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Appendix 6
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Nonfatal Choking on Food Among Children 14 Years or Younger in the United
States, 2001-2009
Article in PEDIATRICS · July 2013
DOI: 10.1542/peds.2013-0260 · Source: PubMed
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Appendix 6
Nonfatal Choking on Food Among Children 14 Years
or Younger in the United States, 2001–2009
AUTHORS: Meyli M. Chapin,a Lynne M. Rochette, PhD,a,b
WHAT’S KNOWN ON THIS SUBJECT: In 2001, an estimated 10 438
Joseph L. Annest, MS, PhD,c Tadesse Haileyesus, MS,c
children were treated in US emergency departments for nonfatal
Kristen A. Conner, MPH,a and Gary A. Smith, MD, DrPHa,d,e
choking on food. The foods most frequently associated with
aCenter for Injury Research and Policy, The Research Institute at
pediatric fatal choking are hot dogs, seeds, nuts, candy, and
Nationwide Children’s Hospital, Columbus, Ohio; bUnited States
certain types of fruits and vegetables.
Army Research Institute for the Behavioral and Social Sciences,
Fort Belvoir, Virginia; cDivision of Analysis, Research, and
WHAT THIS STUDY ADDS: From 2001 through 2009, an estimated
Practice Integration, National Center for Injury Prevention and
annual average of 12 435 children ages 0 to 14 years were treated
Control, Centers for Disease Control and Prevention, Atlanta,
Georgia; dThe Ohio State University College of Medicine,
in US emergency departments for nonfatal choking on food; 0- to
Columbus, Ohio; and eChild Injury Prevention Alliance, Columbus,
1982
4-year-olds accounted for 61.7% of episodes. Foods most
Ohio
frequently involved were candy, meat, bone, and fruits/vegetables.
KEY WORDS
Act
aspiration, choking, emergency department, epidemiology, injury
prevention, National Electronic Injury Surveillance System–All
Injury Program
ABBREVIATIONS
AAP
abstract
—American Academy of Pediatrics
CDC—Centers for Disease Control and Prevention
OBJECTIVE: The objective of this study was to investigate the epidemi-
CI—conﬁdence interval
ology of nonfatal choking on food among US children.
CPSC—Consumer Product Safety Commission
ED—emergency department
Information
METHODS: Using a nationally representative sample, nonfatal pediatric
FHSA—Federal Hazardous Substances Act
choking-related emergency department (ED) visits involving food for
NEISS–AIP—National Electronic Injury Surveillance System–All
Injury Program
2001 through 2009 were analyzed by using data from the National
RR—risk ratio
Electronic Injury Surveillance System–All Injury Program. Narratives
Ms Chapin prepared data for analysis, conducted data analyses
abstracted from the medical record were reviewed to identify choking
Official
with Drs Rochette and Smith, interpreted results, and wrote the
cases and the types of food involved.
ﬁrst draft of the manuscript; Dr Rochette participated in the
conceptualization of the study, supervised and conducted data
RESULTS: An estimated 111 914 (95% conﬁdence interval: 83 975–139
the
analyses, assisted with interpretation of results, and critically
854) children ages 0 to 14 years were treated in US hospital EDs from
reviewed the manuscript for revisions; Dr Annest participated in
2001 through 2009 for nonfatal food-related choking, yielding an
the conceptualization of the study, assisted with interpretation
of results, and critically reviewed the manuscript for revisions;
average of 12 435 children annually and a rate of 20.4 (95% conﬁdence
under
Mr Haileyesus prepared data for analysis, conducted
interval: 15.4–25.3) visits per 100 000 population. The mean age of children
preliminary data analyses with Dr Annest, assisted with
treated for nonfatal food-related choking was 4.5 years. Children aged
interpretation of results, and critically reviewed the manuscript
for revisions; Ms Conner assisted with data analysis and with
#1 year accounted for 37.8% of cases, and male children accounted for
interpretation of results and critically reviewed the manuscript
more than one-half (55.4%) of cases. Of all food types, hard candy was
for revisions; Dr Smith conceptualized the study, arranged for
most frequently (15.5% [16 168 cases]) associated with choking, followed
access to the data with Dr Annest, supervised all aspects of the
by other candy (12.8% [13 324]), meat (12.2% [12 671]), and bone (12.0%
study, reviewed and interpreted results, reviewed comments by
Released
co-authors, and revised the manuscript; and all authors
[12 496]). Most patients (87.3% [97 509]) were treated and released, but
approved the ﬁnal manuscript as submitted.
10.0% (11 218) were hospitalized, and 2.6% (2911) left against medical
(Continued on last page)
advice.
CONCLUSIONS: This is the ﬁrst nationally representative study to focus
solely on nonfatal pediatric food-related choking treated in US EDs over
a multiyear period. Improved surveillance, food labeling and redesign,
and public education are strategies that can help reduce pediatric
choking on food. Pediatrics 2013;132:275–281
PEDIATRICS Volume 132, Number 2, August 2013
275
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Appendix 6
Choking on food and nonfood sub-
2001, more than one-half (59.5% [10
the National Electronic Injury Surveil-
stances is a leading cause of childhood
438]) were associated with a food
lance System–All Injury Program
morbidity and mortality. In 2001, an
substance; candy/gum was the most
(NEISS-AIP). The NEISS is operated by
estimated 17 537 children ages 0 to 14
frequently cited food item.1 Food ac-
the CPSC to provide nationally repre-
years were treated in US emergency
counted for 75.7% of nonfatal choking-
sentative data on consumer product–
departments (EDs) for a nonfatal
related episodes among children ages
related ED visits using a stratiﬁed
choking episode involving food or
5 to 14 years, 58.4% among children ages
probability sample of ∼100 hospitals,
nonfood substances.1 Nonfood items
1 to 4 years, and 52.1% among children
including 7 children’s hospitals, which
often responsible for nonfatal choking
age ,1 year.1 According to the Centers
have 24-hour EDs with at least 6 beds in
episodes among children include toys
for Disease Control and Prevention
the United States and its territories.16
and coins.2–7 In recent decades, the US
(CDC), an average of 57 deaths among
The NEISS-AIP is a nationally represen-
Consumer Product Safety Commission
children ages 0 to 14 years due to in-
tative subsample of 66 of the NEISS
(CPSC) has responded to the problem
halation and ingestion of food causing
hospitals, which collects data on all
of hazardous toys by issuing numerous
obstruction of the respiratory tract oc-
types and external causes of nonfatal
1982
safety recalls and regulations. In 1994,
curred each year from 2001 through
injuries treated in the participating
the Federal Hazardous Substances Act
2009.13 High-risk foods presenting fatal
EDs, regardless of consumer product
Act
(FHSA) was amended by the Child
and nonfatal choking hazards to children
involvement. Each year, the NEISS-AIP
Safety Protection Act to require chok-
include hot dogs, hard candy, nuts/
collects data on ∼500 000 injury-
ing hazard warning labels on packag-
seeds, certain raw fruits and vegeta-
related ED visits. Trained NEISS-AIP
ing for small balls, balloons, marbles,
bles, and chewing gum.4–7,9,10,14,15 These
coders review all ED medical records
and other toys and games that contain
foods that present a choking risk to
at participating hospitals daily to ex-
small parts when these items are
children share many of the physical
tract data, including age, gender, prin-
intended for use by children in deﬁned
characteristics often described for
cipal diagnosis, primary body region
Information
age groups.8 This act also bans any
high-risk toys: cylindrical in shape,
affected (eg, airway-related events for
toy intended for use by children aged
airway sized, and compressible,
the current study), consumer products
,3 years that may pose a choking,
allowing a tight and complete occlu-
involved (eg, food for the current study),
aspiration, or ingestion hazard. In addi-
sion of a child’s airway. Despite the
disposition at ED discharge, locale
Official
tion, the FHSA deﬁnes test of an object
frequency of pediatric food-related chok-
where the event occurred, and a short
size by using the small-parts test ﬁxture,
ing, and the risk similarities to haz-
narrative abstracted from the medical
the
which simulates the mouth and pharynx
ardous toys, choking on food remains
record describing the precipitating
of a small child.4 An object is considered
a relatively underaddressed problem
event for each patient. Sample weights
a small part if it ﬁts completely within
in the United States.
are applied to provide national esti-
the small-parts test ﬁxture. Finally, the
mates of nonfatal injuries treated in
To the best of our knowledge, the cur-
under
Consumer Product Safety Improvement
US hospital EDs.16
rent study is the ﬁrst to comprehen-
Act of 2008 amended the FHSA to require
sively investigate nonfatal food-related
choking hazard warnings to be dis-
Data Selection
choking among children treated in US
played on or adjacent to Internet or
EDs over a multiyear period. The pre-
A food-related choking case for the
printed product advertisements that
vious study by the CDC evaluated non-
current study was deﬁned as any
provide a direct means for purchasing
Released fatalchokingepisodesamongchildren nonfatalchokingeventpresentingtoan
a product for which the FHSA requires
due to food and nonfood items during
NEISS-AIP hospital ED for children aged
a warning.4
only a single year (ie, 2001).1 The current
#14 years in which the patient choked
Despite these improvements in the
study provides a much more in-depth
on or aspirated a food item (including
safety and labeling of nonfood items
analysis of nonfatal food-related chok-
liquids other than water) and/or a food
distributed for children, studies have
ing over a 9-year period.
item was removed from the child’s
continually shown that the majority
airway or throat. An initial data ex-
of foreign bodies that cause choking-
METHODS
traction of the NEISS-AIP database from
related injuries are not toys but
2001 through 2009 was made, selecting
foods.1,2,9–12 Of the estimated 17 537
Data Source
nonfatal cases with an unintentional in-
nonfatal choking episodes reported
Nonfatal food-related choking data an-
jury diagnosis that had a precipitating
among children ages 0 to 14 years in
alyzed in this study were obtained from
cause indicating suffocation/inhalation
276
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ARTICLE
Appendix 6
and a product code involving foods (ex-
into 17 different categories: hard candy,
988–84 581]), followed by school (3.3%,
cluding hot water) or with the words
other candy (eg, gum, soft candy), meat
2384 cases [95% CI: 1416–3352]). Most
“choke” or “swallow” identiﬁed by a
(other than hot dogs), hot dogs, bone,
patients with food-related choking
keyword search of the narratives. The
fruits/vegetables, formula (including
were treated and released from the
narrative description for each patient’s
milk and breast milk), seeds/nuts/shells,
ED (87.3%, 97 509 cases [95% CI: 72
choking event was subsequently re-
chips/pretzels/popcorn, biscuits/cookies/
395–122 623]), whereas 10.0% (11 218
viewed by 1 of the study researchers to
crackers, bread/pastries, french fries,
cases [95% CI: 7614–14 822]) were
identify food-related choking cases and
noodles/pasta, multiple speciﬁed foods,
hospitalized and 2.6% (2911 cases
classify each case for type of food. Clas-
other foods, other/unspeciﬁed liquids,
[95% CI: 1455–4366]) left against medical
siﬁcation of all cases was then reviewed
and unknown.
advice.
by 3 other study researchers, and dif-
ferences in coding were resolved by
Statistical Analysis
Patient Age
consensus. Case narratives that stated
Study results were based on weighted
The mean 6 SE patient age in this study
difﬁculty breathing, foreign body sensa-
data for 2953 nonfatal choking-related
was 4.5 6 0.2 years. Patients aged #1
1982
tion, stuck in throat, or throat pain were
NEISS-AIP cases. Statistical analyses
year accounted for 37.8% (42 296 cases
retained. Cases in which the narrative
were performed by using SAS version
[95% CI: 30 832–53 760]) of all food-
Act
indicated smoke inhalation, submer-
9.2 (SAS Institute, Inc, Cary, NC) and
related choking episodes. The esti-
sion, strangulation, a breath-holding
SUDAAN release 10.0 (Research Triangle
mated number of choking episodes
spell, exposure to noxious or toxic sub-
Institute, Research Triangle Park, NC)
decreased with increasing age until
stances, or poisoning were excluded.
software. Sample weights for NEISS-AIP
age 7 years, after which the esti-
Cases were also excluded if the child
cases were used to calculate national
mated number remained relatively
choked on an unknown or nonfood item
food-related choking incidence esti-
unchanged through age 14 years
(including vomitus), if food was found
mates and risk ratios (RRs) with 95%
(Fig 1). There were 69 087 (95% CI:
Information
in the esophagus or ingested without
conﬁdence intervals (CIs).16 Data re-
51 946–86 229) food-related choking
mention of a foreign body sensation or
ported in this study are national esti-
episodes among children ages 0 to 4
choking, or if the only symptom was
mates unless otherwise speciﬁed.
years, 24 263 (95% CI: 16 384–32 141)
difﬁculty swallowing.
Missing values were not included in
episodes among children ages 5 to 9
Official
our analyses. Rates per 100 000 per-
years, and 18 564 (95% CI: 13 467–23 660)
Variables
sons were calculated by using 2001
episodes among children ages 10 to 14
through 2009 national population esti-
the
For analysis, NEISS-AIP variables were
years. Patients 0 to 4 years of age
mates acquired from the US Census
collapsed into broader categories to
experienced the highest rate of chok-
Bureau.17
increase statistical stability of national
ing during the study period (37.6 [95%
estimates. Consistent with previous
CI: 28.5–46.7]) episodes per 100 000
under
RESULTS
research on choking on food in the
population), followed by children ages
pediatric population, age was divided
An estimated 111 914 (95% CI: 83 975–
5 to 9 years (13.5 [95% CI: 9.2–17.8]
into 3 groups: 0 to 4 years, 5 to 9 years,
139 854) children ages 0 to 14 years
episodes per 100 000 population) and
and 10 to 14 years.1 In addition, single
presented to US hospital EDs from 2001
children ages 10–14 years (10.0
year of age for those aged 1 to 14 years
through 2009 for episodes of nonfatal
[95% CI: 7.3–12.7] episodes per 100 000
and month of age for children aged
Released ,1 food-related choking, with an average population).
year were used to calculate mean ages.
of 12 435 children per year (34 children
Disposition at ED discharge was col-
per day). The overall rate of food-
Patient Gender
lapsed into 3 categories: treated and
related choking during the study
Male patients accounted for 55.4%
released, hospitalized (including those
period was 20.4 (95% CI: 15.4–25.3)
(61 942 cases [95% CI: 46 411–77 474]) of
transferred to another hospital or held
episodes per 100 000 population. No
all food-related choking episodes. Al-
for observation), and left against medi-
signiﬁcant linear trend for the number
though not statistically signiﬁcant, the
cal advice. Event location was described
of choking episodes was found during
percentage of female patients treated
as home, school (including day care
the 9-year study period. Event location
for food-related choking episodes was
settings), and other. Case narratives
was identiﬁed for 73 247 cases (65.4%),
higher than that of male patients at
were used to generate a variable for
and the majority of these occurred at
several single age levels (ie, ,1 year,
type of food. Type of food was classiﬁed
home (89.8%, 65 785 cases [95% CI: 46
5 years, and 10 years) (Fig 1). The rate
PEDIATRICS Volume 132, Number 2, August 2013
277
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Appendix 6
males is similar to that observed
in previous studies, including both
fatal and nonfatal food-related chok-
ing episodes.1,2,14,18
The mean age for choking on foods
in this study was 4.5 years. Previous
investigations that included both food
and nonfood items have typically re-
ported a younger mean age; the most
hazardous age range for choking-
related injuries is reportedly younger
than 3 or 4 years,1,4–6,11,12,15 with several
FIGURE 1
studies ﬁnding more than one-half
Number of children presenting to US hospital EDs for food-related choking, grouped according to age and
of patients to be aged
gender (2001–2009).
,2 years.1,14,18
1982
In the current study, ∼62% of all non-
fatal cases occurred among children
of food-related choking episodes for
likely to require hospitalization than
Act
aged ,4 years. Compared with older
male subjects during the study period
those who choked on another type of
children, those ,4 years of age are
was 22.0 (95% CI: 16.6–27.4) episodes
food (RR = 2.23 [95% CI: 1.20–4.15]). In
at greater risk of food-related choking.
per 100 000 population and for female
addition, patients who choked on a
Before molars erupt (age #2 years),
subjects, it was 18.6 (95% CI: 13.9–23.3)
seed/nut/shell were more likely to re-
children are able to bite off a piece
episodes per 100 000 population.
quire hospitalization than those who
of food with their incisors but lack the
choked on another food type (RR = 2.58
ability to grind it adequately. By 3 to 4
Information
[95% CI: 1.56–4.25]).
Food Type
years of age, children have developed
The distribution of the most common
molars but are still learning to chew
The types of food that contributed to
food types involved in choking episodes
and swallow effectively. Children in this
choking episodes among children in
among patients ages 0 to 4 years, by
age range also may be easily dis-
this study are shown in Table 1. Of all
year of age, is displayed in Table 2. The
tracted and not focused on the task
Official
known food types, hard candy caused
number of choking episodes involving
of eating. In addition, behavioral fac-
the most choking episodes (15.5%),
candy (both hard and other candy
tors, such as high activity levels while
the
followed by other candy (12.8%), meat
combined) increased with increasing
eating, as well as developmental dis-
(other than hot dogs) (12.2%), and
age. By age 4 years, 55.2% of choking
abilities and neurologic conditions may
bone (12.0%). These 4 food types alone
episodes involved candy. In addition,
increase choking risk among young
accounted for more than one-half under
patients 0 to 4 years of age were more
children.4,6
(52.5%) of choking episodes with
likely to choke on fruits/vegetables than
a known food type. The mean age of
Similar to the study by the CDC in
patients aged 5 to 14 years (RR = 1.94
those treated for food-related choking
2001,1 the current study found that
[95% CI: 1.41–2.68]).
varied according to food type. Children
candy was the top contributor to
with bone-induced choking episodes
nonfatal food-related choking epi-
had a mean age of 7.6 years, whereas
DISCUSSION
sodes. In addition to candy, our study
Released
those with formula/milk/breast milk–
also identiﬁed meat, bone, and fruits/
This study estimated that .12 000
induced choking episodes had a mean
vegetables as common causes of non-
nonfatal choking-related injuries at-
age of 0.3 year (ie, 4 months). Although
tributable to food occurred annually
fatal food-related choking episodes
formula/milk/breast
milk
was
re-
from 2001 through 2009. This estimate
among children. Previous studies
sponsible for 6.7% of all food-related
is higher than that previously reported
have identiﬁed hot dogs, seeds, nuts,
choking, it accounted for more than
(10 438) by the CDC in a study of nonfatal
candy, and raw fruits/vegetables as the
one-third (36.3%) of the choking epi-
choking-related injuries in 2001.1 In the
most common foods associated with
sodes among children aged ,1 year.
current study, male subjects accounted
fatal choking episodes.2–7,14 Seeds/nuts/
Hot dogs accounted for 2.6% of food-
for a higher number of nonfatal food-
shells and hot dogs were the seventh
related choking (Table 1). Patients
related choking episodes than female
and 12th, respectively, most commonly
who choked on a hot dog were more
subjects. This higher frequency among
noted foods in our study of nonfatal
278
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ARTICLE
Appendix 6
d
d
d
b
episodes. These differences in asso-
%
9.7
6.7
6.5
4.6
3.1
2.9
2.6
2.3
0.8
0.6
1.3
6.4
15.5
12.8
12.2
12.0
ciated foods between fatal and nonfatal
5
4
0
85
choking episodes may be due in part
32
982
449
600
555
182
85
CI
96
84
52
9
to the physical characteristics of
–20 –16 –16 –17 –13 –10 –9059 –6507 –4632 –4559 –3697 –3507 –13 –10 –24 –9108 –10 –13
95%
83
45
45
51
22
63
2
5
4
5
011
37
35
25
31
97
certain foods. Hot dogs, for example,
9666
8893
7393
6594
3788
44
31
17
14
16
12
4272
46
12
83
are cylindrical in shape, similar in
l
e
diameter to a child
Tota
’s airway, and com-
d
d
d
168
324
671
496
075
83
914
pressible, allowing them to com-
Estimat
6985
6771
4826
3189
3005
2660
2385
874
670
13
6690
7743
al
1
16
13
12
12
10
11
pletely block a child’s hypopharynx
and resulting in an increased risk of
Nation
.
fatal injury. Some high-risk foods are
No
74
70
70
49
33
24
66
53
more dif
361
307
307
332
248
233
203
153
186
237
ﬁcult to chew (eg, raw fruits
29
Actual
and vegetables) or are frequently
d
d
d
b
c
c
c
c
c
c
consumed by the mouthful (eg, seeds,
%
6.1
4.9
2.6
2.5
2.8
7.8
1982
19.6
10.2
19.0
22.1
NR
NR
NR
NR
NR
NR
nuts, some candies), which may over-
482
480
326
whelm a child
58
94
15
74
45
88
’s chewing and swallowing
CI
c
c
c
c
c
c
Act
%
–10 –57 –98 –12 –37
–27 –1630
–1695 –1720
–43 –39 –55
abilities, resulting in aspiration of food
–2009
NR
NR
NR
NR
NR
NR
95
95
70
430
349
516
327
a
52
2443
5397
52
1217
1189
1895
1208
fragments.6
2001
30
Years
Although the CPSC has well-established
Food,
ate
surveillance systems in place, as well
of
–145
d
d
d
Estim
c
c
c
c R c R c R
827
as legislation and regulations to protect
Age
7889
4100
7645
8875
2466
NR
1981
1030
NR
1022
1118
NR
3120
2598
Types
42
ional
children from nonfood-related choking,
ﬁc
Nat
unstable.
no similar monitoring systems, legis-
Information
.
Speci
No
lation, or regulations currently exist
to
l
4
2
6
8
3
9
8
8N
2N
3N
54
51
43
25
34
87
57
16
10
18
22
1064
to address food-related choking among
due
Actua
r.
considered
e
children. The American Academy of
ar
d
d
d
erro
b %
7.9
5.7
7.5
5.9
4.6
3.1
2.4
3.2
1.1
0.8
2.1
5.6
Pediatrics (AAP) has proposed mea-
12.9
14.4
11.9
10.8
Official
Episodes
sures to prevent pediatric food-related
0
1
0
7
rounding
estimates
34
80
47
56
08
06
15
54
48
229
of
choking.4 These recommendations in-
CI
–10 –11 –71 –53 –10 –10 –6637 –5173 –4345 –31 –23 –3098 –11 –891 –2418 –5217 –7498 –86
the
Choking
clude instituting a mandatory system
95%
19
46
37
94
41
19
76
05
22
93
weighted
62
66
2904
1886
51
37
851
730
217
157
946
29
24
15
10
293
19
27
because
for
s
51
30%.
to label high-risk foods with appropri-
.
Year
e
because
ate information regarding their choking
EDs
100.0%
–4
to
0
d
d
d
risk to children, detailed surveillance
7
under
cases
Estimat
sum
variation
Age
683
08
8280
9224
5025
3621
7609
6930
4789
3796
2960
1983
1542
2051
524
1355
3570
5145
of
of food-related choking incidents, and
Hospital
al
69
counts.
not
y
atum.
public awareness campaigns to educate
US
cell
ma
NEISS-AIP
ﬁcient
to
Nation
str
20
the public about food-related choking
.
low
and
, coefa
No
to
on
hazards. The AAP recommends that the
65
45
36
41
25
22
63
99
89
or
197
205
121
104
194
230
152
110
180
due
types
sampling
18
US Food and Drug Administration take
esenting
based
1200
Pr
Actual
food
, within
the lead on these measures, while
Released
en
y
combined
known
working closely with the US Depart-
Age,
categories
estimate
Childr
0.27
0.29
0.46
0.28
0.31
0.05
0.32
0.32
0.18
0.61
0.74
0.51 e
0.66
0.29
0.54
0.61
0.17
for
variation
SE
were
ment of Agriculture (which has regula-
for
of
6
6 6 6 6 6 6 6 6 6 6 6 6
6 6 6 6 6
0
2
9
8
3
7
6
8
9
0
2
6
3.38
9
0
3
6
8
tory jurisdiction over meat products)
years
4.9
4.2
6.8
7.5
3.3
0.2
3.8
3.0
1.5
3.9
5.9
2.7
2.9
1.0
5.2
3.4
4.4
(NR)
weighed
ﬁcient
14
estimate
a
ted
and the CPSC. In addition, more detail
Mean
to
to
insuf
Number
10
of
in the medical records collected in EDs
repor
due
rs
national
and
and
dogs)
milk
of
not
about the type of foods involved and
ods
acke
because
Age
hot
fo
liquids
years
are
unstable
circumstances surrounding choking
east
Food
9
br
ﬁed
centage
be
table
than
iﬁed
to
y
episodes would help document the
of
ci
Mean
/shells
5
per
ookies/cr
es
ma
ndy
repor
her
/milk/
etzels/popcorn
spec
pasta
estimates
problem and provide data relevant
1
Type
astries
fri
oups
candy
ca
(ot
foods
not
s/vegetables
esents
s/pr
dogs
gr
is
to developing interventions aimed at pre-
d
er
at
e
ds/nuts
cuits/c
ltiple
dles/
nown
ead/p
er/unspe
er
Age
Repr
Estimates
TABLE
National
SE
Har
Oth
Me
Bon
Fruit
Formula
See
Chip
Bis
Mu
Hot
Br
French
Noo
Oth
Oth
Unk
Total
a
b
c
d
e
venting food choking among children. In
PEDIATRICS Volume 132, Number 2, August 2013
279
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Appendix 6
TABLE 2 Top 3 Types of Food Associated With Choking-Related US Hospital ED Visits for Children Ages 0 to 4 Years, 2001–2009
Age
First Type of Food
Second Type of Food
Third Type of Food
National Estimate
95% CI
%a
National Estimate
95% CI
%a
National Estimate
95% CI
%a
,1 y
Formula/milk/breast milk
Fruits/vegetables
Biscuits/cookies/crackers
6690
3640–9739
36.3
1906
807–3004
10.3
1626
723–2529
8.8
1 y
Fruits/vegetables
Seeds/nuts/shells
Other candy
3525
2105–4945
18.5
2617
1366–3868
13.7
2156
1019–3294
11.3
2 y
Hard candy
Other candy
Meat (other than hot dogs)
2186
1274–3098
22.4
1871
1084–2658
19.2
1012b
339–1685
10.4b
3 y
Other candy
Hard candy
Bone
2195
1322–3069
22.7
2121
1230–3013
22.0
1266b
325–2207
13.1b
4 y
Hard candy
Other candy
Meat (other than hot dogs)
2039
1072–3007
28.9
1853
997–2709
26.3
767b
173–1362
10.9b
a Represents percentage of national estimate for known food types in each age category.
b Estimates may be unstable due to a weighted estimate ,1200 or a coefﬁcient of variation .30%.
1982
addition, food manufacturers can play an
these recommendations. In addition,
short narratives provided by the
important role in prevention by using
the AAP recommends that young
NEISS-AIP were unable to provide
Act
population-based food choking data,
children should be supervised while
enough information for several addi-
such as those of the NEISS-AIP, to support
eating, should eat sitting down, and
tional variables we attempted to code,
efforts to better protect the public
should never run, walk, play, or
including adult presence during the
through changes in the design and
lie down with food in their mouth.4
choking event, concurrent activities of
manufacturing of food products con-
If a choking incident does occur,
the child when the choking occurred,
sumed by children, with the goal
caretakers can be prepared by being
how the child obtained the food, amount
of reducing the likelihood of pediatric
Information
familiar with and practicing choking-
of time between the choking event and
choking.
related rescue maneuvers.
the child presenting to the ED, whether
the food was prepared in a manner
Advice for Child Caregivers
Study Limitations
thought to reduce the likelihood of
Information from the current study
choking, the use and success of choking
As with all studies using prerecorded
Official
can alert medical and public health
rescue maneuvers, and the perfor-
data, the current study had some
professionals and others about the
mance of any diagnostic or therapeutic
limitations. First, we were unable to
the
potential dangers of choking on foods
medical procedures.
document all cases of choking on food,
and, speciﬁcally, which foods pose
for a number of reasons. For example,
the greatest risks to children. Child
choking episodes that resolved at
CONCLUSIONS
caregivers should also be aware of under
home or were treated in a medical
This is the ﬁrst multiyear, nationally
food choking prevention recommen-
facility other than an ED were not in-
representative study on nonfatal
dations and age guidelines provided by
cluded in this study. In addition, it
food choking among children. The
professional organizations, such as
was sometimes difﬁcult to discern
current study found that .12 000
the AAP. For example, the AAP recom-
what caused the choking event, which
nonfatal choking-related injuries
mends that children ,5 years of age
potentially
excluded
some
true
attributable to food occur each
Released
not be given hard candies or gum
food-related choking cases. The cases
year. Improved surveillance, food la-
and that raw fruits and vegetables be
reported in the current study thus may
beling and redesign, and public edu-
cut into small pieces.4 The current
not be representative of all cases
cation are strategies that can help
study provides evidence supporting
of food-related choking. Second, the
reduce pediatric food choking.
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Neck Surg. 2010;136(4):373–379
Information
Official
the
under
(Continued from ﬁrst page)
Released
The ﬁndings and conclusions in this article are those of the authors and do not necessarily represent the ofﬁcial positions of the Centers for Disease Control and
Prevention or the Department of the Army.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-0260
doi:10.1542/peds.2013-0260
Accepted for publication May 21, 2013
Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s
Dr, Columbus, OH 43205. E-mail: [email address]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.
FUNDING: Ms Chapin received support for this research from a scholarship stipend provided by the Centers for Disease Control and Prevention (grant
1R49CE001172).
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Appendix 6

Nonfatal Choking on Food Among Children 14 Years or Younger in the United
States, 2001 2009
−
Meyli M. Chapin, Lynne M. Rochette, Joseph L. Annest, Tadesse Haileyesus, Kristen
A. Conner and Gary A. Smith
; originally published online July 29, 2013;
2013;132;275
Pediatrics
DOI: 10.1542/peds.2013-0260
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Appendix 6

1982

Nonfatal Choking on Food Among Children 14 Years or Younger in the United
Act
States, 2001 2009
−
Meyli M. Chapin, Lynne M. Rochette, Joseph L. Annest, Tadesse Haileyesus, Kristen
A. Conner and Gary A. Smith
; originally published online July 29, 2013;
2013;132;275
Pediatrics
DOI: 10.1542/peds.2013-0260
Information

The online version of this article, along with updated information and services, is
located on the World Wide Web at:

/content/132/2/275.full.html

Official
the
under
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
Released
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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