Appendix 2
Food Related Choking in Children/Early
Learning Centres
(2011). "Preventing choking in children." Nursing
41(10): 56.
Aguiar, R. S., et al. (2018). "Physical hazards in dairy products: Incidence in a consumer
complaint website in Brazil." Food Control
86: 66-70.
The incidence of physical hazards in dairy products (2012–2016) was investigated
through a complaint website (Reclame Aqui) used by Brazilian consumers to report
complaints. Among the complaints, 2% referred to the presence of physical hazards
in the products. With regard to milk and dairy products, 515 complaints were
reported, with the greatest percentage for yogurt/milk drink (37%) followed by UHT
milk (14.6%) and milk powder (10.7%). The least cited products were Prato Cheese,
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Brie-type cheese, and Cottage cheese (0.3–0.4%). The most reported hazards were
the presence of foreign objects (42.4%), followed by insects (23.3%), hair (15.2%),
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plastics (11.1%), metal (6.2%) and fabric (1.8%). The results showed failures in both
Brazilian dairy foods processing and the public-sector inspection, and demonstrated
that the Internet has proven to be an effective tool for spreading consumer
dissatisfaction. © 2017 Elsevier Ltd
Anonymous (2011). "Preventing choking in children." Nursing
41(10): 56.
Information
Anonymous (2017). "Grapes are common cause of food-related choking." Emergency nurse
: the journal of the RCN Accident and Emergency Nursing Association
24(9): 12.
After hot dogs and sweets, grapes are the third most common cause of food-related
choking, a report concludes.
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Anonymous (2017). "Grapes pose danger of choking for under fives." Nursing children and
young people
29(1): 13.
the
Grapes eaten whole are the third-biggest cause of food-related choking in under
fives, according to research. More than half of fatal choking cases in this age group
are caused by food, most commonly hot dogs, sweets and grapes.
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Arantes, A. L. A. E., et al. (2018). "THE BABY-LED WEANING METHOD (BLW) IN THE
CONTEXT OF COMPLEMENTARY FEEDING: A REVIEW." METODO BABY-LED
WEANING (BLW) NO CONTEXTO DA ALIMENTACAO COMPLEMENTAR: UMA
REVISAO.
36(3): 353-363.
OBJECTIVE: To review the scientific findings on the baby-led weaning method
(BLW) in the context of complementary feeding., DATA SOURCES: Two
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independent examiners searched the Medical Literature Analysis and Retrieval
System Online (MEDLINE)/PubMed database in August 2016. No time-period was
defined for the publication dates. The following descriptors were used: "baby-led
weaning" OR "baby-led" OR "BLW". Inclusion criteria were: original studies that were
available in English, and which addressed the BLW method. Exclusion criteria were:
references in other languages, opinion articles and literature reviews, editorials and
publications that did not elaborate on the intended subject. Of the 97 references
identified, 13 were included in the descriptive synthesis., DATA SYNTHESIS: The
BLW group of babies, when compared to the traditional eating group, were less
prone to being overweight, less demanding of food, and ate the same foods as the
family. The number of choking episodes did not differ between groups. Mothers who
opted for the implementation of BLW had higher levels of schooling, held managerial
Appendix 2
positions at work, and were more likely to have breastfed until the sixth month of the
child's life. Concerns were raised about messes made during meals, wasting food,
and choking, but most of the mothers recommended adopting the method. Health
professionals were hesitant to indicate this method., CONCLUSIONS: BLW was
recommended by mothers who followed the method with their own children.
However, concerns have been reported, which, coupled with professionals' fears
about the inability of infants to self-feed, reflect a lack of knowledge about the
method.
Awadalla, N., et al. (2018). "Chew on This: Not All First Finger Foods Are Created Equal."
Clinical Pediatrics
57(8): 889-894.
The American Academy of Pediatrics (AAP) recommends when to start first finger
foods (FFFs) and what types of foods to start with, but it is unclear whether products
marketed as FFF comply with these recommendations. We evaluated FFF products
for compliance with AAP recommendations and product safety using 41 adult product
testers, who were asked to dissolve each product in their mouth. Product
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characteristics, comments pertaining to product safety, and time to dissolve each
product were recorded. Only 2 products met all AAP criteria, and safety concerns
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were raised for an additional 2 products. One product showed a large change in
dissolvability after being left out of original packaging. Consumers should not assume
that products marketed for infant/toddler consumption comply with AAP
recommendations. Also, products left out of original packaging may change
consistency, presenting a choking hazard. Additional research is warranted to guide
the development of regulations surrounding labeling and marketing of these foods. ©
2018, The Author(s) 2018.
Information
Bamber, A. R., et al. (2014). "Fatal aspiration of foreign bodies in infants and children." Fetal
and pediatric pathology
33(1): 42-48.
PURPOSE: To investigate the frequency, circumstances, demographics and autopsy
findings of infants and children dying as a result of foreign body aspiration.,
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METHODS: Retrospective review of autopsy cases in children aged between seven
days and 18 years, at one specialist centre over a 16-year period, in which death was
the
the result of aspiration of a foreign body., RESULTS: Ten cases were identified out of
a total autopsy population of 2165. Only one individual had an underlying diagnosis
potentially contributing to aspiration. All but one case involved aspiration of food, with
grapes being a feature of four cases. In cases with a prolonged survival interval,
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autopsy demonstrated bronchopneumonia and hypoxic-ischaemic encephalopathy.
In the remaining cases autopsy findings were non-specific., CONCLUSIONS: Fatal
aspiration of a foreign body is rare in this population. The cases involve normal
children who aspirate food, particularly grapes. There are typically minimal, non-
specific findings at autopsy.
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Bentivegna, K. C., et al. (2018). "Basic choking education to improve parental knowledge."
International journal of pediatric otorhinolaryngology
113: 234-239.
OBJECTIVE: To evaluate the effect of an educational intervention on parental
knowledge of choking hazards and prevention., METHODS: A quasi experimental
study was performed utilizing an internet based educational video intervention for
parents with a child 6 months to 4 years old presenting to a Pediatric Otolaryngology
clinic at a Level 1 pediatric hospital. Following the clinic visit, participants were sent a
choking video (intervention) or general safety video (control) with a pretest and
posttest knowledge survey (via email). An additional posttest knowledge survey was
sent 30 days later as a surrogate measure for knowledge retained over time.
Frequencies, chi square test, Independent t-test and McNemar's test were used for
statistical analyses., RESULTS: 202 participants viewed the video and completed
both the pretest and immediate posttest knowledge survey. Average change in total
Appendix 2
knowledge scores from the pretest to immediate posttest was statistically significant
between the intervention (mu=1.88, sigma=1.20) and control group (mu=0.14,
sigma=1.05); t (200)=-10.99, P<.001. This finding was consistent when assessing
change from the pretest to 30 day posttest between the intervention (mu=1.41,
sigma=1.32) and control group (mu=0.17, sigma=1.41); t (118)=-4.95, P<.001. A
majority of the knowledge questions (5 of 7) showed a significant change in score
from the pretest to immediate posttest (P=.001-.027). Additional analyses revealed
accuracy on 4 of 7 knowledge questions significantly changed from the pretest to 30
day later posttest (P<.001- .002)., CONCLUSION: The brief educational video overall
improved parental knowledge of choking hazards and prevention immediately after
the video and 30 days later. Importantly, improved parental knowledge may decrease
rates of choking among children. Copyright © 2018 Elsevier B.V. All rights reserved.
Boufersaoui, A., et al. (2013). "Foreign body aspiration in children: experience from 2624
patients." International journal of pediatric otorhinolaryngology
77(10): 1683-1688.
OBJECTIVES: The objective of this study is to analyze the epidemiological, clinical,
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radiological and endoscopic characteristics of pediatric foreign body aspiration in
Algeria., METHODS: In this retrospective study, the results of 2624 children younger
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than 18 years admitted in our department for respiratory foreign body removal
between 1989 and 2012, were presented. Most of them had an ambulatory rigid
bronchoscopy., RESULTS: The children (62.34% males and 37.65% females) were
aged 4 months to 18 years with 66% between 1 and 3 years. Choking was related in
65% of cases. The delay between aspiration and removal was 2-8 days in 65.8% and
within 24 h in 9.2%. In the most cases, the children arrived with cough, laryngeal or
bronchial signs and unilateral reduction of vesicular murmur. The examination was
normal in 13%. The most common radiologic finding was pulmonary air trapping
Information
(40.7%). The aspirated bodies were organic in 66.7%, dominated by peanuts, while
sunflower seeds, beans and ears of wheat were the most dangerous. In the other
cases, they were metallic or plastic as pen caps and recently scarf pins. The
endoscopic removal by rigid bronchoscopy was successful and complete in 97%.
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Cases with extraction failure (3%) limited to certain FBs, all of them inorganic were
assigned to surgery. The complications related to the endoscopic procedure were
the
0.29% with a mortality of 0.26%., CONCLUSION: Foreign body aspiration is a real
public health problem in Algeria. The best way to manage it is an early diagnosis and
a rigid bronchoscopy removal under general anesthesia used by fully trained staff.
The prevention of this domestic accident should consider the population lifestyle and
under
cultural habits to be more effective. Copyright © 2013 Elsevier Ireland Ltd. All rights
reserved.
Brkic, F., et al. (2018). "Death as a Consequence of Foreign Body Aspiration in Children."
Medical archives (Sarajevo, Bosnia and Herzegovina)
72(3): 220-223.
Aim: To analyze the rate of mortality in children with foreign body aspiration (FBA).,
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Methods: We outlined a retrospective review of hospital data of patients between
1971 and 2013. FBA occurring in children 0 year to 14 years was considered for
inclusion (patient ages ranged from 0.6 to 15 years, with a median age of 2.2 years).
The gender structure within the investigated cases was 75.8% males and 24.2%
females. During the study period, 772 patients undergoing rigid bronchoscopy with
the diagnosis of FBA were included. Deaths on arrival were excluded., Results: Total
rate of mortality (for whole investigated period) was 0.785. For last fifteen years of
the investigated period the rate of mortality was zero., Conclusion: For prevention of
foreign body aspiration in children and its mortality should be taken two strategies:
non-medical (alterations in product design and public education campaigns) and
medical (education of medical staff and improvement of equipment).
Appendix 2
Brown, A. (2018). "No difference in self-reported frequency of choking between infants
introduced to solid foods using a baby-led weaning or traditional spoon-feeding approach."
Journal of Human Nutrition and Dietetics
31(4): 496-504.
Background: Baby-led weaning (BLW) where infants self-feed family foods during the
period that they are introduced to solid foods is growing in popularity. The method
may promote healthier eating patterns, although concerns have been raised
regarding its safety. The present study therefore explored choking frequency
amongst babies who were being introduced to solid foods using a baby-led or
traditional spoon-fed approach. Methods: In total, 1151 mothers with an infant aged
4–12 months reported how they introduced solid foods to their infant (following a
strict BLW, loose BLW or traditional weaning style) and frequency of spoon-feeding
and puree use (percentage of mealtimes). Mothers recalled if their infant had ever
choked and, if so, how many times and on what type of food (smooth puree, lumpy
puree, finger food and specific food examples). Results: In total, 13.6% of infants
(n = 155) had ever choked. No significant association was found between weaning
style and ever choking, or the frequency of spoon or puree use and ever choking. For
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infants who had ever choked, infants following a traditional weaning approach
experience significantly more choking episodes for finger foods (F2,147 = 4.417,
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P = 0.014) and lumpy purees (F2,131 = 6.46, P = 0.002) than infants following a strict
or loose baby-led approach. Conclusions: Baby-led weaning was not associated with
increased risk of choking and the highest frequency of choking on finger foods
occurred in those who were given finger foods the least often. However, the
limitations of noncausal results, a self-selecting sample and reliability of recall must
be emphasised. © 2017 The British Dietetic Association Ltd.
Cameron, S. L., et al. (2012). "Healthcare professionals' and mothers' knowledge of,
Information
attitudes to and experiences with, Baby-Led Weaning: A content analysis study." BMJ open
2(6).
Objective: Baby-Led Weaning (BLW) is an alternative approach for introducing
complementary foods to infants that emphasises infant self-feeding rather than adult
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spoon-feeding. Here we examined healthcare professionals' and mothers' knowledge
of, attitudes to and experiences with, BLW. Design, setting and participants:
the
Healthcare professionals (n=31) and mothers who had used BLW (n=20) completed
a semistructured interview using one of two tailored interview schedules examining
their knowledge of, attitudes to and experiences with, BLW. Interview notes and
transcripts were analysed using content analysis to identify subcategories and extract
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illustrative quotes. Results: Healthcare professionals had limited direct experience
with BLWand the main concerns raised were the potential for increased risk of
choking, iron deficiency and inadequate energy intake. Although they suggested a
number of potential benefits of BLW (greater opportunity for shared family meal
times, fewer mealtime battles, healthier eating behaviours, greater convenience and
possible developmental advantages) most felt reluctant to recommend BLW because
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of their concern about the potential increased risk of choking. In contrast, mothers
who had used this style of feeding reported no major concerns with BLW. They
considered BLW to be a healthier, more convenient and less stressful way to
introduce complementary foods to their infant and recommended this feeding
approach to other mothers. Although mothers did not report being concerned about
choking, 30% reported at least one choking episode-most commonly with raw apple.
Conclusions: Given the lack of research on BLW, further work is needed to determine
whether the concerns expressed by healthcare professionals and potential benefits
outlined by mothers are valid. The current study suggests that there is a mismatch
between healthcare professionals' and mothers' knowledge of, attitudes to and
experiences, with BLW.
Appendix 2
Cameron, S. L., et al. (2012). "How feasible is Baby-Led Weaning as an approach to infant
feeding? A review of the evidence." Nutrients
4(11): 1575-1609.
Abstract: Baby-Led Weaning (BLW) is an alternative method for introducing
complementary foods to infants in which the infant feeds themselves hand-held foods
instead of being spoon-fed by an adult. The BLW infant also shares family food and
mealtimes and is offered milk (ideally breast milk) on demand until they self-wean.
Anecdotal evidence suggests that many parents are choosing this method instead of
conventional spoon-feeding of purées. Observational studies suggest that BLW may
encourage improved eating patterns and lead to a healthier body weight, although it
is not yet clear whether these associations are causal. This review evaluates the
literature with respect to the prerequisites for BLW, which we have defined as
beginning complementary foods at six months (for safety reasons), and exclusive
breastfeeding to six months (to align with WHO infant feeding guidelines); the gross
and oral motor skills required for successful and safe self-feeding of whole foods
from six months; and the practicalities of family meals and continued breastfeeding
on demand. Baby-Led Weaning will not suit all infants and families, but it is probably
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achievable for most. However, ultimately, the feasibility of BLW as an approach to
infant feeding can only be determined in a randomized controlled trial. Given the
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popularity of BLW amongst parents, such a study is urgently needed. © 2012 by the
authors; licensee MDPI, Basel, Switzerland.
Cameron, S. L., et al. (2015). "Development and pilot testing of Baby-Led Introduction to
SolidS--a version of Baby-Led Weaning modified to address concerns about iron deficiency,
growth faltering and choking." BMC pediatrics
15: 99.
BACKGROUND: In Baby-Led Weaning (BLW), infants are offered 'finger' foods from
the start of the complementary feeding period instead of being spoon-fed. Healthcare
Information
professionals have expressed concerns about adequacy of iron and energy intake,
and about choking, for infants following Baby-Led Weaning., METHODS: We
developed a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to
address these concerns. In a 12-week pilot study, families who had chosen to use a
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BLW approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants
received 2 intervention visits, resources and on-call support. BLW participants
the
received no intervention. Participants were interviewed weekly for 12 weeks and
completed a three-day weighed record or three 24-h iron questionnaires., RESULTS:
Compared to the BLW group, the BLISS group were more likely to introduce iron
containing foods during the first week of complementary feeding, and to offer more
under
serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P =
0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P =
0.027)., CONCLUSIONS: This pilot study suggests BLISS may result in higher iron
intakes and lower choking risk than unmodified BLW. However, the results need to
be confirmed in a large randomised controlled trial.
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Cameron, S. L., et al. (2013). "Parent-led or baby-led? Associations between
complementary feeding practices and health-related behaviours in a survey of New Zealand
families." BMJ open
3(12).
Objective: To determine feeding practices and selected health-related behaviours in
New Zealand families following a 'baby-led' or more traditional 'parent-led' method for
introducing complementary foods. Design, setting and participants: 199 mothers
completed an online survey about introducing complementary foods to their infant.
Participants were classified into one of four groups: 'adherent baby-led weaning
(BLW)', the infant mostly or entirely fed themselves at 6-7 months; 'self-identified
BLW', mothers reported following BLWat 6-7 months but were using spoon-feeding
at least half the time; 'parentled feeding', the mother reported not having tried BLW;
and 'unclassified method', the mother reported they were not following BLWat 6-7
months but reported the infant mostly or entirely fed themselves at 6-7 months.
Appendix 2
Results: 8% were following 'adherent BLW', 21% 'selfidentified BLW' and 0% were
following the 'unclassified method'. Compared with 'self-identified BLW' and 'parent-
led feeding', a higher proportion of the 'adherent BLW' met the WHO
recommendations to exclusively breastfeed for 6 months and to introduce
complementary foods at 6 months. The 'adherent BLW' group was more likely to
have family foods ( p=0.018), and less likely (p=0.002) to have commercially
prepared baby food. Both BLW groups were more likely to share meals with the
family compared with 'parent-led feeding'. In contrast to 'self-identified BLW' and
'parentled feeding', the 'adherent BLW' group did not offer iron-fortified cereal as a
first food. Conclusions: This study suggests that although many parents consider
they follow BLW, a very few are following it strictly. The extent to which BLW was
followed was associated with potential benefits (eg, sharing family meals) and risks
(eg, low iron first foods) highlighting the importance for health professionals and
researchers of accurately determining the extent of adherence to BLW.
Cameron, S. L., et al. (2015). "Development and pilot testing of Baby-Led Introduction to
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SolidS - a version of Baby-Led Weaning modified to address concerns about iron deficiency,
growth faltering and choking." BMC pediatrics
15(1).
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Background: In Baby-Led Weaning (BLW), infants are offered 'finger' foods from the
start of the complementary feeding period instead of being spoon-fed. Healthcare
professionals have expressed concerns about adequacy of iron and energy intake,
and about choking, for infants following Baby-Led Weaning. Methods: We developed
a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to address
these concerns. In a 12-week pilot study, families who had chosen to use a BLW
approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants
received 2 intervention visits, resources and on-call support. BLW participants
Information
received no intervention. Participants were interviewed weekly for 12 weeks and
completed a three-day weighed record or three 24-h iron questionnaires. Results:
Compared to the BLW group, the BLISS group were more likely to introduce iron
containing foods during the first week of complementary feeding, and to offer more
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serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P =
0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P =
the
0.027). Conclusions: This pilot study suggests BLISS may result in higher iron
intakes and lower choking risk than unmodified BLW. However, the results need to
be confirmed in a large randomised controlled trial. © 2015 Cameron et al.
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Casalini, A. G., et al. (2013). "Foreign body aspiration in adults and in children: advantages
and consequences of a dedicated protocol in our 30-year experience." Journal of
bronchology & interventional pulmonology
20(4): 313-321.
BACKGROUND: Foreign body (FB) inhalation is a potentially life-threatening
emergency also in clinically stable patients as the situation could worsen at any
moment. There is varying opinion regarding the urgency for removal of inhaled FBs,
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and there are no guidelines in the literature. The aim of our study was to present our
experience with FB aspiration in children and adults from 1993, when we introduced
our Thoracic Endoscopy Service with the availability "on call" of a bronchologist 24
hours a day, 7 days a week, defining a dedicated protocol together with our
anaesthesiologists for prompt intervention in this situation., METHODS: We
consulted our database and examined the records of all patients undergoing
bronchoscopy for suspected FB aspiration from 1993 onwards; our previous
experience of 11 children and 14 adults with FBs from 1981 to 1992 was also
included to compare the results obtained., RESULTS: In this period, we removed 159
FBs (in 70 children and 89 adults) and performed 23 negative bronchoscopies in
children and 6 in adults for suspected aspiration. All FBs were removed successfully.
We were able to intervene immediately also in critical situations: in 60/70 children
within 24 hours of admission to hospital, in 44 of these 60 on the actual day of
Appendix 2
admission, thus avoiding a potentially dangerous delay between aspiration and
removal. We had no complications, and no patients needed surgery.,
CONCLUSIONS: We conclude that an efficient organization involving a dedicated
protocol of intervention, trained staff available 24 hours a day, 7 days a week,
appropriate setting, and the right instrumentation enabled us to tackle this important
emergency.
Chapin, M. M., et al. (2013). "Nonfatal choking on food among children 14 years or younger
in the united states, 2001-2009." Pediatrics
132(2): 275-281.
OBJECTIVE: The objective of this study was to investigate the epidemiology of
nonfatal choking on food among US children. METHODS: Using a nationally
representative sample, nonfatal pediatric choking-related emergency department
(ED) visits involving food for 2001 through 2009 were analyzed by using data from
the National Electronic Injury Surveillance System-All Injury Program. Narratives
abstracted from the medical record were reviewed to identify choking cases and the
types of food involved. RESULTS: An estimated 111 914 (95% confidence interval:
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83 975-139 854) children ages 0 to 14 years were treated in US hospital EDs from
2001 through 2009 for nonfatal food-related choking, yielding an average of 12 435
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children annually and a rate of 20.4 (95% confidence interval: 15.4-25.3) visits per
100 000 population. The mean age of children treated for nonfatal food-related
choking was 4.5 years. Children aged ≥1 year accounted for 37.8% of cases, and
male children accounted for more than one-half (55.4%) of cases. Of all food types,
hard candy was most frequently (15.5% [16 168 cases]) associated with choking,
followed by other candy (12.8% [13 324]), meat (12.2% [12 671]), and bone (12.0%
[12 496]). Most patients (87.3% [97 509]) were treated and released, but 10.0% (11
218) were hospitalized, and 2.6% (2911) left against medical advice.
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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-
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281 © 2013 by the American Academy of Pediatrics.
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Cheek, J. A. and D. Egerton-Warburton (2014). "Dangers of eating vegetables: contralateral
perfusion deficit with an inhaled foreign body." Emergency medicine Australasia : EMA
26(4): 411-412.
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Cheng, J., et al. (2017). "The public health resource utilization impact of airway foreign
bodies in children." International journal of pediatric otorhinolaryngology
96: 68-71.
Objective Quantify the resource utilization associated with airway foreign bodies in
children in the United States using a national database and report observed trends
over time. Study type: Cross-sectional analysis of national inpatient database with
weighted estimates. Data source The KID database (2000–2009). Methods ICD-9-
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DM codes for foreign body aspiration were used to identify patients to be included for
investigation. Admission rates and charges were aggregated and compared among
geographic region, location, and teaching hospital status. These factors were then
also trended over time. Results From 2000 to 2009, airway foreign body diagnoses in
children accounted for an estimated 4000 to 5000 admissions, resulting in a mean
admission rate of 6.6 per 10,000 pediatric patients annually. Charges related to
airway foreign bodies in children rose from a total of $93 million to $486 million in the
observed period. There is an increasing trend over time of total charges per patient.
Charges appear to be higher in urban locations and teaching hospitals. Conclusions
The public health and economic burden of pediatric airway foreign bodies appears to
be rising. Further investigation may be helpful to examine factors that may be
contributing to increasing charges and creating strategies to improve cost
Appendix 2
effectiveness, as well as why there seems to be increased resource utilization in
urban locations and teaching hospitals. © 2017 Elsevier B.V.
Cheng, J., et al. (2019). "National estimations of airway foreign bodies in children in the
United States, 2000 to 2009." Clinical Otolaryngology
44(3): 235-239.
Objective: Identify risk factors associated with airway foreign bodies in children in the
United States and report observed trends over time. Data source: KID database
(2000-2009). Methods: ICD-9-CM codes for airway foreign bodies were used to
identify patients. Risk factors were used for univariate analysis and a multivariate
model to identify any increased risk of mortality. These factors were then also
trended over time. Results: Children with airway foreign bodies demonstrate similar
risk factors as previously reported, such as male gender, age less than five years
and lack of private insurance. The weighted mortality rate for paediatric inpatients
with airway foreign bodies was about 2.75%. Fortunately, the rate remained relatively
unchanged from 2000 to 2009. Geographically, urban hospital settings appeared to
be more affected. Increased risks of mortality were noted for older age, urban
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hospital setting and teaching hospital status. Conclusions: Our findings confirm
previous findings and identified that the diagnosis of airway foreign bodies in children
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were associated with male gender, age <5 years, lack of private insurance and
geographic location in an urban setting. Further investigation may be warranted to
provide clarity on other factors found to have increased association with mortality for
quality improvement. © 2018 John Wiley & Sons Ltd
Chinski, A., et al. (2010). "Foreign bodies causing asphyxiation in children: the experience of
the Buenos Aires paediatric ORL clinic." The Journal of international medical research
38(2):
655-660.
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Inhalation or aspiration of a foreign body (FB) occurs relatively frequently in young
children. The size, shape, type and site of arrest of the FB lead to variability in the
clinical picture. The present study included data from 65 cases of FB inhalation
presenting over 1 year at the Children's Hospital Gutierrez, Buenos Aires, Argentina,
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compared with information from four well-known published case series chosen as
representative of other cultural and geographical backgrounds: the USA, Europe,
the
North Africa (Egypt) and Asia (India). The mean age of children studied was 4.03
years. Injuries happened mainly at home (53 cases [81.54%]) and under adult
supervision (59 cases [90.77%]). The most frequently inhaled FB was nuts, however,
in contrast to previous reports, the majority of incidents involved inhalation of an
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inorganic, rather than an organic (food) FB. Complications included pneumonia
(three cases), atelectasis (two cases) and pneumonitis (one case). No deaths were
recorded. These data suggest that children play with objects inappropriate for their
age, such as pins and nails, that adults may not be aware of the choking risks, and
that more effort is required in educating caregivers about these risks.
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Choroomi, S. and J. Curotta (2011). "Foreign body aspiration and language spoken at home:
10-year review." The Journal of laryngology and otology
125(7): 719-723.
OBJECTIVE: To review foreign body aspiration cases encountered over a 10-year
period in a tertiary paediatric hospital, and to assess correlation between foreign
body type and language spoken at home., STUDY DESIGN AND METHOD:
Retrospective chart review of all children undergoing direct laryngobronchoscopy for
foreign body aspiration over a 10-year period. Age, sex, foreign body type,
complications, hospital stay and home language were analysed., RESULTS: At direct
laryngobronchoscopy, 132 children had foreign body aspiration (male:female ratio
1.31:1; mean age 32 months (2.67 years)). Mean hospital stay was 2.0 days. Foreign
bodies most commonly comprised food matter (53/132; 40.1 per cent), followed by
non-food matter (44/132; 33.33 per cent), a negative endoscopy (11/132; 8.33 per
cent) and unknown composition (24/132; 18.2 per cent). Most parents spoke English
Appendix 2
(92/132, 69.7 per cent; vs non-English-speaking 40/132, 30.3 per cent), but non-
English-speaking patients had disproportionately more food foreign bodies, and
significantly more nut aspirations (p = 0.0065). Results constitute level 2b evidence.,
CONCLUSION: Patients from non-English speaking backgrounds had a significantly
higher incidence of food (particularly nut) aspiration. Awareness-raising and public
education is needed in relevant communities to prevent certain foods, particularly
nuts, being given to children too young to chew and swallow them adequately.
Chung, P. H. Y., et al. (2012). "Peanut aspiration: an avoidable life-threatening condition."
Hong Kong medical journal = Xianggang yi xue za zhi
18(4): 340-342.
Foreign body aspiration is a potentially fatal condition. Yet, an accurate diagnosis
may not be easy. Management is also challenging and requires a high level of
expertise with proper instruments. In this article, we report our experience in the
management of peanut aspiration in two young children by means of a ventilating
bronchoscope.
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Cichero, J. A. Y. (2016). "Introducing solid foods using baby-led weaning vs. spoon-feeding:
A focus on oral development, nutrient intake and quality of research to bring balance to the
Act
debate." Nutrition Bulletin
41(1): 72-77.
The World Health Organization recommends that infants be introduced to first solid
foods from 6 months of age to complement milk feeds. The introduction of
complementary foods is required to help infants meet their changing nutritional
requirements. In recent years, baby-led weaning and spoon-feeding have been
discussed as mutually exclusive approaches to introducing first solids. Baby-led
weaning advocates that babies direct and control the process of weaning, deciding
what they will eat, how much and how quickly. There is an emphasis on parents
Information
providing chunks of soft food that babies can pick up and chew. A traditional spoon-
feeding approach involves introducing smooth runny purees as the texture for first
foods and progressing to chewable solids as oral motor skills develop. Spoon-feeding
provides an opportunity for infants to develop oral skills necessary for safe
Official
management of solids and may facilitate intake of iron-rich foods at weaning, whilst
baby-led weaning promotes greater participation in family meals and exposure to
the
family foods. The need to supervise infants whilst eating to avoid risk of choking on
food is required for both approaches. The review highlights the need for quality, well-
designed research on different approaches to the introduction of first solid foods and
suggests that a combined approach to baby-led weaning should be considered. ©
under
2016 British Nutrition Foundation.
Committee on Injury, V. and P. Poison (2010). "Prevention of choking among children."
Pediatrics
125(3): 601-607.
Choking is a leading cause of morbidity and mortality among children, especially
those aged 3 years or younger. Food, coins, and toys are the primary causes of
Released
choking-related injury and death. Certain characteristics, including shape, size, and
consistency, of certain toys and foods increase their potential to cause choking
among children. Childhood choking hazards should be addressed through
comprehensive and coordinated prevention activities. The US Consumer Product
Safety Commission (CPSC) should increase efforts to ensure that toys that are sold
in retail store bins, vending machines, or on the Internet have appropriate choking-
hazard warnings; work with manufacturers to improve the effectiveness of recalls of
products that pose a choking risk to children; and increase efforts to prevent the
resale of these recalled products via online auction sites. Current gaps in choking-
prevention standards for children's toys should be reevaluated and addressed, as
appropriate, via revisions to the standards established under the Child Safety
Protection Act, the Consumer Product Safety Improvement Act, or regulation by the
CPSC. Prevention of food-related choking among children in the United States has
Appendix 2
been inadequately addressed at the federal level. The US Food and Drug
Administration should establish a systematic, institutionalized process for examining
and addressing the hazards of food-related choking. This process should include the
establishment of the necessary surveillance, hazard evaluation, enforcement, and
public education activities to prevent food-related choking among children. While
maintaining its highly cooperative arrangements with the CPSC and the US
Department of Agriculture, the Food and Drug Administration should have the
authority to address choking-related risks of all food products, including meat
products that fall under the jurisdiction of the US Department of Agriculture. The
existing National Electronic Injury Surveillance System-All Injury Program of the
CPSC should be modified to conduct more-detailed surveillance of choking on food
among children. Food manufacturers should design new foods and redesign existing
foods to avoid shapes, sizes, textures, and other characteristics that increase
choking risk to children, to the extent possible. Pediatricians, dentists, and other
infant and child health care providers should provide choking-prevention counseling
to parents as an integral part of anticipatory guidance activities.
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Cyr, C., et al. (2012). "Preventing choking and suffocation in children." Paediatrics and Child
Act
Health
17(2): 91-92.
Choking, suffocation, and strangulation cause serious unintentional injuries in
children and are leading causes of unintentional death in infants and toddlers. Nearly
all choking, suffocation and strangulation deaths and injuries are preventable. The
present statement reviews definitions, epidemiology and effective prevention
strategies for these injuries. Recommendations that combine approaches for
improving safety, including research, surveillance, legislation and standards, product
design and education, are made. Paediatric health care providers should be
Information
encouraging parents and other caregivers to learn CPR and choking first aid, as well
as offering anticipatory, age-appropriate guidance to prevent these injuries, at regular
health visits.
Official
da Costa, S. P., et al. (2017). "Exposure to texture of foods for 8-month-old infants: Does the
size of the pieces matter?" Journal of texture studies
48(6): 534-540.
the
This study examined the effect of meals varying in amount, size, and hardness of
food pieces on the development of the chewing capabilities of 8-month-old infants.
The study also examined changes in shivering, gagging, coughing, choking, and their
ability to eat from a spoon. In an in-home setting two groups were given commercially
under
available infant meals and fruits, purees with either less, smaller and softer or more,
larger and harder pieces. Both groups were given these foods for 4 weeks and were
monitored several times during this period. After the 4-week exposure period infants
in both groups were given the same five test foods. Structured questionnaires with
questions on eating behavior and the child's development were conducted 6 times in
the 4 to 12-month period and video analyses of feedings were conducted 4 times
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between 8 and 9 months. After the 4-week exposure period, the group that had been
exposed to the foods with more, larger and harder pieces showed a significantly
higher rating for chewing a piece of carrot and potato for the first time, but not for a
piece of banana nor for mashed foods. Shivering, gagging, coughing, choking, and
ability to eat from a spoon were not different between the two groups. These results
contribute to the insight that exposure to texture is important for young children to
learn how to handle texture. PRACTICAL APPLICATIONS: (a) The study shows the
feasibility of testing the effects of texture interventions on chewing capability and oral
responses such as gagging, coughing, and choking in infants. (b) The study
contributes to the insight that exposure to food texture to learn how to handle texture
is important for infants and showed that exposing children to a higher amount of
larger pieces improves their chewing capability for a piece of carrot and potato, at
least immediately after the intervention. Copyright © 2017 Wiley Periodicals, Inc.
Appendix 2
Daniels, L., et al. (2015). "Baby-Led Introduction to SolidS (BLISS) study: a randomised
controlled trial of a baby-led approach to complementary feeding." BMC pediatrics
15: 179.
BACKGROUND: In 2002, the World Health Organization recommended that the age
for starting complementary feeding should be changed from 4 to 6 months of age to 6
months. Although this change in age has generated substantial debate, surprisingly
little attention has been paid to whether advice on how to introduce complementary
foods should also be changed. It has been proposed that by 6 months of age most
infants will have developed sufficient motor skills to be able to feed themselves rather
than needing to be spoon-fed by an adult. This has the potential to predispose infants
to better growth by fostering better energy self-regulation, however no randomised
controlled trials have been conducted to determine the benefits and risks of such a
"baby-led" approach to complementary feeding. This is of particular interest given the
widespread use of "Baby-Led Weaning" by parents internationally.,
METHODS/DESIGN: The Baby-Led Introduction to SolidS (BLISS) study aims to
assess the efficacy and acceptability of a modified version of Baby-Led Weaning that
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has been altered to address potential concerns with iron status, choking and growth
faltering. The BLISS study will recruit 200 families from Dunedin, New Zealand, who
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book into the region's only maternity hospital. Parents will be randomised into an
intervention (BLISS) or control group for a 12-month intervention with further follow-
up at 24 months of age. Both groups will receive the standard Well Child care
provided to all parents in New Zealand. The intervention group will receive additional
parent contacts (n = 8) for support and education on BLISS from before birth to 12
months of age. Outcomes of interest include body mass index at 12 months of age
(primary outcome), energy self-regulation, iron and zinc intake and status, diet
quality, choking, growth faltering and acceptability to parents., DISCUSSION: This
Information
study is expected to provide insight into the feasibility of a baby-led approach to
complementary feeding and the extent to which this method of feeding affects infant
body weight, diet quality and iron and zinc status. Results of this study will provide
important information for health care professionals, parents and health policy
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makers., TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry
ACTRN12612001133820 . the
D'Auria, E., et al. (2018). "Baby-led weaning: what a systematic review of the literature adds
on." Italian journal of pediatrics
44(1): 49.
The term weaning describes the time period in which a progressive reduction of
under
breastfeeding or the feeding of infant-formula takes place while the infant is gradually
introduced to solid foods. It is a crucial time in an infant's life as not only does it
involve with a great deal of rapid change for the child, but it is also associated with
the development of food preferences, eating behaviours and body weight in
childhood and also in adolescence and adulthood.Therefore, how a child is weaned
may have an influence later, on the individual's entire life. Babies are traditionally first
Released
introduced to solid foods using spoon-feeding, in most countries.Beside to traditional
approach, an alternative method, promoting infant self-feeding from six months of
age, called baby-led weaning or "auto-weaning", has grown in popularity. This
approach causes concern to healthy professionals and parents themselves as data
from observational studies pointed out to a potential risk of iron and energy
inadequacy as well as choking risk. Aim of this systematic review was to critically
examine the current evidence about baby-led weaning approach and to explore the
need for future research.A systematic search was conducted in Cochrane library
databases and DARE (Database of Abstract of Reviews of Effects), EMBASE and
MEDLINE in the period 2000-2018 (up to March 1st) to address some key questions
on baby-led weaning. Prisma guidelines for systematic reviews has been
followed.After the inclusion/exclusion process, we included for analysis of evidence
12 articles, 10 observational cross-sectional studies and 2 randomized controlled
Appendix 2
trials. Pooling of results from very different outcomes in the studies included was not
possible. Both randomized trials have potential bias; therefore, the quality of the
evidence is low.There are still major unresolved issues about baby-led weaning that
require answers from research and that should be considered when advices are
requested from health professionals by parents willing to approach this method.
Dogan, E., et al. (2018). "Baby-led complementary feeding: Randomized controlled study."
Pediatrics international : official journal of the Japan Pediatric Society
60(12): 1073-1080.
BACKGROUND: Baby-led weaning (BLW) is an approach to introducing solid foods
to infants that gives control of the feeding process to the infant. Anecdotal evidence
suggests that BLW is becoming popular with parents, but scientific research is limited
to a few publications. This study assessed growth, hematological parameters and
iron intake in 6-12-month-old infants fed by traditional or baby-led complementary
feeding., METHODS: We recruited 280 healthy 5-6-month-old infants allocated to a
control (traditional spoon feeding; TSF) group or an intervention (BLW) group in a
randomized controlled trial. Infant growth, hematologic parameters and iron intake
1982
were evaluated at age 12 months., RESULTS: Infants in the TSF were significantly
heavier than those in the BLW group. Mean weight in the BLW group was 10.4 +/-
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0.9 kg compared with 11.1 +/- 0.5 kg in the TSF group. There was no statistically
significant difference in the iron intake from complementary foods between the BLW
(7.97 +/- 1.37 mg/day) and TSF (7.90 +/- 1.68 mg/day) participants who completed
the diet records. Hematologic parameters were similar at 12 months. The incidence
of choking reported in the weekly interviews was not different between the groups.,
CONCLUSIONS: To the best of our knowledge, this is the first randomized -
controlled study to have examined the impact of weaning method on iron intake,
hematological parameters and growth in breast-fed infants. BLW can be an
Information
alternative complementary feeding type without increasing the risk of iron deficiency,
choking or growth impairment. Copyright © 2018 Japan Pediatric Society.
Fangupo, L. J., et al. (2016). "A baby-led approach to eating solids and risk of choking."
Official
Pediatrics
138(4).
Objective: To determine the impact of a baby-led approach to complementary
the
feeding on infant choking and gagging. METHODS: Randomized controlled trial in
206 healthy infants allocated to control (usual care) or Baby-Led Introduction to
SolidS (BLISS; 8 contacts from antenatal to 9 months providing resources and
support). BLISS is a form of baby-led weaning (ie, infants feed themselves all their
under
food from the beginning of complementary feeding) modified to address concerns
about choking risk. Frequencies of choking and gagging were collected by
questionnaire (at 6, 7, 8, 9, 12 months) and daily calendar (at 6 and 8 months); 3-day
weighed diet records measured exposure to foods posing a choking risk (at 7 and 12
months). RESULTS: A total of 35% of infants choked at least once between 6 and 8
months of age, and there were no significant group differences in the number of
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choking events at any time (all Ps >.20). BLISS infants gagged more frequently at 6
months (relative risk [RR] 1.56; 95% confidence interval [CI], 1.13-2.17), but less
frequently at 8 months (RR 0.60; 95% CI, 0.42-0.87), than control infants. At 7 and
12 months, 52% and 94% of infants were offered food posing a choking risk during
the 3-day record, with no significant differences between groups (7 months: RR 1.12;
95% CI, 0.79-1.59; 12 months: RR 0.94; 95% CI, 0.83-1.07). CONCLUSIONS:
Infants following a baby-led approach to feeding that includes advice on minimizing
choking risk do not appear more likely to choke than infants following more traditional
feeding practices. However, the large number of children in both groups offered
foods that pose a choking risk is concerning. © 2016 by the American Academy of
Pediatrics.
Appendix 2
Fangupo, L. J., et al. (2016). "A Baby-Led Approach to Eating Solids and Risk of Choking."
Pediatrics
138(4).
OBJECTIVE: To determine the impact of a baby-led approach to complementary
feeding on infant choking and gagging., METHODS: Randomized controlled trial in
206 healthy infants allocated to control (usual care) or Baby-Led Introduction to
SolidS (BLISS; 8 contacts from antenatal to 9 months providing resources and
support). BLISS is a form of baby-led weaning (ie, infants feed themselves all their
food from the beginning of complementary feeding) modified to address concerns
about choking risk. Frequencies of choking and gagging were collected by
questionnaire (at 6, 7, 8, 9, 12 months) and daily calendar (at 6 and 8 months); 3-day
weighed diet records measured exposure to foods posing a choking risk (at 7 and 12
months)., RESULTS: A total of 35% of infants choked at least once between 6 and 8
months of age, and there were no significant group differences in the number of
choking events at any time (all Ps > .20). BLISS infants gagged more frequently at 6
months (relative risk [RR] 1.56; 95% confidence interval [CI], 1.13-2.17), but less
frequently at 8 months (RR 0.60; 95% CI, 0.42-0.87), than control infants. At 7 and
1982
12 months, 52% and 94% of infants were offered food posing a choking risk during
the 3-day record, with no significant differences between groups (7 months: RR 1.12;
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95% CI, 0.79-1.59; 12 months: RR 0.94; 95% CI, 0.83-1.07)., CONCLUSIONS:
Infants following a baby-led approach to feeding that includes advice on minimizing
choking risk do not appear more likely to choke than infants following more traditional
feeding practices. However, the large number of children in both groups offered
foods that pose a choking risk is concerning. Copyright © 2016 by the American
Academy of Pediatrics.
Feltbower, S., et al. (2015). "Fatal and near-fatal grape aspiration in children." Pediatric
Information
emergency care
31(6): 422-424.
Choking remains an important cause of morbidity and mortality in young children.
Whole seedless grapes are a popular fruit snack to give to young children.We
present 3 cases of grape aspiration, discussing the emergency care from basic life
Official
support to specialist treatment.The lessons learned will be applicable to a wide range
of health professionals from frontline emergency medical service personnel to
the
physicians and nurses working in a hospital.
Gardner, H. G., et al. (2010). "Policy statement - Prevention of choking among children."
Pediatrics
125(3): 601-607.
under
Choking is a leading cause of morbidity and mortality among children, especially
those aged 3 years or younger. Food, coins, and toys are the primary causes of
choking-related injury and death. Certain characteristics, including shape, size, and
consistency, of certain toys and foods increase their potential to cause choking
among children. Childhood choking hazards should be addressed through
comprehensive and coordinated prevention activities. The US Consumer Product
Released
Safety Commission (CPSC) should increase efforts to ensure that toys that are sold
in retail store bins, vending machines, or on the Internet have appropriate choking-
hazard warnings; work with manufacturers to improve the effectiveness of recalls of
products that pose a choking risk to children; and increase efforts to prevent the
resale of these recalled products via online auction sites. Current gaps in choking-
prevention standards for children's toys should be reevaluated and addressed, as
appropriate, via revisions to the standards established under the Child Safety
Protection Act, the Consumer Product Safety Improvement Act, or regulation by the
CPSC. Prevention of food-related choking among children in the United States has
been inadequately addressed at the federal level. The US Food and Drug
Administration should establish a systematic, institutionalized process for examining
and addressing the hazards of food-related choking. This process should include the
establishment of the necessary surveillance, hazard evaluation, enforcement, and
Appendix 2
public education activities to prevent food-related choking among children. While
maintaining its highly cooperative arrangements with the CPSC and the US
Department of Agriculture, the Food and Drug Administration should have the
authority to address choking-related risks of all food products, including meat
products that fall under the jurisdiction of the US Department of Agriculture. The
existing National Electronic Injury Surveillance System - All Injury Program of the
CPSC should be modi.ed to conduct more-detailed surveillance of choking on food
among children. Food manufacturers should design new foods and redesign existing
foods to avoid shapes, sizes, textures, and other characteristics that increase
choking risk to children, to the extent possible. Pediatricians, dentists, and other
infant and child health care providers should provide choking-prevention counseling
to parents as an integral part of anticipatory guidance activities. Copyright © 2010 by
the American Academy of Pediatrics.
Iversen, R. H. and T. E. Klug (2012). "Need for more clear parental recommendations
regarding foreign body aspiration in children." Danish medical journal
59(9): A4498.
1982
INTRODUCTION: Foreign body (FB) aspiration is a common cause of respiratory
emergency in early childhood and is associated with a high rate of airway distress.
Act
FB aspiration peaks at the age of 1-2 years. Factors placing children at higher risk
include incomplete dentition, immature swallowing coordination and the tendency to
be easily distracted while eating. Symptoms may vary from an un-affected child to
impending airway failure. Mucosal cough receptors often accommodate and the child
may be asymptomatic when evaluated., MATERIAL AND METHODS: Files of
children (0-15 years) admitted with suspected FB aspiration were reviewed. Patients
were included if the FB was confirmed by bronchoscopy., RESULTS: Among 136
children undergoing bronchoscopy, a FB was confirmed in 59 patients. The median
Information
age was one year. All children had a history of aspiration and in 48% a persistent
cough was present at the initial examination. Eleven children (19%) had a normal
physical examination at admission. Nuts were identified in 34% and carrots in 20%.
Of the FBs removed, 86% were organic and 14% were inorganic. Organic FBs were
Official
more common in patients younger than three years (p < 0.001)., CONCLUSION:
Parental suspicion of FB aspiration indicates acute bronchoscopy in children, even in
the
case of no abnormal findings. The completion of the bronchoscopy within 24 hours
facilitates the examination and reduces the risk of complications. We recommend
increased awareness of the hazards associated with small crunchy organic food
items, especially nuts and carrots, given to children under three years of age.,
under
FUNDING: not relevant., TRIAL REGISTRATION: not relevant.
Levin, R. A. and G. A. Smith (2010). "Choking prevention among young children." Pediatric
annals
39(11): 721-724.
Lumsden, A. J. and J. G. Cooper (2017). "The choking hazard of grapes: a plea for
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awareness." Archives of disease in childhood
102(5): 473-474.
Deaths from choking are a major cause of childhood mortality, especially in the very
young. Whole grapes are ideally suited to cause paediatric airway obstruction and,
though regularly implicated, knowledge that this popular fruit, and other similarly
shaped foods, is a choking hazard is not widespread. We present the cases of three
children who presented to our institution after grape aspiration. Increased
dissemination of the learning points among health professionals working with children
may aid in the prevention of further episodes. Copyright Published by the BMJ
Publishing Group Limited. For permission to use (where not already granted under a
licence) please go to http://www.bmj.com/company/products-services/rights-and-
licensing/.
Appendix 2
Marduel Boulanger, A. and M. Vernet (2018). "Introduction of new food textures during
complementary feeding: Observations in France." Archives de pediatrie : organe officiel de
la Societe francaise de pediatrie
25(1): 6-12.
INTRODUCTION: Complementary feeding plays a crucial role in the development of
infants and toddlers and studies suggest benefits specific to the introduction of food
textures., OBJECTIVES: Evaluate the recommendations given to parents, their
practices, and their attitudes towards the introduction of food textures during
complementary feeding in France., METHODS: This was a cross-sectional pilot study
conducted in 2013. One hundred and eighty-one parents with at least one child aged
6-36 months living in France completed an ad hoc questionnaire., RESULTS: Eighty-
eight percent of the parents surveyed received oral information on complementary
feeding, but only 46% received such information on the introduction of food textures.
Pediatricians were the most frequently listed source of oral information on
complementary feeding. More than half the parents also looked for additional
information in books and on the internet. While oral recommendations matched
parents' practices, they seemed to occur at a later age compared to infants'
1982
physiological ability to handle new textures. The quality of information on food texture
advice available in paper and electronic formats evaluated using a 4-point scale was
Act
found to be limited. Introducing new food texture was spontaneously reported as the
most common difficulty in complementary feeding (16%). Fear of choking when first
introducing food pieces was reported by 54% of the parents., CONCLUSIONS: The
parents' lack of information on the introduction of food textures, as well as their fear
that their child may choke, should encourage providing new recommendations in
France. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Mohammad, M., et al. (2017). "Foreign body aspiration in children: A study of children who
Information
lived or died following aspiration." International journal of pediatric otorhinolaryngology
98:
29-31.
Foreign body aspiration (FBA) is a preventable cause of mortality and morbidity in
children. We conducted a chart review of children who presented to a university
Official
hospital due to FBA in the period 1999-2014. Children were either managed with
bronchoscopy for removal of the foreign body or died due to FBA. A total of 103
the
children were seen due to FBA including 27 deaths. The majority of children were
boys and were less than 3 years old. Most aspirated foreign bodies were food-
related, mainly peanuts. The majority of children presented with acute choking
incidents, a smaller number presented with recurrent chest infections, and few
under
children's choking incidents were unwitnessed. X-ray had a high rate of false
negatives and bronchoscopy was the gold standard technique for assessment and
management. Aspiration of foreign bodies is a preventable, life-threatening condition
that calls for increased parent education and awareness. Copyright © 2017 Elsevier
B.V. All rights reserved.
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Morison, B. J., et al. (2016). "How different are baby-led weaning and conventional
complementary feeding? A cross-sectional study of infants aged 6-8 months." BMJ open
6(5).
Objectives: To compare the food, nutrient and 'family meal' intakes of infants
following baby-led weaning (BLW) with those of infants following a more traditional
spoon-feeding (TSF) approach to complementary feeding. Study design and
participants: Cross-sectional study of dietary intake and feeding behaviours in 51
age-matched and sex-matched infants (n=25 BLW, 26 TSF) 6-8 months of age.
Methods: Parents completed a questionnaire, and weighed diet records (WDRs) on
1-3 non-consecutive days, to investigate food and nutrient intakes, the extent to
which infants were self-fed or parent-fed, and infant involvement in 'family meals'.
Results: BLW infants were more likely than TSF infants to have fed themselves all or
most of their food when starting complementary feeding (67% vs 8%, p<0.001).
Appendix 2
Although there was no statistically significant difference in the large number of infants
consuming foods thought to pose a choking risk during the WDR (78% vs 58%,
p=0.172), the CI was wide, so we cannot rule out increased odds with BLW (OR,
95% CI: 2.57, 0.63 to 10.44). No difference was observed in energy intake, but BLW
infants appeared to consume more total (48% vs 42% energy, p<0.001) and
saturated (22% vs 18% energy, p<0.001) fat, and less iron (1.6 vs 3.6 mg,
p<0.001), zinc (3.0 vs 3.7 mg, p=0.001) and vitamin B12 (0.2 vs 0.5 μg, p<0.001)
than TSF infants. BLW infants were more likely to eat with their family at lunch and at
the evening meal (both p≤0.020). Conclusions: Infants following BLW had similar
energy intakes to those following TSF and were eating family meals more regularly,
but appeared to have higher intakes of fat and saturated fat, and lower intakes of
iron, zinc and vitamin B12. A high proportion of both groups were offered foods
thought to pose a choking risk. © 2016, BMJ Publishing Group. All rights reserved.
Morison, B. J., et al. (2016). "How different are baby-led weaning and conventional
complementary feeding? A cross-sectional study of infants aged 6-8 months." BMJ open
1982
6(5): e010665.
OBJECTIVES: To compare the food, nutrient and 'family meal' intakes of infants
Act
following baby-led weaning (BLW) with those of infants following a more traditional
spoon-feeding (TSF) approach to complementary feeding., STUDY DESIGN AND
PARTICIPANTS: Cross-sectional study of dietary intake and feeding behaviours in
51 age-matched and sex-matched infants (n=25 BLW, 26 TSF) 6-8 months of age.,
METHODS: Parents completed a questionnaire, and weighed diet records (WDRs)
on 1-3 non-consecutive days, to investigate food and nutrient intakes, the extent to
which infants were self-fed or parent-fed, and infant involvement in 'family meals'.,
RESULTS: BLW infants were more likely than TSF infants to have fed themselves all
Information
or most of their food when starting complementary feeding (67% vs 8%, p<0.001).
Although there was no statistically significant difference in the large number of infants
consuming foods thought to pose a choking risk during the WDR (78% vs 58%,
p=0.172), the CI was wide, so we cannot rule out increased odds with BLW (OR,
Official
95% CI: 2.57, 0.63 to 10.44). No difference was observed in energy intake, but BLW
infants appeared to consume more total (48% vs 42% energy, p<0.001) and
the
saturated (22% vs 18% energy, p<0.001) fat, and less iron (1.6 vs 3.6 mg, p<0.001),
zinc (3.0 vs 3.7 mg, p=0.001) and vitamin B12 (0.2 vs 0.5 mug, p<0.001) than TSF
infants. BLW infants were more likely to eat with their family at lunch and at the
evening meal (both p<=0.020)., CONCLUSIONS: Infants following BLW had similar
under
energy intakes to those following TSF and were eating family meals more regularly,
but appeared to have higher intakes of fat and saturated fat, and lower intakes of
iron, zinc and vitamin B12. A high proportion of both groups were offered foods
thought to pose a choking risk. Copyright Published by the BMJ Publishing Group
Limited. For permission to use (where not already granted under a licence) please go
to http://www.bmj.com/company/products-services/rights-and-licensing/
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Nichols, B. G., et al. (2012). "Pediatric exposure to choking hazards is associated with
parental knowledge of choking hazards." International journal of pediatric
otorhinolaryngology
76(2): 169-173.
OBJECTIVE: To evaluate parental knowledge regarding household food and non-
food choking hazards., DESIGN: Cross Sectional Survey., SETTING: Tertiary Care
Children's Hospital., PARTICIPANTS: Parents presenting to a Pediatric
Otolaryngology Clinic with a child <4 years old., METHODS: Parental survey asking
which choking hazard foods (CHF) they allow their child to eat, previous instruction of
CHF, knowledge of non-food choking hazards, and their knowledge sources.,
STATISTICS: adjusted odds ratios (AOR) and logistic regressions., RESULTS: 492
respondents. Adjusted for significant covariates associations between correct
knowledge of CHF and correct parents actions of disallowing CHF: fruit chunks (prior
Appendix 2
instruction=42%; correct action=25%; AOR=3.51; P<0.0001), hot dogs (59%; 28%;
1.75; 0.0178), raw vegetables (41%; 47%; 1.28; 0.198) popcorn (67%; 49% 2.64;
<0.0001), whole grapes (68%; 51%; 2.2; <0.0001), nuts (73%; 66%; 2.47; <0.0001),
chunks of peanut butter (45%; 79%; 2.55; 0.0003), sticky candy (79%; 80%; 2.16;
<0.0033), gum (72%; 84%; 1.75; 0.028), seeds (65%; 87%; 1.4; 0.247), 76% always
supervise meals, 57% always cut food, 62% know CPR. KNOWLEDGE OF NON-
FOOD HAZARDS: Coins (97%), marbles (94%), small batteries (93%), small toy
parts (93%), dice (92%), pen caps (92%), safety pins (85%), balloons (84%),
syringes (40%). Sources of choking hazard knowledge: physicians (67%),
family/friends (52%), books/magazines (40%), and the Internet (25%).,
CONCLUSIONS: Parental knowledge of CHF is incomplete. The consumption of
CHF in children under 4 is significantly associated with decreased parental
knowledge. Therefore, more parental education is needed. Copyright © 2011
Elsevier Ireland Ltd. All rights reserved.
Seiverling, L., et al. (2016). "The effects of a brief behavioral intervention on food refusal in a
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child with a fear of choking." Clinical Case Studies
15(2): 117-125.
This study examined the effects of an exposure-based behavioral treatment on food
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refusal in a 4-year-old girl who developed a fear of choking after an acute choking
episode. Prior to treatment, the child had stopped eating almost all solid foods for 3
months and was primarily consuming a chocolate-flavored pediatric formula.
Treatment occurred across the span of 2 weeks and took place at a pediatric feeding
program. At the end of treatment, the child accepted over 30 new foods and was no
longer dependent on a pediatric formula to meet her nutritional needs. © The
Author(s) 2015.
Information
Shah, R. K., et al. (2010). "Management of foreign bodies obstructing the airway in children."
Archives of otolaryngology--head & neck surgery
136(4): 373-379.
OBJECTIVE: To review national trends in the management of pediatric airway
foreign bodies (A-FBs) and esophageal foreign bodies (E-FBs) that obstruct the
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airway., DESIGN: Retrospective review using a national pediatric data set (Kids'
Inpatient Database)., SETTING: Pediatric patients admitted across the United States
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during 2003., PATIENTS: The Kids' Inpatient Database 2003 samples 2 984 129
pediatric discharges from 3438 hospitals in 36 states., MAIN OUTCOME
MEASURES: The Kids' Inpatient Database 2003 was analyzed for A-FBs and E-FBs
(International Classification of Diseases, Ninth Revision, Clinical Modification codes
under
E911 and E912) in patients 20 years or younger, and weighted data are presented to
facilitate national estimates., RESULTS: A total of 2771 patients (59% male) were
admitted for an A-FB or an E-FB that was obstructing the airway. The mean (SE) age
of the patients was 3.5 (0.17) years; 55% were younger than 2 years. The foreign
bodies were classified as food (42%; mean age, 2.5 years) or other (58%; mean age,
4.3 years). The average length of stay was 6.4 days (median [SE], 1.5 [0.6] days),
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and the average number of procedures was 2.4 (median [SE], 1.3 [0.1] procedures).
Seventy-one percent of the patients were treated at teaching hospitals. The mean
(SD) total charges were $34 652 ($3543), with regional variation (P < .001).
Children's hospitals (28%) had higher mean total charges than nonchildren's
hospitals (P = .03); 3.4% of admissions died in the hospital (mean [SE] age, 4.6 [0.9]
years), with an average length of stay of 11.7 (SE, 2.7) days and an average of 6.2
(SE, 0.7) procedures. Bronchoscopy (52%), esophagoscopy (28%), and tracheotomy
(1.7%) were the primary procedures performed. The rates of positive FB findings for
bronchoscopy and esophagoscopy were 37% and 46%, respectively.,
CONCLUSIONS: Pediatric A-FBs and E-FBs that obstruct the airway occur
infrequently. Most of the patients are referred to teaching institutions. Among patients
who were admitted with a diagnosis of airway obstruction from an A-FB or an E-FB,
the rates of positive findings at surgery were 37% and 46%, respectively. A
Appendix 2
surprisingly high mortality rate was noted. Alternative education measures should be
considered to train physicians in the management of this infrequent, potentially lethal
condition.
Sidell, D. R., et al. (2013). "Food choking hazards in children." International journal of
pediatric otorhinolaryngology
77(12): 1940-1946.
OBJECTIVES: To review the literature on pediatric food choking risks, with the long-
term goal of supporting legislation regulating the production, labeling, and distribution
of high-risk foods., METHODS: A PubMed search (Keywords: choking, obstruction,
asphyxiation, foreign body, food) was conducted in July-September 2010 with
publication dates ranging from 1966 to 2010., STUDY SELECTION: Articles related
to pediatric foreign body aspiration (FBA) were selected by three independent
reviewers. 1145 articles were initially identified. Abstracts were then screened
utilizing a tool designed to isolate relevant pediatric choking events; this tool helped
to only select abstracts which presented data on patients younger than 18 years of
age who had choked on food items. Through this, a total of 72 pertinent articles were
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isolated (55 observational studies, 17 case reports/series)., DATA EXTRACTION:
For each study, patient age, sex, foreign body location, presenting signs and
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symptoms, utility of radiographic studies, and type of foreign body detected in the
majority of study participants were determined. A "majority" of patients for each study
was predetermined arbitrarily to be 2/3 of the studied population., RESULTS: The
majority of patients in each observational study was determined to be: male (87% of
all studies) and age <5 years (95% of all studies). Aspirated foreign bodies were
mostly detected in the right main bronchus foreign body (72% of all studies), and
there were abnormal radiographic signs (81% of all studies) at the time of evaluation.
Food-object foreign bodies were the most frequent factors associated with choking
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(94% of all studies)., CONCLUSION: Childhood aspiration of food-objects is a
significant public health issue. Although there is substantial legislation regulating non-
food items that pose a choking hazard, equivalent guidelines do not exist for high-risk
foods. Our study identifies and confirms several risk factors for pediatric FBA events.
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In doing so, it echoes the concerns and suggestions of various groups in supporting
the development of legislation which may reduce the incidence of food-object
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aspiration. Copyright © 2013. Published by Elsevier Ireland Ltd.
Sink, J. R., et al. (2016). "Predictors of foreign body aspiration in children." Otolaryngology -
Head and Neck Surgery (United States)
155(3): 501-507.
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Objectives To examine the sensitivity and specificity of history, physical examination,
and radiologic studies as predictors of foreign body aspiration in children. Study
Design Case series with chart review. Setting Tertiary care children's hospital.
Subjects and Methods Medical records were reviewed for 102 children who
presented to our institution from 2006 to 2013 with suspected foreign body aspiration
and who underwent endoscopy. Data included symptoms, physical examination,
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radiologic, and endoscopy findings. Descriptive statistics, sensitivity and specificity,
and univariate and multivariable analyses were performed. Results A total of 102
patients were included (62% male). The mean age was 3.3 years (SD, 3.7). A foreign
body was identified on endoscopy in 69 cases (68%). The most common presenting
symptoms were cough (88%), choking/gagging (67%), and wheezing (57%).
Decreased breath sounds and wheezing on examination were independently
associated with increased odds of foreign body. The most common abnormal
radiographic finding was air trapping (33%). The most frequent items retrieved were
fragments of seeds and nuts (49%). There were no serious complications related to
endoscopy. The sensitivity and specificity of any finding on history, physical
examination, and imaging were 100% and 3%, 90% and 33%, 61% and 77%,
respectively. Having a positive history, examination, and chest radiograph combined
was 46% sensitive and 79% specific. Conclusions Patients with airway foreign bodies
Appendix 2
have varied presentations. The presence of any radiologic finding suggests that
endoscopy should be performed, as a foreign body is probable. The absence of any
history or physical examination finding was associated with a low likelihood of a
foreign body. © Official journal of the American Academy of Otolaryngology-Head
and Neck Surgery Foundation.
Sink, J. R., et al. (2016). "Diagnosis of Pediatric Foreign Body Ingestion: Clinical
Presentation, Physical Examination, and Radiologic Findings." The Annals of otology,
rhinology, and laryngology
125(4): 342-350.
OBJECTIVES: (1) To describe clinical and radiologic findings in patients with
esophageal foreign bodies. (2) To examine the sensitivity and specificity of history,
physical examination, and radiologic studies in children with suspected foreign body
ingestion., METHODS: A retrospective cohort study was performed evaluating all
children who underwent esophagoscopy for suspected foreign body ingestion at our
institution from 2006 to 2013., RESULTS: Five hundred forty-three patients were
included (54% male). Average age was 4.7 years (SD = 4.1 years). Foreign bodies
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were identified on esophagoscopy in 497 cases (92%). Ingestion was witnessed in
23% of cases. Most common presenting symptoms were choking/gagging (49%),
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vomiting (47%), and dysphagia/odynophagia (42%). Most patients with foreign
bodies had a normal exam (76%). Most foreign bodies were radiopaque (83%). In
59% of patients with normal chest radiographs, a foreign body was present.
Sensitivity and specificity of 1 or more findings on history, physical examination, and
imaging were 99% and 0%, 21% and 76%, and 83% and 100%, respectively.,
CONCLUSIONS: Most patients with esophageal foreign bodies are symptomatic.
Although many patients will have a normal physical examination, an abnormal exam
should increase suspicion for a foreign body. Most esophageal foreign bodies are
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radiopaque, but a normal chest radiograph cannot rule out a foreign body. Copyright
© The Author(s) 2015.
Sjogren, P. P., et al. (2018). "Predictors of complicated airway foreign body extraction." The
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Laryngoscope
128(2): 490-495.
OBJECTIVES: To evaluate outcomes of foreign body aspiration (FBA) and to
the
investigate surgeon and hospital volume as risk factors for a complicated course.,
STUDY DESIGN: Retrospective case series., METHODS: Children with FBA in a
multihospital network were identified from January 2005 to September 2015.
Demographic information, surgeon, and hospital location were reviewed. Mean
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operative time and hospital length of stay were recorded. Cases requiring intensive
care unit admission, hospital stay greater than 24 hours, need for more than one
bronchoscopy, operative time greater than 1 hour, or death were considered
"complicated.", RESULTS: A total of 450 cases of airway foreign body extraction
were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of
1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different
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surgeons at 11 different facilities. There were one to 24 surgeons for each facility,
with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were
considered complicated, including five (1.1%) deaths. Increased rates of
complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency
(P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association
was found between surgeon type or facility as related to a complicated case.,
CONCLUSIONS: Unwitnessed aspiration events and abnormalities on chest
radiograph may be associated with a more complicated course in children with FBA.
This multihospital study identified a low number of procedures by many surgeons;
however, surgeon and hospital volume did not significantly correlate with higher
complication rates., LEVEL OF EVIDENCE: 4. Laryngoscope, 128:490-495, 2018.
Copyright © 2017 The American Laryngological, Rhinological and Otological Society,
Inc.
Appendix 2
Susy Safe Working, G. (2012). "The Susy Safe project overview after the first four years of
activity." International journal of pediatric otorhinolaryngology
76 Suppl 1: S3-11.
OBJECTIVES: to collect relevant, up-to-date, representative, accurate, systematic
information, related to foreign bodies (FB) injuries., METHODS: The "Susy Safe"
registry, a DG SANCO co-funded project gathering data on choking in all EU
Countries and beyond, was established in order to create surveillance systems for
suffocation injuries able to provide a risk-analysis profile for each of the products
causing the injury. Main findings after 4 years of activities are resumed here.,
RESULTS: 16,878 FB injuries occurred in children aged 0-14 years have been
recorded in the SUSY SAFE databases; 8046 cases have been reported from
countries outside EU. Almost one quart of the cases involving very young children
(less than one year of age) presented a FB located in bronchial tract, thus
representing a major threat to their health. Esophageal foreign bodies are still
characterizing injuries occurred to children younger than one year, in older children
the most common locations are the ears and the nose. FB type was specified in
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10,564 cases. Food objects represented the 26% of the cases, whereas non-food
objects were the remaining 74%. Among food objects, the most common were
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bones, nuts and seed, whereas for the non-food objects pearls, balls and marbles
were observed most commonly (29%). Coins were involved in 15% of the non-food
injuries and toys represented the 4% of the cases., CONCLUSIONS: this data
collection system should be been taken into consideration for the calculation of the
risk of injuries in order to provide the EU Commission with all the relevant estimates
on FB injuries. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Testa, R., et al. (2010). "Choking injuries and food products containing inedibles: a survey
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on mothers' perception in the United Kingdom." Acta otorhinolaryngologica Italica : organo
ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale
30(2): 100-
102.
Although recent investigations showed no specific hazard resulting from Food
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Products Containing Inedibles as compared to the wider category of toys, in view of
recent findings and subsequent study of the European Registry of Foreign Bodies
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Injuries, a potential threat has been identified in a lack of parental supervision in the
event of injury. Indeed, according to the report of the European Registry of Foreign
Bodies Injuries, almost 80% of the injuries occur under parental supervision, which is
obviously inadequate. The aim of this short contribution is to present the results of a
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Computer Assisted Personal Interviewing survey in the UK focused on the
knowledge that mothers, fathers and other adults have on the issue of choking. A
total of 1946 interviews have been conducted in the UK, in January 2001, all of which
directed to subjects over 15 years of age. Data are presented as percentages and
absolute numbers. The statistical significance of group differences has been
evaluated with the chi-square test with continuity correction. All analyses have been
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performed using the R system. Those replying to the interview comprised 804 males
and 1102 females. Of these, 10% had a child between 0 and 36 months, 9%
between 3 and 4 years, 16% between 5-10 years and 13% between 11-15 years. Of
those responding, 7% had bought Kinder Surprise within the last two weeks before
the interview, 14% within the last three months, and the remaining 53% before, while
26% had never bought Kinder Surprise. These findings would appear to offer a
confirmation that mothers tend to balance potential risks with the benefits of exposing
the child to a stimulating activity. This mechanism of a controlled exposure to risk,
has already been identified as one of the important mechanisms in the psychological
development of the child.
Wise, J. (2016). "Young children risk choking on whole grapes, doctors warn." BMJ (Clinical
research ed.)
355: i6831.
Appendix 2
Wu, X., et al. (2018). "Fatal choking in infants and children treated in a pediatric intensive
care unit: A 7- year experience." International journal of pediatric otorhinolaryngology
110:
67-69.
INTRODUCTION: Foreign bodies aspiration can lead to significant morbidity, few
have examined in detail the deaths resulting from foreign bodies aspiration.,
METHODS: We conducted a review of children who presented to the pediatric
intensive care unit of a university hospital due to fatal foreign bodies aspiration during
the period of 2010-2017., RESULT: Of the 28 patients, 17 (61%) patients were male
and 11 (39%) were female. The range of age was 1-63 months, with mean of 15.2
months. The common foreign bodies included milk, nuts and fruits. Majority of them
had round shapes. All the patients died due to asphyxia or serious complications
after foreign bodies aspiration., CONCLUSIONS: Prevention and early recognition
remains a critical factor to reduce the mortality of foreign bodies aspiration. Copyright
© 2018 Elsevier B.V. All rights reserved.
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Search Strategy
Database: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations,
Daily and Versions(R) <1946 to August 13, 2019>
Search Strategy:
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Information
1 safe feeding.ab,ti. (44)
2 Feeding Behavior/ (78482)
3 Asphyxia/ (6090)
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4 Airway Obstruction/ (18473)
5 1 or 2 (78522)
the
6 3 or 4 (24303)
7 5 and 6 (35)
under
8 Infant, Newborn/ or Infant Behavior/ or Infant/ (1101562)
9 Child, Preschool/ (886276)
10 ((early or childhood) adj2 (education or learning*)).mp. [mp=title, abstract, original title, name of
substance word, subject heading word, floating sub-heading word, keyword heading word, organism
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supplementary concept word, protocol supplementary concept word, rare disease supplementary
concept word, unique identifier, synonyms] (6453)
11 (preschool or pre-school).ab,ti. (26901)
12 kindergarten*.ab,ti. (6168)
13 (daycare and (child* or baby or babies or toddler* or infant*)).mp. [mp=title, abstract, original
title, name of substance word, subject heading word, floating sub-heading word, keyword heading
word, organism supplementary concept word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier, synonyms] (968)
Appendix 2
14 (toddler* or babies or baby or infant*).ab,ti. (439045)
15 8 or 9 or 10 or 11 or 12 or 13 or 14 (1657088)
16 7 and 15 (19)
17 limit 16 to yr="2010 -Current" (10)
18 Eating/ (51100)
19 6 and 18 (51)
20 15 and 19 (16)
21 limit 20 to yr="2010 -Current" (7)
22 choking.mp. (1885)
23 1 or 2 or 18 (124025)
24 15 and 22 and 23 (31)
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25 limit 24 to yr="2010 -Current" (20)
26 Foreign Bodies/ and Airway Obstruction/ (837)
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27 foreign body airway obstruction.mp. (48)
28 26 or 27 (863)
29 15 and 28 (408)
30 limit 29 to yr="2010 -Current" (104)
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31 17 or 21 or 25 or 30 (127)
32 limit 31 to english language (113)
33 Airway Obstruction/pc [Prevention & Control] (880)
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34 Foreign Bodies/pc [Prevention & Control] (390)
35 33 or 34 (1261)
the
36 exp Food/ (1234938)
37 exp Health Education/ (234672)
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38 36 or 37 (1461409)
39 35 and 38 (61)
40 health promotion.mp. or feeding behavior/ or diet/ or (prevent* adj3 chok*).mp. [mp=title,
abstract, original title, name of substance word, subject heading word, floating sub-heading word,
keyword heading word, organ
Released ism supplementary concept word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier, synonyms] (297833)
41 35 and 40 (33)
42 39 or 41 (80)
43 limit 42 to (english language and yr="2010 -Current") (23)
44 32 or 43 (131)
Cochrane Library
Appendix 2
#1 MeSH descriptor: [Feeding Behavior] explode all trees
#2 ("safe feeding"):ti,ab,kw
#3 MeSH descriptor: [Asphyxia] explode all trees
#4 MeSH descriptor: [Airway Obstruction] explode all trees
#5 #3 OR #4
#6 #1 AND #5
#7 MeSH descriptor: [Foreign Bodies] explode all trees
#8 #4 AND #7
#9 ("foreign body airway obstruction"):ti,ab,kw
#10 #2 OR #9 OR #6 OR #8
with Cochrane Library publication date from Jan 2010 to Aug 2019
Scopus was used to perform a citation analysis on some of the older articles to see what had
cited them more recently.
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