Unsafe Chewing: Choking and Other Risks

You have accessThe ASHA LeaderFeature1 Nov 2019Unsafe Chewing: Choking and Other RisksLack of attention to chewing can set people up for dangerous consequences: aspiration or even choking. Screening and intervention can put them on a safer path. Nicole Archambault andEdS, MS, CCC-SLP Licia Coceani PaskayMS, CCC-SLP Nicole Archambault Google Scholar More articles by this author , EdS, MS, CCC-SLP and Licia Coceani Paskay Google Scholar More articles by this author , MS, CCC-SLP https://doi.org/10.1044/leader.FTR1.24112019.42 SectionsAboutPDF ToolsAdd to favorites ShareFacebookTwitterLinked In When it comes to food, people tend to focus on what they eat. Does it taste good? What’s the nutritional value? How many calories and grams of fat? Does it contain allergens or harmful chemicals? They’re less likely to consider how they eat. But there’s a reason our parents tell us, “Chew your food properly.” Regardless of our age, when we fail to consider the how part of eating—which includes chewing—we’re more likely to experience eating problems. Among these problems are aspiration, in which foreign material enters the lower respiratory tract, or choking, in which (as defined by the American Academy of Pediatrics, AAP) a foreign body hinders or obstructs breathing. The life-threatening danger of choking cannot be underestimated or overlooked. However, some schools and health care facilities may lack protocols for addressing problems with eating that could contribute to this danger. Speech-language pathologists can be key players in developing and enacting such protocols, especially in health care settings and in outpatient and private practice clinics, where they’re more integrally involved with feeding of patients and managing swallowing problems (dysphagia). SLPs can help identify those at risk, conduct assessments, provide treatment, offer feeding recommendations, and conduct patient, family, and interprofessional education. No matter the arena, SLPs’ vigilance regarding choking is essential, given how many of their patients have problems with oral-sensory, swallowing, feeding, and airway functions. Neurological and neuromuscular conditions, also common in SLPs’ patients, may also increase choking risk. Life or death A number of factors affect a person’s risk of choking, including how they behave at mealtimes—speed of eating and distractibility, for example. Consider how often people eat while alone and distracted by screens, or while driving or riding in cars. Other contributors to choking can be the anatomy of the face, head, mouth, and respiratory system, and how people chew (see sources). The first step in digestion, chewing is the act of breaking down food to ease swallowing and safe transit of the bolus to the stomach. Lack of chewing, insufficient chewing, or excessive chewing can all cause swallowing problems. People can choke on food or non-food items, though it happens more with the latter (see the list below). Characteristics of foods that pose the highest risk of choking (see sources) include being: Too big (hamburgers, sandwiches, cakes). Round and slippery (candies and gummies). Cylindrical and cut into rounds (carrots, grapes, hot dogs). Hard (candies, some meats). Dry (sandwich, muffins, dried fruits). Sticky or viscous (peanut butter or honey). Fibrous or stringy (some veggies, pizza, cheese, cured ham). Compressible (marshmallows, popcorn, hot dogs). Difficult to chew (mixed salad, beef, snack bars). Choking is on the rise across cultures, genders, and ages, and is not limited to toddlers. The fourth-leading cause of unintentional death in the United States, it’s increasingly seen in the country’s growing elderly population (see sources). Of the 5,000 choking deaths in 2017, more than 2,800 occurred in people older than 74. Roughly one child dies in the U.S. every five days from choking on food. Yet in our experience, people tend to underestimate the risk of choking to themselves and others. Consider that the odds of dying from choking on food is 1 in 2,696, while those of dying in an airplane crash are 1 in 205,552. People often fear flying more than choking, however. Although these statistics are alarming, we believe they don’t fully reflect the gravity of the problem. For example, at our own lectures on these topics, we informally surveyed SLPs and other health care professionals in the audience on whether they or someone they know has ever had a choking episode. Nearly all hands went up. However, when we asked, “How many of these choking incidents resulted in an ER visit?” only a few hands went up. This shows the discrepancy between actual choking episodes and choking-related statistics compiled at ERs and morgues. Pathways to choking In our practices, we build choking prevention into screening, given that many of the children on our caseloads experience feeding difficulties and/or have myofunctional disorders. We screen for structural, functional, oral-sensory, behavioral, environmental, lifestyle, and other risk factors for choking. We also consider the interplay between these factors, incorporating chart reviews, clinical observations, and patient and family interviews. We ask about previous choking episodes (if any), nasal versus oral breathing, cultural differences around mealtimes, daily food intake, positioning for meals, pace of eating, and digestive problems. To delve more deeply, we consider the cranio-facial-respiratory complex (CFRC)—the anatomy of their face, head, mouth, and respiratory system. Additional medical conditions that could contribute to choking risk include dysphagia, neurological diseases (such as Alzheimer’s disease and Parkinson’s disease), neuromuscular diseases (such as ALS and MS), psychiatric illnesses (such as schizophrenia), stroke, traumatic brain injury, cerebral palsy, pica, Down syndrome, intellectual disabilities, xerostomia, seizures, and gastroesophageal reflux. We also consider history of aspiration pneumonia, prior choking incidents, myorelaxant and psychotropic medications, surgeries (especially ones involving the tongue), and use of dentures and other orthodontics. And we look for any physical anomaly—such as tongue-tie in children—that limits tongue lateralization and range of motion affecting chewing. Assessment and treatment When it comes to diagnostics, SLPs can choose from an array of tests to assess swallowing. But there are fewer tests for assessing chewing, or the “oral preparatory phase” of swallowing. According to the scientific literature, existing chewing assessments include optical scanning, sieving, colorimetric beads, colorimetric chewing gum, Rosin-Rammler Equation, and Surface Electromyography. Also, a 2018 study led by Selen Serel Arslan and colleagues—and published in the Journal of Oral Rehabilitation—indicates the Karaduman Chewing Performance Scale (KCPS) is a reliable, valid measure of chewing performance in children with neuromuscular diseases. The KCPS assesses levels of chewing function, from normal to severely impaired. SLPs can also use the Behavioral Pediatric Feeding Assessment Scale (BPFAS) to investigate a child’s eating behavior and their parents’ related behaviors. Another tool available to SLPs is the Screening Tool of Feeding Problems Applied to Children (STEP-CHILD), which includes a subscale that assesses chewing skills. When diagnosing chewing problems, clinicians need to analyze chewing patterns. Questions to ask include: Does the client use a munch pattern versus a rotary chewing pattern? Is there tongue lateralization to get the food to the molars for proper chewing? Is the client swallowing the bolus effectively? Is the client pocketing food—holding excess food in the mouth instead of chewing and swallowing it? How quickly is the client eating? Do they prefer softer foods over ones they need to chew? Are they refusing or spending a long time trying to chew foods with more resistive textures? Diagnosis of chewing disorders falls under SLP assessment of the oral preparatory stage of swallowing. When coding for diagnosis of chewing issues, we use the R13.1- series of codes related to dysphagia and swallowing and feeding disorders from the International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10). According to the American Medical Association’s Current Procedural Terminology (CPT) coding rules for SLPs, we use the diagnosis CPT code of 92610: Evaluation of oral and pharyngeal swallowing function. For treatment we use CPT 92526: Treatment of swallowing dysfunction and/or oral function for feeding. In our practices we use a combined approach to chewing assessment and intervention with children and adults called the Chewing Efficiency and Awareness Method (CEAM). A simple, cost-effective “chewing and spitting” test, CEAM focuses clients’ attention on properly chewing different food consistencies and increases their awareness of chewing skills. Here’s how it works: We have the client chew small bites of different foods, from softer to harder, then spit the bolus into a clear plastic condiment cup just before feeling the need to swallow. Most of the time the bolus is as expected: dry, poorly cohesive, and poorly comminuted (pulverized). We start client testing with non-juicy foods. When clients next chew juicy fruits and vegetables, we have them swallow the liquid part before chewing and spitting out the bolus into a clear cup. We then have clients chew a bite of the same food more thoroughly and for longer, until the bolus is blended and thick like veggie soup. The client then spits the food into the cup, and we compare the poorly chewed and well-chewed bolus side by side. The client can now match the proprioceptive event of chewing with two different food outcomes—one that enables safe swallowing and one that doesn’t. This helps clients better monitor their chewing behavior and salivation. SLPs looking to use other chewing interventions, including for patients on nothing-by-mouth regimens, can also try sham chewing—practice chewing with non-food items like silicone wafers, silicone and rubber tubing, or chewing gum. Another method, Functional Chewing Training—a holistic approach to chewing support—has been found effective in children with cerebral palsy. Prevention across the lifespan Even in people who don’t have known chewing problems, improper chewing can elevate choking risk. That’s why we always need to consider choking prevention at mealtimes, no matter people’s ages, as indicated in a recent American Journal of Speech-Language Pathology study on strategies to reduce choking risk. Better awareness starts with knowing the signs and symptoms of choking, which include putting the hands to the throat, being unable to talk or cough or vocalize, having a panicked look, and showing a sudden difference in skin color (for example, turning blue). Eventually, a choking person may lose consciousness if unaided by bystanders. The standard way to stop a person (infants, too) from choking is performing the abdominal thrust, or Heimlich maneuver. Everyone should learn how to do this. Also important in prevention is minimizing choking hazards—to this end, many toys carry warning labels about choking risks. However, such labels are missing from risky foods and food packaging (such as lids of applesauce pouches that children drink from), despite AAP recommendations that warnings be added and that food products posing significant choking hazards be recalled. AAP has also recommended creation of a nationwide food-related choking-incident surveillance and reporting system. In our own practices, we advise families of small children to keep food-scented items, such as fruity erasers, and small non-food items, such as hard candies, buttons, or small toy parts, out of reach or locked away. We also recommend that parents check for labels on little toys and measure foods and objects to determine their choking risk. SLPs working in early intervention can offer parents early feeding advice to set the stage for lifelong efficient chewing and choking prevention. We can recommend baby-led weaning onto solid foods when appropriate and we can demonstrate when and how to introduce different textures and flavors during weaning, under supervision. We can also guide parents on promoting optimal chewing during mealtimes and limiting use of food pouches as substitutes for chewing. In our practices, we also share the following choking-prevention strategies with parents: Prepare food properly. Keep food from getting lodged in the airways by cutting it lengthwise and into small pieces. Avoid round shapes that can get lodged in a child’s smaller, more funnel-shaped airway. Eat mindfully. Encourage children to focus on chewing by removing excess visual and auditory distractions like screens during mealtimes. Model good chewing. Children learn from watching. Parents can illustrate chewing by incorporating foods with a variety of chewable textures into their own diets. Define “well chewed.” Teach children early the correct consistency of food well-chewed. Gently discourage them from putting too much food in their mouths. Stay seated. Sitting down and maintaining good posture are critical for safe eating. Discourage children from walking around, running, or playing while eating. Laugh later. Help children realize the importance of not talking or laughing with food in their mouths. Slow down. Designate enough time for mealtimes so that children can chew their food into safe sizes. Turn up the lights. Children benefit from seeing what they are eating. Provide ample lighting during mealtimes. Supervise eating. Ensure that an adult or other responsible person is present when children eat. Choking can happen without sounds and can easily go undetected. Set limits on siblings. Instruct older siblings not to put food or non-food items in their younger siblings’ mouths. Practice spitting out extraneous items from foods, such as pits, seeds, shells, or tiny bones. Avoiding foods containing these items reduces children’s ability to safely analyze food. Learn the Heimlich maneuver. Be sure to know the age-appropriate and body-type/size-appropriate rescue techniques. SLPs can also use many of the above recommendations with adults with dysphagia and the gamut of neurological conditions. Of course, any adult with serious neurological or psychiatric issues needs supervision during meals. When tailoring prevention strategies to their needs, we can coach them to: Note that dentures reduce the oral sensitivity needed to find smaller items such as little bones. Eat slowly and practice mindful chewing to identify small changes in texture. Limit alcohol intake because it can impair oral sensitivity and motor performance. Avoid talking quickly or laughing with their mouths full. Across settings, SLPs can play a key role in choking prevention by increasing community awareness, identifying signs and symptoms of choking, including a list of risk factors on screening tools, and sharing preventive strategies. While everyone is at risk of experiencing this traumatic, life-threatening situation, the patients we see on our caseloads are at even higher risk than most. Non-Food Items Most Likely to Cause Choking Marbles Balloons Coins Buttons Pills Pebbles Beads Small erasers Small batteries (for hearing aids, watches) Small toys and toy parts Sources Allen, D. E., de Nesnera, A., & Robinson, D. A. (2012). Psychiatric patients are at increased risk of falling and choking. Journal of American Psychiatric Nurses Association, 18(2), 91–95. CrossrefGoogle Scholar Awadalla, N., Pham, T., & Milanaik, R. (2018). Chew on this: Not all first finger foods are created equal. Clinical Pediatrics, 57(8), 889–894. 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