baby and gradually moves back over the first year. It is triggered easily, it looks alarming, and it is doing its job. The signs are noise, a tongue pushed forward, watering eyes, a red face and often a small retch that brings the food back to the front of the mouth.
The temptation is to reach in and fish the food out. That is the one thing not to do, because a finger in a gagging baby's mouth can push food backwards into the airway and turn a normal event into an emergency. The same applies to picking a baby up out of a highchair mid-gag and tipping them forward.
Choking looks different. It is silent, or close to it — a cough with no sound behind it, a face that goes from red to grey or blue, panic, and no air moving. A child who can cry, cough or speak has an airway. One who cannot does not.
If the cough still works
A loud, forceful cough is the most effective thing available for clearing an airway, better than anything a bystander can do. So a child who is coughing hard is encouraged to keep coughing, kept upright, and not left alone for a second. Nothing else is needed unless the cough weakens or goes quiet.
When the cough becomes silent or the child cannot breathe in, the sequence below starts, and someone shouts for help while it does.
A baby under one year
Babies under one get back blows and chest thrusts. Abdominal thrusts are not used under one at all — the liver sits low and unprotected in a baby and the risk of serious internal injury is real.
Five back blows. Sitting down helps. Lay the baby face down along a forearm or across the thigh, head lower than the chest, with the head and jaw supported by the hand — thumb and finger along the jaw, taking care not to press on the soft throat. Give up to five sharp blows between the shoulder blades with the heel of the other hand. Look in the mouth after each one and stop the moment the obstruction comes out.
Five chest thrusts. If the back blows have not worked, turn the baby face up along the forearm or thighs, still with the head lower than the feet. Place two fingertips on the breastbone, a finger's width below the nipple line, and push sharply downwards up to five times. These are sharper and slower than the compressions of resuscitation, and the aim is to force air up rather than to pump the heart. Check the mouth after each one.
A child over one year
Over one, it is back blows and abdominal thrusts.
Five back blows. A small child can go face down across a lap in the same way. A larger one is leaned well forward, supported across the chest with one arm, so that anything dislodged falls out rather than back down. Five sharp blows between the shoulder blades with the heel of the hand, checking after each.
Five abdominal thrusts. Standing or kneeling behind the child, both arms around the upper abdomen, a clenched fist placed between the navel and the bottom of the ribcage, the other hand gripping it, and a sharp pull inwards and upwards. Up to five, checking after each. The fist stays below the ribs — pressing on the lower ribcage is how ribs get broken.
Keeping going, and the 999 call
If three cycles of back blows and thrusts have not cleared it, that is the point at which the situation is not going to resolve itself. In practice the ambulance should be called sooner than that: as soon as it is clear the cough is not working, someone dials 999, puts the phone on speakerphone and leaves it on the floor, and the cycles continue without pause. The call handler will talk through the sequence, which is worth more than it sounds when panic has taken the technique away.
Nobody leaves the child to go and find a phone. Shouting for a neighbour is better than walking out of the room.
If the child goes limp and unresponsive, the airway is still blocked but the situation has changed: lower them onto a firm flat surface, look in the mouth and remove anything clearly visible and easy to grab — but no blind sweep with a finger — and begin resuscitation, which the 999 handler will talk through.
Afterwards, even when it worked
A child who has had chest or abdominal thrusts is seen by a doctor afterwards, every time, even if they are bouncing around ten minutes later. Two reasons: a fragment of whatever it was may still be lodged lower down, and the thrusts themselves can cause injury that does not announce itself straight away. Anything coughed up that is clearly only part of the object makes this urgent rather than precautionary.
If the airway cleared on its own with coughing and the child is entirely well, that does not need a hospital. A persistent cough, wheeze, noisy breathing or chest pain over the following days does, because an inhaled fragment that has gone down into a lung is easy to mistake for a chest infection.
Food
Most choking in young children happens at mealtimes, and most of it is preventable by changing the shape of what is on the plate rather than removing it.
Foods best left until a child is a competent eater:
- Whole grapes — close to the exact diameter of a small airway, smooth enough to seal it completely and difficult to shift once there. Cut lengthways, then quartered. The same goes for cherry tomatoes, cherries, blueberries and whole strawberries.
- Whole nuts — not before five. Chopped, flaked or ground is fine, and so is peanut butter spread thinly. A spoonful of peanut butter on its own is not, because a glob of it can seal an airway and will not come out with back blows.
- Popcorn — hard, irregular and prone to lodging. Also not before five.
- Round hard sweets, including mini eggs — slippery enough to go down whole and block completely.
- Marshmallows and jelly cubes — these become adhesive when wet, mould to the airway and resist back blows in a way that a solid object does not.
- Lollipops — fine until the sweet parts company with the stick, which it eventually does. Best avoided under three.
Preparation that makes the rest of it safe:
- Sausages and similar — skin removed, cut into short thin strips lengthways rather than into discs. A disc of sausage is the same shape problem as a grape.
- Meat and fish — bones, skin and fat removed, cut into thin strips rather than cubes.
- Hard fruit and vegetables — apple, carrot, melon, cucumber, pepper, celery: peeled and cut into narrow sticks, or grated, mashed, steamed or simmered soft for a younger child.
- Stones and pips out, always.
- Beans and chickpeas — mashed or cooked soft.
- Cheese — grated, or in narrow batons rather than cubes.
- Bread — brown or lightly toasted, in narrow strips. Soft white bread compresses into a dense ball that behaves very badly in a small throat.
- Dried fruit — chopped small, and not whole for a baby under one.
Two habits matter more than any of the above. One is that children eat sitting down and sitting still — walking, running, lying back, or being bounced on a knee while eating accounts for a good share of incidents. The other is that an adult stays in the room. Cutting the grapes and then going to answer the door is not the same as cutting the grapes.
A propped bottle is in a category of its own and should never be used. A baby left with a bottle wedged in place cannot stop the flow, and the result can be aspiration rather than simple choking, with consequences that develop over hours.
Everything that is not food
The rough test is a 2p coin: anything that size or smaller can block a young child's airway, and anything that fits in the mouth will end up there.
- Balloons are the worst of the non-food hazards — an uninflated one or a burst fragment is thin, wet and elastic, seals an airway completely and is almost impossible to pull out. Young children should not be the ones blowing them up, and burst pieces are picked up immediately, before a crawling baby reaches the floor.
- Small parts from older children's toys, which is the commonest route by which a hazard reaches a toddler in a house with more than one child. Toys sold for the under-threes should have no small parts; cheap toys bought from online marketplaces often do not meet that standard, and are worth a tug-test on eyes, wheels and buttons.
- Coins, buttons, beads, marbles, magnets, pen caps, batteries, screws and the general sediment of adult pockets, bags and sofas.
- Magnets deserve a separate mention. A single small magnet usually passes. Two or more can attract each other through the wall of the bowel and cause a perforation, and that is a hospital matter rather than a wait-and-see.
More on how this is dealt with room by room is under childproofing the home.
Button batteries are a different emergency
A swallowed button battery is widely assumed to be a choking hazard, and it usually is not. A coin cell lodged in the food pipe generates a current that burns through tissue, and it can reach a major blood vessel. The damage starts quickly, and a child can be entirely well in the meantime.
So if a button battery has been swallowed, or might have been, the response is straight to A&E, or 999. Not 111, not the GP, and not waiting to see whether symptoms appear.
- Nothing to eat or drink.
- Do not try to make the child sick.
- Take the packaging, or the gadget it came out of, so the battery can be identified by type and size.
There is no reliable symptom. Coughing, drooling, refusing solid food, pointing at the throat or chest, unexplained tummy upset, unusual quietness or lethargy can all appear, and all of them look like other things. Vomiting bright red blood is the one sign specific to this, and it means immediate emergency help.
Honey is sometimes mentioned, on the basis of animal studies suggesting it slows the reaction. It is not a treatment, it is not given to a child under one, it would need a couple of spoonfuls every ten minutes to do anything, and going to look for it delays the thing that actually matters. If an anaesthetic turns out to be needed, an empty stomach is better anyway. Getting to hospital is the whole of the advice.
Worth knowing where they are, because it is not only the obvious places: car keys, bathroom scales, thermometers, kitchen timers, remote controls, hearing aids, flameless candles, musical greetings cards, novelty slippers, light-up toys and shoes, and almost anything cheap that flashes. A battery that no longer powers the device still holds enough charge to do the damage, so used ones are not harmless.
Household products and medicines
Swallowing something harmful rather than something that blocks is a separate problem with a separate response, and it is covered under poisoning in children.
Learning it properly
The sequences above are accurate and they are not a substitute for having done it hands-on with a training manikin. The difference in a real event is substantial, and the training is short.
St John Ambulance and the British Red Cross both run paediatric first aid courses and both publish free step-by-step guidance and short videos that are worth watching once before they are needed rather than during. Many NHS health visiting teams and children's centres run free sessions locally, and it is worth asking.
Two things are worth doing today regardless. Watching one video of back blows and chest thrusts on a baby takes three minutes. And anyone else who looks after the child — a grandparent, a childminder, an older sibling old enough to be left briefly in charge — should have watched it too, because the person in the room is the one who has to do it.