Boston-area mom Teresa Stewart thought she was playing it safe by cutting her daughter's grapes in half. But the fruit still proved too much for 9-month-old Ava to chew. Years later, Stewart still remembers seeing her gag, then start to turn pale.
The new mom had taken a CPR course while pregnant so she knew what to do. Four back slaps dislodged the grape.
Stewart was so upset by the experience that she decided to become a CPR instructor, which served her well when Ava choked - again - on a balloon shortly before she turned 4.
A study published Monday in the journal Pediatrics confirms that choking is a common hazard of childhood, with 34 children a day admitted to emergency departments because they've choked on food. That amounts to more than 12,000 emergency visits a year from kids ages birth to 14, but the problem is actually even more significant since most kids who choke don't wind up at the hospital.
"As dramatic as this study is, this is clearly an underestimate," says Dr. Gary Smith, the study's senior author and director of the Center for Injury Research and Policy at Nationwide Children's Hospital in Columbus, Ohio.
Those children between the ages of birth to 4 were most likely to choke on food, with hard candy accounting for 15 percent of choking incidents. Other kinds of candy and gum were the culprit behind 13 percent of episodes, followed by meat - not including hot dogs - and bones. Nuts, seeds and hot dogs were the foods most likely to end up in a hospital stay - nuts and seeds because they're difficult for little teeth to chew and hot dogs because they can be sucked into the airway and cause more serious choking.
"If you were going to get the best engineer in the world, you couldn't design a better plug for a child's airway than a hot dog," says Smith.
Children's airways are relatively small compared to those of adults, notes Dr. Phyllis Agran, a pediatric gastroenterologist and professor emerita at the University of California, Irvine's medical school. "The bigger you are, the more room there is," says Agran.
The American Academy of Pediatrics recommends keeping foods including hot dogs, nuts, chunks of meat or cheese, whole grapes and hard candy away from kids younger than 4. Any food given to babies and young children should be chopped into pieces no larger than half an inch.
Some parents may need to keep mincing even longer, depending on the child. Hot dogs, grapes and raw carrots are the top three choking hazards for children. Take a cue from Stewart, who began cutting choke-worthy food in quarters after Ava's unfortunate grape encounter. "I always tell families to cut them in quarters, nice and small," she says.
Parents and caregivers shouldn't overlook the importance of educating older siblings not to feed their younger brothers and sisters. Several years ago, Agran said, there was a case in which an older sibling gave a baby an almond; tragically, the baby choked on the nut and died. "All parents need to know CPR and the Heimlich maneuver," says Agran. "But the best thing we have is prevention."
The study tracked only nonfatal episodes between 2001 and 2009, but nearly 30 years ago, Smith conducted a similar study in the Journal of the American Medical Association about children who died after choking on food. "Roughly a child every five to six days chokes to death on a food," says Smith, whose study has not been repeated. "I have no reason to think those numbers have changed because there haven't been major changes in surveillance or protection."
But that's exactly what Smith and his colleagues are calling for. In their study, they suggest boosting public awareness of choking hazards and attaching warning labels to food with a high choke factor. Slapping a caution on a package of Oscar Mayers may sound a bit odd, but toy manufacturers routinely label toys that have potentially dangerous parts.
In 1994, Congress passed legislation prohibiting manufacturers from marketing toys with small balls, marbles or balloons to children under 3; if such items are part of toys for older kids, the product must also carry a warning label. "All these protections have existed for years for toys, but none of this exists for food," says Smith. "And children choke more often on food than on toys. If we take everything we've learned over the past two decades on protecting children from choking on toys and apply it to food, we will save lives and prevent injuries."
If, despite the best precautions, your child still chokes, be prepared to act. Babies require five back slaps and five chest thrusts, repeated until the object is removed. After age 1, only abdominal thrusts - commonly known as the Heimlich maneuver - are required. "It's not safe to do abdominal thrusts on a baby," says Stewart, who now educates other parents about what to do when food or other objects get lodged in their children's throats.
"Having gone through that again, it was a turning point," says Stewart, program manager for safety, wellness and sleep support at Isis Parenting, which offers prenatal and parenting courses in Boston, Atlanta and Dallas. "Watching your child choke is emotional and traumatic."
Bonnie Rochman NBC News contributor