Hot Dogs, Marshmallows, Candy Choking Kids

Pediatricians Urge Warning Labels on Foods Risky to Kids

Medically Reviewed by Louise Chang, MD on February 22, 2010

Feb. 22, 2010 -- Every five days, a child in the United States chokes to death while eating. Even more children die after swallowing items like balloons and small toys.

Things have to change, says the American Academy of Pediatrics (AAP), perhaps starting with labels on hot dogs, marshmallows, and round or cylindrical hard candies, which pose a high choking risk to children.

In a policy statement released today, the group is also asking the FDA to establish a nationwide food related choking-incidence surveillance and reporting system “to warn the public of existing and emerging hazards.”

“This is a call to action,” pediatric emergency medicine specialist Gary A. Smith, MD, tells WebMD. “Choking is preventable; and government, industry, and consumer protection groups need to work together to protect children.”

Hot Dogs, Balloons Most Deadly

Very young children who are just beginning to eat solid foods have the highest choking risk, but older children are at risk too.

In a 2001 CDC review of choking injuries, about one-third of choking episodes occurred in infants and three-fourths occurred in children under the age of 3.

According to one analysis, each year in the U.S., between 66 and 77 children under the age of 10 die after choking on foods, and more than 10,000 children under age 15 are treated in emergency departments.

Hot dogs are the biggest culprits, Smith says, because they are cylindrical, compressible, and about the size of a young child’s airway.

Whole grapes, popcorn, peanuts, other nuts and seeds; round, hard candies; meat, marshmallows, carrots, apples, chewing gum, and chunks of peanut butter also pose a choking risk.

“Many of these foods ... share the same high-risk physical characteristics that create effective plugs for the pediatric airway,” the AAP report states. “Similar to latex balloons, peanut butter can conform to the airways and form a tenacious seal that is difficult to dislodge or extract.”

For every choking-related death, there are 100 ER visits every year, according to the CDC.

And choking is a leading cause of brain injury in young children. When food or other small objects get caught in the throat and block the airways, oxygen cannot get to the brain. Even a few minutes without oxygen can result in brain damage.

In one analysis of about 450 choking fatalities among children over two decades, the inhalation of latex balloons was responsible for 29% of deaths and 17% of deaths were caused by hot dogs.

Lessons From ‘Gel Candy’

Smith, who co-authored the AAP policy statement, says the FDA needs to take a more active role in protecting children from manufactured foods that pose a risk.

He directs the Center for Injury, Research and Policy at the Nationwide Children’s Hospital in Columbus, Ohio.

He cites a 2002 case where the FDA seized candy from a California manufacturer after several choking deaths were linked to the product in one California community.

The candies were thick fruit-flavored gels sucked from little cups about the size of a single-serve coffee creamer. The gels contained an ingredient called konjac, which does not dissolve easily in the mouth.

Smith says the FDA became aware of the candy only after a local paper broke the story of the deaths and a U.S. congressman introduced legislation to require warnings on the candies.

“The problem is there really isn’t a mechanism for the FDA to respond to this kind of problem,” he says. “It was a big deal for them to step in.”

The AAP policy statement recommends giving FDA the authority to:

  • Recall foods that pose “a significant and unacceptable choking hazard to the public”
  • Establish a nationwide surveillance and reporting system for food choking injury
  • Evaluate foods and require manufacturers to put warning labels on those that pose a high choking risk to children
  • Educate the public about the risk of food-related choking death among children, in collaboration with the U.S. Department of Agriculture, AAP and other groups.

Parents Need to Recognize Risk

Parents of young children need to recognize that choking is something that can happen to their child, and take steps to minimize the risk, Smith says.

That means cutting hot dogs lengthwise and in quarters, cutting grapes in quarters, and grating carrots instead of serving them to their children in coin shapes or sticks, he says.

And it is especially important to keep an eye on children when they are eating. Walking, running, talking, laughing and eating quickly all increase choking risk.

Pediatric emergency medicine specialist Richard Lichenstein, MD, tells WebMD that foods such as peanuts and sunflower seeds can also get lodged in the lungs, causing chronic bronchial infections.

Lichenstein is an associate professor in the Department of Pediatric and Emergency Medicine at the University of Maryland School of Medicine in Baltimore.

“This is not uncommon, but it is often missed,” he says. “And while it is not immediately life threatening, it can cause real problems.”

Show Sources


AAP Policy Statement – ‘Prevention of Choking Among Children’, Pediatrics, March 2010; vol 125: pp 601-607.

Smith, Gary A. Smith, MD, immediate past chairman, AAP Committee on Injury, Violence and Poison Prevention; director, Center for Injury, Research and Policy, Nationwide Children’s Hospital, Columbus, Ohio.

Richard Lichenstein, MD, associate professor, pediatric and emergency medicine, University of Maryland School of Medicine, Baltimore.

Harris, C.S., JAMA, 1984; vol 251: pp 2231-2235.

CDC: Choking Episodes Among Children, CDC web site.

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