Starting solids safely: preventing choking

Why those first bites feel nerve-racking

At around six months your baby starts on solid food, and almost every parent holds their breath for the first few weeks. That is understandable, because eating is roughly the only daily activity in which you deliberately bring something close to your child's airway. At the same time, learning to eat is a normal and necessary step that virtually all children get through without trouble. The difference between a relaxed and a tense start comes down to knowledge: knowing what is normal, knowing which foods need preparing, and knowing what to do if something does go wrong. This article covers those three things. It is emphatically not an argument for delaying solids, because postponing solves nothing and creates other problems. It is an argument for starting well prepared, so you can enjoy the mess and the fun of those first months for what they are.

Gagging is not choking

The difference between these two is the single most useful thing you can learn, because parents often panic at something that is actually working properly. Gagging is a protective reflex: your baby makes loud noises, turns red, pushes the tongue forward and moves the food back out. It looks alarming, but it is exactly the mechanism that prevents choking, and in babies that reflex sits far forward on the tongue, so it triggers often. With choking the opposite happens: it goes quiet. Your baby stops making sound, does not cough or barely coughs, cannot cry, looks panicked and turns blue around the lips. Silence is the alarm signal, not noise. During gagging, stay seated and calm, do not slap the back and do not put fingers in the mouth, because that pushes the food deeper. Step in only when the sound stops.

When is your baby ready

In the Netherlands the advice is to start solids at around six months, and never before four months. More important than the calendar are the signals from your child. Your baby is ready when they can sit upright with some support and hold their head steady, when they show interest in what you are eating, and when they bring their hands purposefully to their mouth. The tongue-thrust reflex, which automatically pushes anything entering the mouth back out, should also have largely disappeared. If your baby still slumps or cannot hold their head up, wait a while longer; posture is not a detail when eating but a safety measure. Your consultatiebureau checks this as a matter of routine and is the obvious place to go if you are unsure. For babies born prematurely, timing is often counted from the due date rather than the birth date, so discuss that explicitly.

Posture at the table does half the work

A child who sits well is far less likely to choke, and that is the cheapest safety measure there is. Let your baby sit upright in a sturdy high chair, with hips and back supported and the upper body at roughly ninety degrees. Feet resting on something add stability; dangling legs make sitting wobblier than you would think. Never give solid food to a child who is lying down, leaning back, or sitting in a car seat or pram, because in that position gravity works against you. Never let your child eat while walking, crawling, running or riding in a moving car; one startle or bump sends the food exactly the wrong way. Eating happens seated, at the table, with an adult present. Switch off the television and put the phone away, because distraction works in both directions.

Shape and texture decide the risk

It is not the type of food but its shape that makes something dangerous. The risky combination is round, firm and slippery, because that fits a small airway precisely and slides in easily too. Grapes, cherry tomatoes, blueberries and olives should therefore not be halved crosswise but quartered lengthwise. Cut sausages and hot dogs lengthwise first and then into small pieces; never into round coins, because that is exactly the shape of an airway. Serve hard raw vegetables and fruit such as carrot and apple cooked, grated or in thin strips rather than in cubes. Large blobs of peanut butter or other nut spreads stick fast and are hard to clear, so spread them thinly. Soft, mashed, in strips or grated are the four preparations that make almost anything safe.

Foods to skip, or to prepare first

• •Whole nuts and peanuts: not before age five; thinly spread nut butter is fine
• •Whole grapes, cherry tomatoes and olives: always quartered lengthwise
• •Hot dogs and sausages: cut lengthwise, never into round slices
• •Popcorn, hard sweets, liquorice and marshmallows: not for young children at all
• •Hard raw chunks of carrot or apple: grate them, shave them thin or cook them
• •Fish bones, small bones and stones: always remove, even from fish sold as boneless

Supervision: the rules that actually matter

Almost every serious incident happens in a moment when nobody was really looking, so supervision is not a side issue but the core of it. Stay within arm's reach and keep your child in sight at every meal; stepping into the kitchen while there is still food in the mouth is precisely the gap where things go wrong. Do not let older siblings feed the baby, however kindly they mean it, because they do not know the shape rules. Brief your babysitter, grandparents and childminder explicitly on what your child does and does not get, and agree that sweets and nuts from visitors go past you first. Never send food along into a cot, a playpen or a pram without supervision. And keep an eye on the floor: a crawling child reliably finds the pieces an older eater dropped.

If it does go wrong: what to do

If your baby is coughing forcefully, crying or making noise, let them cough it out themselves, because that is the strongest way to shift something. Step in the moment it goes quiet, your child can no longer cry, or they turn blue. Lay your baby face down along your forearm, head lower than the body and your hand supporting the jaw, and give up to five firm blows with the heel of your hand between the shoulder blades. If that does not work, turn them over and give up to five compressions with two fingers on the middle of the breastbone, just below the nipple line, alternating the two sets. Never give abdominal thrusts to a child under one year, and never sweep blindly with your fingers inside the mouth. Call 112, put the phone on speaker and follow the dispatcher. This is exactly the kind of thing you want to have practised physically once, for instance in a Rode Kruis course.

Messy eating is good eating

Learning to eat takes months and looks frankly chaotic throughout, and that is part of it. Children stuff their mouths, spit things out, gag, smear and refuse what they loved yesterday. As long as you stick to the shape rules, your child sits upright and you are there, all of that is normal development rather than a warning sign. Stay calm yourself, because a baby reads your tension effortlessly and tense meals go worse. Work through the kitchen checklist in this app once, because most choking risks sit away from the plate: loose nuts in a bowl on the coffee table, a visitor's bag with sweets in it, beads and buttons at crawling height. If you have doubts about how eating is developing, about gagging that is not easing off, or about a cough that lingers after a bite, call your GP, the out-of-hours GP service or 112 if in doubt.