Pediatric airway obstruction may be a rare occurrence for EMS responders, but they are a frequent cause of pediatric death worldwide. According to the Mayo Clinic, choking is a common cause of injury and death among children.¹ And it could simply be a matter of time before you are called upon to relieve an obstructed airway or treat a child who is choking.
Let's explore some of the reasons choking is so common in children.
Behavioral Factors in Childhood Choking
Before we discuss the anatomical differences that make children vulnerable to airway obstruction, let's touch on some of the behavioral factors that put kids at risk.
- Exploring their environments: Young children tend to put things in their mouths as they explore the world around them. Small objects can be easily inhaled into the airway.
- Lack of dexterity: Children are still mastering control of their limbs and digits, making it difficult for them to dislodge an item from their own throats.
- Inability to communicate: In the case of partial obstructions, children may be unable to relay the immediacy and/or severity of their situation.
- Transitioning to solid foods: Children who are still learning how to properly bite and chew solid foods are particularly vulnerable to food obstructions from foods like hot dogs, grapes, and hard candy.
- Inability to recognize hazards: Small children lack the ability to recognize hazards and foresee the potential risks of putting objects in their mouths.
As children grow, develop, and learn, they are better able to avoid risky behavior that could lead to an airway obstruction.
Anatomical and Physiological Differences that Predispose Children to Choking
There are many anatomical and physiological differences in children that make them prone to choking. Their smaller size is one of them. Here are some of the other unique attributes of children that leave them vulnerable:
- Tongue: In children, the size of the tongue is larger in relation to the oral cavity than it is in adults.
- Trachea: A child’s trachea is not only smaller in diameter, but its immature tracheal rings make it more pliable, which can result in hyperflexion or hyperextension that can then occlude the airway. The smaller diameter is also problematic when it comes to swelling, because minimal amounts can lead to airway occlusion.
- Epiglottis: A child’s epiglottis is larger and more difficult to elevate during intubation, which is why a straight blade is a better choice for pediatric patients.
- Larynx: A child’s larynx is higher and more anterior—something to consider, especially when performing a surgical airway.
- Heart: A child’s heart is unable to increase stroke volume, because it cannot increase the strength of contractions, only the rate. Use bradycardia as an indicator of hypoxia in infants and children.
- Lungs: A child’s lungs are less able to increase capacity, because the heart takes up much of the thoracic cavity.
- Abdomen: A child’s abdomen is smaller and more crowded, making it difficult for the diaphragm to move downward in order to allow increased lung capacity.
- Temperature regulation: This is more difficult, because children have greater surface area but less ability to generate heat. Beware of hypothermia.
With all of these variations, it is no wonder that children suffer from airway obstruction or have difficulty compensating during a respiratory emergency.
Know the Danger Signs
- Tachypnea (> 60/min)
- Bradycardia (< 60/min)
- Nasal flaring
- Use of accessory muscles
- Positioning (tripod)
- Altered level of consciousness
- Pallor or cyanosis
- Abnormal breathing sounds/patterns
- Loss of consciousness
Being aware of the unique attributes of infants and children—behaviorally, anatomically, and physiologically—and recognizing the signs and symptoms of a child in distress are important first steps in knowing the risks of airway obstruction in kids. Staying alert for trouble and correcting respiratory emergencies immediately can help reduce the risk of death of infants and children.
¹ “Infant Choking: How to Keep Your Baby Safe,” Mayo Clinic, 2016,
“Beyond the Basics: Pediatric Assessment,” EMS World, 2006,