Anyone who has spent time with toddlers will know that they are quite liable to pick up anything that catches their eye and stuff it in their mouths.

Adults usually tend to rush in and grab these objects out of their mouths and hands out of the fear of germs and the potential for choking.

According to Dr Hardip Singh Gendeh, those aged between 12 and 24 months are the most likely to experience choking due to a foreign object or body.

This is due to the fact that this is the age when their ability to move around increases, but they have not yet developed enough teeth to chew properly.

The Universiti Kebangsaan Malaysia Medical Centre Department of Otorhinolaryngo-logy – Head and Neck Surgery (UKMMC ORL-HNS) medical officer noted that it is usually children under the age of five who run the highest risk of choking on a foreign body.

Health Ministry Otolaryngology Service head Datin Dr Siti Sabzah Mohd Hashim said that cases involving foreign bodies – usually in children – are a common occurrence in hospitals across the country, whether they be in the large tertiary centres or smaller district hospitals. (Otolaryngology and otorhinolaryngology are used interchangeably to mean the study of diseases of the ear, nose and throat.)

For example, a Sarawak General Hospital study published in the February 2012 edition of the Malaysian Medical Journal reported that 1,084 such cases, comprising 825 outpatients and 259 inpatients, were seen at the hospital between 2005 to 2009.

With about 30% of the Malaysian population consisting of children below the age of 15, this can be a significant problem.

“Foreign bodies within the ear, nose, larynx, trachea, pharynx and oesophagus can present as a minor irritation, or it can be life-threatening.

“Usually in 70% of cases, we are able to remove it with ease, but the other 30%, which is usually in the paediatric age group, may have to be subjected to anaesthesia, which increases the risk for removal and the outcome,” explained Dr Siti.


Part of that complication arises because of the physical limitations of the body.

UKMMC ORL-HNS senior consultant otorhinolaryngologist Prof Datuk Dr Balwant Singh Gendeh said: “When a child comes into the emergency room, the surgeon and anaesthetist both sweat in their pants because they have to share one airway (to remove the foreign body and to administer the anaesthetic).

“We don’t want to reach that stage in the emergency room. We want to prevent it.”

Dr Siti, who is a senior consultant paediatric otolarynologist at Hospital Sultanah Bahiyah in Alor Setar, Kedah, explained that foreign bodies in children can be inhaled, aspirated, ingested and “the naughty ones insert them”.

Both food and non-food items are culprits in such incidences, although food is responsible for more than 70% of choking injuries, according to Prof Dr Dario Gregori from the University of Padua, Italy.

“This food is usually not pro- perly prepared, it’s not properly served to children,” he said du- ring the SafeFood4Children Project presentation in Putrajaya recently.

Both Prof Balwant and Dr Siti spoke at the same event, which was part of the 9th International Symposium on Recent Advances in Rhinosinusitis and Nasal Polyposis (ISRNP).

“These kind of choking injuries are occurring with and without supervision from the adults,” said Prof Grigori, who holds the Chair of Medical Statistics and Risk Analysis at Padua’s Department of Cardiac, Thoracic and Vascular Sciences. (See Stats on choking)

“We know that a large percentage of the injuries occur without the supervision of adults (42%).

“This means basically that the parents are not aware of the risk.

“They think that their child is safe, that the child can play or can deal with the food alone. But injuries happen.”

Pointing out that 85.9% of the choking cases that occur during eating actually happen under adult supervision, he said: “It means that the parent is there, the parent is feeding the child, but the food is not prepared in a proper way.”

According to Dr Hardip, a review of published Malaysian research shows that the top three most common food items involved in choking cases are peanuts, watermelon seeds and coconut kernels.

Meanwhile, the most common non-food items are metal objects and their parts (e.g. toys, springs, hair clips), plastic objects, and parts of various objects (e.g. ballpoint tip, pencil cap, whistle).

Prevention strategy

The SafeFood4Children Project is actually a massive open online course (MOOC) initiated by the University of Padua, the Juan P. Garrahan Pediatric Hospital in Buenos Aires, Argentina, and the Italian non-profit organisation Prochild, and co-funded by the Italian Ministries of Foreign Affairs and International Cooperation, and Health.

The course consists of a series of short videos related to the issue of food choking in children.

The topics covered are the epidemiology of the problem, a child’s anatomy, the mechanics of partial and total obstruction, a child’s behaviour at the table and food preparation.

The three bodies are also working to expand the course to other countries, with the aid of the Italian Ministry of Foreign Affairs and International Cooperation.

Peanuts are the top cause of choking in children due to their elliptical shape that can easily block the airway or oesophagus. Photo: Filepic

Peanuts are the top cause of choking in children due to their elliptical shape that can easily block the airway or oesophagus. Photo: Filepic

In Malaysia, Prof Grigori and his colleagues have collaborated with Prof Balwant, Dr Hardip and Masterchef Malaysia judge Mohd Johari Edrus (also known as Chef Jo) to come up with relevant vi- deos in both Bahasa Malaysia and English.

Members of the public, especially parents, educators and childcare professionals, can sign up for the free course to be educated on the issue of child safety related to choking incidents.

Prof Grigori explained: “It consists of eight videos, and after each video, there is a short set of questions just to verify the comprehension of the viewer.

“The idea here is to keep the barriers as low as possible in terms of the education and pre-existing knowledge of the viewers.”

The SafeFood4Children Project is actually an outgrowth of the Susy Safe Project, of which Prof Grigori is a founding member.

The Susy Safe Project is an international surveillance registry for injuries due to foreign body ingestion, aspiration, inhalation or insertion.

“Up to now, we are the largest database in the world and we use this information – more than 26,000 injuries – to develop prevention strategies in different countries and the world,” said Prof Grigori.

He explained that the registry was initially started to characterise the products and foods commonly involved in choking and foreign body injuries.

Although the European grant funding the project ended in 2009, the registry is still collecting and compiling data from other parts of the world.

With the results they generated from the registry, Prof Grigori said that they realised they needed to come up with a strategy to help prevent such injuries.

“We tried to put together all our expertise.

“The first thing we realised is that we had to educate the families if we wanted to reduce the burden of such injuries.

“The second is that we needed to foster interaction between stakeholders and public bodies. We needed the people involved in the food chain supply to interact with the health ministries to develop strategies.”

He said that they also realised that they needed to be a bit more innovative in reaching out to the public, with the result being the SafeFood4Children Project.

Those interested in either project can log onto and for more information.