Gagging & Baby-led Weaning: How to prevent choking when starting finger foods

Gagging & Baby-led Weaning: How to prevent choking when starting finger foods

Are you starting your baby on solids? The biggest worry I hear from parents and health professionals when offering babies their first finger foods using a baby-led weaning, is fear of choking. I get it! Choking is scary and can be deadly.

In this post, we will discuss the research around choking and baby-led weaning, the difference between gagging and choking and what to do about them, Along with tips to prevent choking and how to serve a variety of foods to decrease choking risk when starting complementary foods.

So let’s dig in!

Gagging

What is gagging?

Gagging is a reflex that’s triggered to prevent swallowing. Gagging is actually protective against choking. And it’s totally normal when starting solid food (no matter the method), and is not dangerous.

Gagging is a part of the learning to eat process for most infants. It just brings the food up to chew a bit more before going back down. This way, only well-chewed foods are allowed to the back of the throat to be swallowed.

Gagging and a baby-led approach to solids

One benefit of baby-led weaning (BLW) and introducing “real” foods sooner, is that your baby’s gag reflex is further forward in the mouth. It moves back as your baby ages. 

And it’s a good thing to get good use of this sensitive gag reflex while learning to eat finger food, as it prevents choking. Babies will still gag when learning how to eat finger foods, whether you introduce them at six months or hold off until later.

How long does gagging last? Rest assured that if your baby is super-gaggy to start, this will decrease with time and practice!

What to do if your baby is gagging

Don’t pat your baby on back or dig the food out of their mouth. That might cause the food to fall farther back and lead to actual choking.

You can demonstrate coughing the food up and spitting it out. 

And try to stay calm and relaxed. If you freak out when your baby gags, so will they and it will make eating less pleasant.

How to prevent gagging

You cannot do much while your baby is eating to prevent gagging.

But in preparation for learning how to eat, bring your baby to the table starting when they’re about 5 months old.

Offer them a “hard munchable” to chew on. This is a hard, stick-shaped food like a rib bone, celery or raw carrot that the baby can’t get a bite out of. They’re not actually eating it.

But your baby will feel like they’re at the family table, a part of the meal. And the hard munchable will help increase your baby’s awareness of their mouth, where it is and how it works! It will increase the strength of the mouth muscles and may decrease a super-sensitive gag reflex. 

What gagging looks like

Here’s a video of what gagging looks and sounds like when starting Baby-led Weaning

When to get help for gagging

If your baby has been trying out foods for a few weeks and still gags with every bite, you might need a referral to an Occupational Therapist or Speech-Language Pathologist.

Sometimes babies will gag so hard it causes them to vomit. That can be common too. Try spacing milk feeding farther away from solids so their tummy isn’t as full at the table. They will be less likely to vomit and won’t lose as many calories if they do!

If your baby exclusively gags every time on solids to the point of vomiting…..you might need to give solids a bit of a break. Maybe your baby isn’t quite ready yet. Wait until they’re six months and try again. 

If they’re over 6 months, offer purees for a week or two and then give finger foods another go. While babies can gag on purees, too, it might be easier for them to manage at first. Bedtruly “baby-led.”

Choking and Baby-led Weaning

What is choking?

With choking, the food mistakenly goes down the airway instead of down the esophagus/food pipe. 

A choking baby won’t make any noise (or very little), as their air pipe is blocked. A good reminder that you can consider those loud gagging noises a good thing…

When your baby can’t get oxygen, they can’t breathe, and their lips and face will turn blue. More on what to do in this situation coming up…

Is choking normal during baby-led weaning?

Choking is not nearly as common as gagging, fortunately!

I’ll get into some stats below when I review the research, but about 13%-35% of babies in these studies were reported to have choked at least once. 

I was lucky and never had this experience with any of my children. Until my eldest was about 8 eating beef from Edo in a food court! Luckily he was able to clear it himself, although I had to quickly put the baby on the ground (ewww) and was ready to try the Heimlich!

What to do if baby chokes

If there’s another adult or older child around, yell for help and get them to call 911. If not, call it yourself and start infant CPR right away. Taking an infant first aid course will give you more confidence that you know what to do in the unlikely case this does happen. Another great online option is Safe Beginnings Infant/Child Safety/CPR/Choking prevention course (also an affiliate link).

Gagging vs Choking

Gagging Signs

• Baby goes red
• Baby makes loud couching and retching noises

Choking Signs

• Baby is silent or making slight wheezing noises

• Baby appears distressed
• Skin colour may change to blue beginning around the mouth

How to remember the difference and what to do:

Loud and red let them go ahead. Silent and blue, they need help from you.

Check out my video talking more about gagging vs choking here

Pocketing Food

If your baby stuffs food into their mouth, this can lead to both gagging and choking. Try and encourage them to chew or to spit it out. 

Here are a few more tips if you have a baby who stuffs food, to discourage this behavior at meals:

• Slow them down: offer utensils which will take them longer to eat with!
• Have water available and remind them to take sips
• Offer one piece of food at a time, if required. 

This is a normal and temporary stage, and will likely decrease as baby’s oral motor skill improves.

Does BLW increase the risk of choking? The research

A 2021 review study quoted: “Fear of choking was an important factor in parents’ decision not to implement BLW; however, this fear was not supported by the literature.”

There have been multiple studies analyzing the risk of choking when using Baby-led Weaning to start solids. Today I’ll break down two of these studies:

The BLISS Study

BLISS stands for “Baby-Led Introduction to Starting Solids”. This clinical trial on choking was published in the “Pediatrics” journal and titled “A Baby-led Approach to Eating Solids and Risk of Choking” This study included 206 families.

The parents answered questionnaires when their baby was 6, 7, 8, 9 & 12 months of age. Questions included frequency of choking and gagging.

Those who reported choking were asked some follow-up questions about what the child was fed and how the choking was resolved.

A total of 35% of babies choked at least once between 6-8 months old. There was no difference between the two groups in incidences of choking at any of the time periods.

Those that started with Baby-led Weaning gagged more often at 6 months, but less by 8 months. The puree group was gagging more by 8 months than the BLW group (because they were now learning to eat finger foods too). You can’t skip the gagging stage!

Of the three incidences of choking in which health care help was required: 2 babies choked on milk and 1 choked on food that was placed in their mouth by a caregiver (not recommended with BLW). This goes to show that it’s possible to choke on anything.

The researchers found that choking hazards were frequently offered in both groups. Not all parents stayed close to supervise their baby.

The second study was published by Dr Amy Brown.

This observational study was titled “No difference in self-reported frequency of choking between infants introduced to solid foods using a baby-led weaning or traditional spoon-feeding approach. “

Dr. Brown surveyed 1151 moms with infants between 4-12 months old. The moms reported how solids were introduced (strict BLW, loose BLW or traditional weaning) and the percentage of mealtimes that included spoon-feeding purees to the baby.

Moms also reported if their baby had ever choked, and if so how many times and on what type of food (smooth puree, lumpy puree or finger food).

The results found that 13.6% of infants (or 155 babies out of the group of 1151) had choked. No significant association was found between the style of starting and choking, or the frequency of spoon or puree feeding and choking.

But one interesting finding is that for infants who had choked, those following a traditional weaning approach experience significantly more choking episodes on finger foods and lumpy purees than infants following either a strict or loose baby-led approach.

Why? BLW mothers are less anxious, so maybe the spoon-feeding parents overinterpreted choking events or provided more assistance for their baby to eat, which can be dangerous. We want them to self-feed. 

Or perhaps lower exposure to the finger foods lead to more choking because the babies hadn’t as much practice early on when gag reflex is more sensitive. A good reason to introduce finger foods from the start, whether you use purees or not!

So according to research, it seems the potential risk of BLW is not any larger using this alternative method of starting solids compared to a traditional approach. Great!

Is combo feeding safe?

Health Canada and the National Health Services (in the UK) actually recommend this combo method of starting solids, including both finger foods and purees from the start.

Despite many Baby-led Weaning Facebook groups being adamant that it will cause choking….the research (and my own experience with clients and my kid) has not proven this to be true.

So if you want to feed pureed food and finger foods – go ahead. It’s not true “Baby-led Weaning” but labels don’t matter (unless you’re part of a research study). 

Just remember when feeding purees to be responsive to baby’s hunger and fullness signals if spoon feeding (when it’s much easier to tend to over-feed more than the baby wants). And offer finger foods to practice with too at each meal.

Tips to prevent choking with baby-led feeding

Choking is a risk, no matter how you start solids. But there is a lot you can do to offer safe finger foods. Here are some tips to prevent choking:

1) Let your baby feed themselves 

Never put a piece of food into your baby’s mouth. If you put food into their mouth, it may immediately fall to the back, without the baby having a chance to control it with their tongue and chew it.

2) Always watch your baby while they eat.

Remember, choking is silent. And sitting down to eat with your baby is one of the benefits of Baby-led Weaning anyways!

3) Offer soft foods.

If food does happen to get past the gag reflex and cause your baby to choke, they will be much more likely to cough up soft food. 

So steam hard fruits and veggies until soft. Soft foods like banana or avocado are fine served raw. But test the foods to make sure you can mash them with your tongue on the roof of your mouth. This is called the “squish test.”

If the food is harder, it’s especially important to make sure it’s in a safe shape (i.e. grated or sliced thinly).

4) Offer safe sizes of food.

It’s common in the baby-led weaning world to hear that you should be offering your baby food in the shape of a stick when they are just starting. This is so that your baby has something to grasp on to before she develops the use of her forefinger and thumb in a pincer grasp to pick up smaller pieces of food. 

But here’s why I don’t suggest offering food in the shape of a stick or finger: if a baby bites off a chunk of the stick or finger-shaped food and it gets past his gag reflex, then it is a shape that could become a choking hazard. 

So what is a safer shape to offer to the beginning baby-led weaner? Slice the food thinly, like a potato chip, making sure that it’s thinner than your baby’s pinky fingernail. Which works well for foods like apple, sweet potato, beets or cucumber for example. 

If you have a mandolin, this is a perfect tool to use!

5) Remove distractions during meals.

Don’t have toys to play with or the TV on during meals, as a distracted baby is more likely to choke. Some families may have to remove the dog during mealtime!

6) Seat Baby Safely.

Use a proper high chair. I preferred not to buckle the high chair (unless there’s a risk of your baby falling or climbing out). That way you can get them out quickly if needed.

Your baby should be well supported in their high chair. If they are leaning to one side or too low, roll up towels to support your baby. The tray (or table) should come between their nipples and belly button. 
Their feet should sit on a footrest. This is an important piece that many people miss. In this post I  talk more about why supportive high chairs are so important, how to modify your high chair and my favourite brands in this post.

High choking risk foods to avoid for baby-led weaning

In Dr. Amy Brown’s study on BLW and choking, the moms specified which foods their infant had choked on (if any). 

The most common finger foods to choke on were hard/snappable foods such as apple slices or carrot sticks (19 incidents) and slippery foods such as banana, melon, avocado (17 incidents).

So below I’ll give an example below of how to safely serve a hard snappable food (apple) and a soft slippery food (banana).

Baby led Weaning Apple

Apples are the #1 food baby-led weaners choke on. 

If you give your baby a full apple, they could take a bite of a perfectly round and hard apple – the potential culprit of choking.

To serve apples to a baby just starting solids, first, peel the apple. Slice thinly and steam so it’s soft.

If your baby has a pincer grasp, use a cheese grater on a raw apple. You can keep the peel on.

This goes for any hard fruits or veggies. The cheese grater makes small shreds that are a safe size.

Baby led Weaning Banana

There are a few ways to serve bananas. Since bananas are soft, they aren’t as big of a choking hazard as apples. BUT anything slippery could slip past the gag reflex and into an air tube.

To prevent bananas, avocados and melons from being so slippery, coat them in iron-fortified infant cereal or ground flax. This also adds more iron and nutrition! And makes the food easier to pick up.

In terms of shape, you can slice peeled bananas into long strips. 

Or peel the banana part way and leave part of the banana sticking out (wash the peel first). While this isn’t quite as safe in terms of shape, it’s easy for the baby to hold and most will just gum the banana slowly away when starting.

As you can see in this video…

List of foods that are at higher risk for causing choking

And how to serve them safely.

• Grapes need to be cut in quarters or at least length-wise. So these won’t be appropriate until your baby has a pincer grasp and can pick up smaller pieces of food.
• Hot dogs are the most common food that causes choking in small children. If you choose to feed your little one sausages of hot dogs, make sure you slice them the long way down the middle.
• Nut butter is spread thinly on toast or crackers, as they can build up on the palate or form a seal on the windpipe if given by a spoon.
• Foods with strings like celery and pineapple can be finely chopped.
• Remove pits from fruit and chop small round fruits like grapes, cherry tomatoes and cherries.
• Whole nuts: finely or use as nut butter spread thinly.
• Dried fruit: Chop finely. Or raisins are fine whole once cooked like in a muffin or oatmeal, as they become soft.
• Bread: bread can be sticky and gummy. So serve it as a strip of toast. Top with mashed avocado, hummus, or nut butter for a baby safe high-energy-density food.
• You can also use a mesh feeder bag for choking hazards when your baby is starting out on solids. They’re good for foods like frozen blueberries or mandarin oranges that may be a choking hazard.

Here are a few more ideas for how to safely serve foods for a baby with a palmer and a more advanced pincer grasp:

When can I serve my baby harder food?

This will depend on your baby’s number of teeth and skill level with eating. As well as your own comfort.

Popcorn, hard candy and whole nuts are suggested to avoid until age 4.

Summary

Phew! Ok we’ve learned about what gagging and choking are, the differences and how to deal with them.

Whether baby-led weaners choke more often than spoon-fed babies (they don’t), and if ‘combo feeding’ is safe (it is).

I shared tips to prevent choking and shared baby-led weaning food ideas for how to serve potential choking hazards safely. So now you have safe feeding practices covered!

Another important aspect of BLW is the adequacy of iron in the diet. Check out this post for a variety of iron-containing foods to offer your baby. 

And want to know more about using BLW to make starting solids fun, easy & healthy? Click here to register for my free webinar “Benefits & Myths of Baby-led Weaning”

Jennifer House is a Registered Dietitian, author & mom of 3. From Baby-led weaning to picky eating and meal planning, she helps you to make feeding your family easier.