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Published Jul. 6, 2006

Choking is the fourth-leading cause of death in young children. Since children will put anything in their mouths, parents must protect them from this preventable tragedy.

Here are some recommendations from the American Academy of Pediatrics:

+ Do not give hard foods to children younger than 4. Small children frequently do not grind or chew their food well and attempt to swallow it whole. Food that is round, hard, small, thick and sticky, smooth or slippery should not be on a small child's menu. Examples included hot dogs and sausage (unless sliced lengthwise and then across), seeds, dried fruit, pretzels, nuts (especially peanuts), chips, marshmallows, spoonsful of peanut butter, sunflower seeds, orange seeds, cherry pits, whole grapes, watermelon seeds, gum, hard candy (including caramels), popcorn, raw carrots, raw peas and raw celery. Warn babysitters and older siblings not to share dangerous hard and soft foods with small children.

+ Teach youngsters to chew all food thoroughly before swallowing.

+ Do not allow children to fill their cheeks with food like a chipmunk.

+ Clean up right away after parties. An especially dangerous time is the morning after get-togethers, when a toddler may find dangerous foods on the floor.

+ Never let a child chew or suck on pieces of rubber balloons. Rubber balloons are the leading cause of choking deaths from objects other than food. Most incidents occur when a child suddenly inhales a deflated balloon he is chewing or trying to blow up.

+ Do not give a young child jewelry or toys with small, detachable parts. Parents can check the safety of a child's toy with a "no-choke tube," an inexpensive device that will show whether an object is too small.

+ Check the youngster's environment daily for small objects. Insist that older children protect their younger siblings by watching for small pieces from toys or games. Insist that older children keep their small toys away from smaller youngsters. Common household items that children choke on include marbles, pen caps, nails, tacks, screws and buttons.

+ Dispose of small batteries immediately.

+ Avoid giving children coins or other small objects as a reward.

+ Do not prop up a bottle for an infant to drink alone.

+ Never let a child eat unattended.

+ Remind children not to run with food, gum, lollipops or other material in their mouths.

Choking is a medical emergency. It is important to know exactly what do in an accidental choking. The first thing is to know what not to do. If the child is breathing, crying, coughing or speaking, do not give first aid immediately. Carefully watch the youngster, since his own cough is sometimes the best remedy for choking.

Stay close, but do not slap the child on the back, turn the youngster upside down, reach into their mouth or grab the object. A well-meaning adult can change a partial blockage into a complete airway obstruction.

First aid should be started only if a child cannot cry or cough, breathe at all, or if the airway is so blocked that there is only a weak cough or cry.

The first step is to make sure someone has called "911" for emergency medical services. If the choking victim is an infant, lay the child face-down on one forearm with the head lower than the baby's chest. Give four rapid blows to the back between the baby's shoulder blades with the heel of the other hand.

If the foreign body is not dislodged, turn the infant over and lay the child down, face up, on a firm surface. Place two or three fingers on the breastbone between the nipples, and give four quick chest thrusts by pushing down about one inch. Repeat back blows and chest thrusts until the object is coughed up and the infant begins to breathe on his own. Continue this routine, four back blows and four presses on the chest, until the object is dislodged or help arrives. Never reach into the infant's mouth to search for the object.

If the infant becomes unresponsive and does not begin to breathe right away, the adult needs to start cardiopulmonary resuscitation until the emergency medical team arrives.

If the choking victim is older than 1 year, place the child on her back and kneel at her feet. Place the base of the palm of one hand against the middle of the child's abdomen, just above the navel. With the other hand on top of the first, give quick inward and upward abdominal thrusts into the abdomen (the Heimlich maneuver) until the object is expelled.

In a larger child, the Heimlich maneuver can be done from behind with the victim standing or sitting by placing the fist of one hand above the navel and preceding as above.

If the child is not breathing and has no pulse (check for about five to 10 seconds), begin CPR until the child starts breathing and emergency personnel arrive.

The infant or child who recovers from a choking episode alone probably does not need to see a physician, but check with the child's doctor just to make sure. Choking can occur at any time. Parents and other caregivers should learn the procedures for dealing with this medical emergency by knowing CPR and taking a first aid course offered by the American Red Cross or many bay area hospitals.

Parents can obtain a free brochure, "Choking Prevention and First Aid for Infants and Children," by sending a self-addressed stamped envelope to the American Academy of Pediatrics, Publications Department, 141 Northwest Point Blvd., Elk Grove Village, IL 60009-0927.

This column is meant to draw attention to the issues discussed and should not be relied upon as medical advice. It is not intended to replace the advice of your child's physician. Dr. Bruce A. Epstein has practiced pediatrics in St. Petersburg since 1973. He is a member of the American Academy of Pediatrics. He is married, has three grown children and a granddaughter.