Foreign body aspiration and choking in children

• Choking is the blocking of the airway by an object such as food, a coin or a toy. In children it is usually sudden, happens while eating or playing, and may be partial (coughing) or complete (no air, no sound).
• The most dangerous objects are latex balloons, hot dogs, whole grapes, hard sweets, coins and button batteries. About two-thirds of children who die of choking are babies under one year old. ^[3][6]
• Adults who find a choking child should first decide whether the child can still cough effectively; if so, do not hit or poke. If not, give up to five back blows, then up to five chest or abdominal thrusts by age, and repeat. ^[1]
• Any child who becomes unconscious should be placed flat, have five rescue breaths, then cardiopulmonary resuscitation (CPR) with the airway checked and cleared only of objects that are clearly visible. ^[1]
• Objects that reach the lungs are removed by bronchoscopy. Objects that pass into the stomach are usually harmless, except button batteries and small high-powered magnets, which can burn or tear the gut and must be found and removed. ^[2][4][5]

By the end of this page you should be able to:

1. Describe the age-specific anatomy and behaviours that make children liable to choke, and say which objects are most dangerous.
2. Tell complete from partial airway obstruction from the bedside, including silent choking.
3. Run the Resuscitation Council UK (RCUK) stepwise first-aid algorithm for infants and for children over one year. ^[1]
4. Decide when a bronchoscopy is needed, which kind is chosen and what the likely findings are.
5. Use chest X-ray, fluoroscopy and computed tomography (CT) sensibly when the diagnosis is uncertain.
6. Recognise the specific dangers of button (disc) battery and small magnet ingestion, and what must be done within hours.

A useful bedside classification is partial versus complete obstruction. In partial obstruction the child can still speak, cry or cough, and air moves audibly; in complete obstruction there is no cry, no cough and no breath, only silent struggling and cyanosis. ^[1] A second, time-based distinction is acute versus retained: a retained object can present weeks later with pneumonia, an abscess or noisy breathing rather than with a single choking event. ^[2]

This page also cross-checks two related ingestion emergencies that are often confused with choking: button battery and high-powered magnet swallowing. They are not airway foreign bodies, but they become airway or mediastinal emergencies rapidly, so every person who may see a choking child should also know their warning signs. ^[5]

Choking is the leading cause of accidental death in infants and a leading cause of death in pre-school children; it is also the fourth leading cause of accidental death across all ages. ^[3] In 2016 the rate of fatal choking in children under five in the United States (US) was 0.43 per 100,000, while the rate of non-fatal choking in children under fourteen was much higher at 20.4 per 100,000. ^[2] About two-thirds of children who die of choking are babies under one year old. ^[6]

Boys make up slightly more than half of cases (55.4% in one large series), and candy was involved in 55.2% of non-fatal cases in children under four years. ^[2] Studies outside the US suggest that about 60% of patients with inhaled foreign bodies are male, and that nuts are responsible for roughly 40% of cases in both high-income and low- and middle-income countries. ^[2] Coins were involved in 13% of choking presentations treated in US emergency departments, candy or gum in 19%, and latex balloons caused about 29% of choking deaths in one long review, making balloons the deadliest single object. ^[3] In adults over 60, choking is strongly linked with neurological disease, reduced saliva and dysphagia rather than with behaviour. ^[3]

Children are not small adults, and early childhood is a special hazard period. Until about the age of sixteen, the right and left main bronchi (airways to the lungs) have a similar branching angle, so an inhaled object is equally likely to lodge in either side (in adults it usually goes right). ^[3] Infants and toddlers explore by mouth, have immature chewing and swallowing coordination, do not yet have their back teeth (molars), and can cry and breathe at the same time, which opens the airway while they manipulate objects. ^[6] Neurological disability increases both the risk of aspiration and the risk of death. ^[2]

A foreign object lodged below the vocal cords can still allow some air movement, which is why the child may squeak, wheeze or develop one-sided breathing sounds rather than fall silent immediately. ^[2][3]

The classic history is sudden onset while eating or playing, often unwitnessed. Key questions are what object, when, whether there was a witnessed choke or cough, and whether there have been symptoms since (wheeze, cough, colour change, drooling, refusal to eat, recurrent fever or pneumonia). ^[2][3] A "cafe coronary" can mimic a heart attack in older adults, but in children the cause is nearly always a foreign body. ^[3]

Look for the signs of partial or complete obstruction:

• Partial obstruction: cough, wheeze (reported in about 60% of cases), asymmetric breath sounds (about 32%), dyspnoea, cyanosis or panic; the child may still speak or cry. ^[2]
• Complete or near-complete obstruction: inability to cry (infants) or speak (older children), stridor, cyanosis, altered consciousness, collapse. ^[1][3]
• Retained object: localised wheeze, recurrent or persistent pneumonia, lung abscess, bronchiectasis or bronchial narrowing. ^[2]

A change in the ordinary physical examination identifies those with an airway foreign body correctly in about 80.4% of cases and correctly excludes it in about 59.5%. ^[2] Coughing during a choking episode often resolves within about 15 minutes whether or not the object is coughed out, but the child must be watched closely during that time. ^[6]

A swallowed or inhaled object is mistaken for several conditions, particularly when it lodges high in the airway and causes stridor:

Chest X-ray is the usual first test but has important limits. Findings that suggest an airway foreign body include collapse (atelectasis), air trapping, mediastinal shift and pneumothorax; air trapping was the most common abnormality in one series (53% of cases) and chest X-rays were normal in 35% of cases. ^[2] Sensitivity and specificity are about 67.9% and 71.4%. ^[2]

Important points for practice:

• Many inhaled objects, such as nuts, plastic and most toys, are radiolucent and cannot be seen directly. ^[2]
• Inspiratory and expiratory films, or lateral decubitus films in children under five, can show air trapping on the affected side. ^[2]
• CT is the next step when X-rays are normal or unhelpful but the history and examination are convincing. ^[2]
• Fluoroscopy and magnetic resonance imaging (MRI) are occasionally used. ^[2]
• Direct bronchoscopic inspection is the only test that definitively confirms or excludes an airway foreign body; if three or more distinct signs or symptoms are present, the chance of finding one is high (91% in one series). ^[2]

The RCUK 2025 paediatric algorithm splits children into three age definitions: infants (up to one year), children (one to twelve years) and adolescents (thirteen to eighteen years). ^[1] For any child:

1. Ensure safety; do not hurt yourself.
2. Assess responsiveness with voice and gentle touch. Do not use painful stimuli.
3. Call the ambulance (or summon help in hospital) early, using speaker phone so your hands stay free.
4. Open the airway with head tilt and chin lift. Look, listen and feel for breathing for no more than ten seconds. ^[1]
5. If breathing is absent or ineffective, begin resuscitation. ^[1]

A child who is still coughing effectively should be encouraged to keep coughing; do not thump or interfere. ^[1] If coughing is ineffective or absent, proceed to emergency care. ^[1]

Give up to five back blows; if they do not work, give up to five chest or abdominal thrusts; then alternate five of each until the obstruction clears or the child becomes unconscious. Stop as soon as the child coughs, breathes loudly or cries. Allow the child to lean forward; lay an infant on your forearm with the head below the chest for back blows. ^[1][3]

Yielding to three common errors matters as much as the blows themselves: do not sweep blindly in the mouth (remove only objects clearly visible), do not give abdominal thrusts to an infant under one year, and if an infant loses consciousness do not attempt a finger sweep or repeat abdominal thrusts. ^[1][3]

Start CPR immediately, beginning with five rescue breaths; use a 15 to 2 compression-to-ventilation ratio if you are trained specifically in paediatric basic life support and 30 to 2 if you are trained only in adult sequences. ^[1] Chest compressions are 100 to 120 per minute, at least one-third of the chest depth (do not exceed 6 cm at any age), with full recoil; compress the lower half of the sternum. ^[1] Do not interrupt CPR except for visible objects removed with a single sweep; use the automated external defibrillator (AED) as soon as it arrives. ^[1]

Once airflow is restored and the child is stable, the question is whether an object remains in the airway. Bronchoscopy is both the diagnostic and the treatment step. ^[2]

• Rigid bronchoscopy is generally preferred for foreign body removal: it allows ventilation through the instrument, gives a clear view through a solid telescope, accommodates tools of varying size, and the wider lumen makes it easier to withdraw the object past the vocal cords. ^[2]
• Flexible bronchoscopy is the better first choice when the history is uncertain, for example recurrent pneumonia with no clear aspiration event, or for distal and infected material. ^[2]

Typical findings depend on delay. Early objects may be seen sitting in a main bronchus, with focal wheeze or unilateral air-trapping on X-ray; later ones cause granulation, stenosis, recurrent pneumonia, abscess and, rarely, bronchiectasis. ^[2] Clinical suspicion should remain high: in children with neurological disability, foreign bodies are more common, carry a higher mortality and more often need mechanical ventilation. ^[2]

Children under ten years should not have surgical airway procedures (tracheotomy) because the trachea is still developing. ^[3]

These two ingestions are common traps. The child may look well for hours, the X-ray may be misread as a coin, and the damage evolves after removal.

Button batteries are found in toys, remote controls, hearing aids and gaming devices. Between 1985 and 2009 there were 56,535 reported swallowing incidents in the US, of which 68.1% were in children under six years and 20.3% in young people aged six to nineteen. Each year US poison centres receive reports of over 3,300 cases. ^[4] More than 97% have mild or no effects, but the risk is concentrated in children under six years and in cells larger than 15 mm. ^[4] Swallowing is often unwitnessed; when symptoms occur they are non-specific (nausea, vomiting, pain on swallowing, irritability, abdominal pain) in 10% to 20% of patients, with later bleeding, hoarseness, stridor or chest pain. ^[4]

The guidelines just described come from the National Battery Ingestion Hotline and the Button Battery Task Force, as summarised in the StatPearls review accessed for this page. ^[4]

Small high-powered magnets, often sold in toy sets or desk sets, are uniquely dangerous because two or more can attract across loops of bowel and trap the wall between them. ^[5] Two or more magnets can punch through the stomach or intestine, and a single magnet plus another metal object (for example a button battery) can do the same. ^[5] In older reviews, magnets accounted for 34% of inorganic foreign bodies, and diagnosis was delayed by more than 24 hours in about 60% of cases. ^[2]

Practical points:

• Any child who may have swallowed a magnet needs imaging of the neck, chest and abdomen, and removal is advised when more than one is present or when a battery is also present. ^[5]
• A single swallowed magnet in an asymptomatic child with a normal X-ray location in the stomach may be observed, but with a very low threshold for removal. ^[5]
• Consider the diagnosis in any child with unexplained abdominal pain, vomiting or obstruction, even without a witnessed ingestion; ingestion is often unobserved. ^[5]

• Prevention comes first. Cut food into pieces no larger than one-half inch and keep balloons, coins, batteries and small parts out of reach; the AAP advises delaying dangerous foods until at least four years of age, depending on development. ^[6]
• Frontline staff and parents can learn the full first-aid sequence without equipment: back blows and age-appropriate thrusts. ^[1][3]
• Where a bronchoscope is not available, a clear history plus asymmetric breath sounds and the X-ray patterns described above are enough to arrange timely referral; delay is what turns a removable object into a perforation or brain injury. ^[2][4]
• If transfer is needed, keep the child nil by mouth and send the X-ray film or image with them.

• Choking is the leading accidental cause of death in infants; most victims are under one year old. ^[3][6]
• Small objects, round foods, latex balloons, hot dogs, grapes, hard sweets, nuts and coins are the most dangerous common hazards; balloons are disproportionately lethal. ^[3][6]
• Partial obstruction coughs and breathes: encourage coughing and do not interfere. Complete obstruction is silent and needs immediate emergency care. ^[1]
• RCUK 2025 age split: infants under one year get chest thrusts, not abdominal thrusts; children one year and older get abdominal thrusts. ^[1]
• Sequence: up to five back blows, then up to five thrusts, alternating; stop at any sign of relief; no blind finger sweeps. ^[1][3]
• If the child is unconscious, start CPR immediately with five rescue breaths first. ^[1]
• Airway foreign bodies are confirmed and removed by rigid bronchoscopy, which also allows ventilation; flexible bronchoscopy is used when the diagnosis is uncertain. ^[2]
• Chest X-ray misses many objects and is normal in about 35% of cases; air trapping and asymmetric sounds are more helpful. ^[2]
• Delayed retained objects present as recurrent or persistent pneumonia; neurological disability raises risk and mortality. ^[2]
• A button battery in the oesophagus is an emergency regardless of symptoms; cells over 20 mm and children under five are the highest-risk groups. ^[4]
• Two or more small magnets, or one magnet plus a battery, can tear the bowel and may present late with unexplained abdominal pain. ^[5]

Plain text only (no links in this draft): paediatric resuscitation and CPR; initial trauma assessment; perfusion and shock in children; thoracic trauma; dysphagia and odynophagia; pneumonia in children; neonatal and childhood vaccination and safety; child abuse and neglect; rhinitis, sinusitis and pharyngitis; anaesthesia and sedation for procedures.