When Mienke Mulder was only six months old, she choked on her milk while in the care of her day mother. On arrival at the hospital, her parents walked into the emergency ward and saw their precious baby lying lifeless on the table. The doctor indicated that they had done the best they could but there was nothing they could do anymore – but after Mienke’s mom’s desperate pleas to try again, they managed to get a pulse.
A real-life nightmare
A video captured just the night before, shows Mienke laughing from her stomach… Little did her doting mother know that just a few hours later she would be sitting beside her baby’s hospital bed, not knowing if her little girl was going to survive.
For Verna and Ryno Mulder, parents of Mienke, the nightmare had just begun. After Mienke aspirated on milk at her day-care centre she was without oxygen for at least 30 minutes. “Because of this lack of oxygen, little Mienke suffered severe brain damage and she now requires 24/7 care,” Verna explains. “My advice to the world is to never leave a child unattended, and it is always advisable to attend a first aid and CPR course so that you know what to do in case of an emergency.”
What is choking?
Choking is the coughing spasm and sputtering that happen when liquids or solids get into the windpipe. In general, choking on liquids is temporary and harmless. However, in cases such as ‘bottle propping’, the baby can turn blue, become limp or pass out, which indicates an emergency. Milk choking occurs when your baby takes more milk into its mouth than it can swallow at a time. Excess milk can spill into the airway and block the flow of air, which leads to choking.
‘Bottle propping’ and why it’s dangerous
Bottle propping is when a bottle is made to rest against a pillow, cushion or other object for the baby to ‘feed themselves’ from it as no one is holding them, or a bottle for them to be fed. It is a very hazardous practice that can be deadly.
According to the 2018 Stats SA’s report on Mortality and Causes of Death in South Africa, the leading cause of death among infants is respiratory and cardiovascular incidences specific to the perinatal period. Professor Siyazi Mda, principal paediatrician at Dr George Mukhari Academic Hospital near Ga-Rankuwa, says: “The oral muscles of a baby are not fully developed and there is often a problem with the coordination of swallowing, increasing the chances of choking, especially when a bottle with fluids is propped.”
Dr Jacques Koning, Specialist Physician from Pretoria, further explains: “The trachea is an air passage to your lungs and the oesophagus is a food passage to your stomach – they are very close together. Fluids aspirated into your lungs can result in choking. Sometimes there are teats that may leak fluids even though it is not sucked on. Also, liquid may continue to flow out of a propped bottle, and this is obviously potentially dangerous.
“A lying-down position also makes it more likely that the liquid will go down the wrong tube. Young babies do not have the head control or strength to move away from the flow of milk (and gravity is not helping either). Older babies can choke to death too as they cannot escape from the flow of fluid, or they aspirate the fluid if a bottle becomes displaced. If your baby has fallen asleep before finishing the bottle, they may breathe in (aspirate) the liquid rather than swallow it.”
How to prevent choking:
- Never feed your baby by propping their bottle.
- Attach a teat that is the recommended size for your baby’s age to the bottle.
- Hold your baby so their head is slightly raised and level.
- Lay the teat against your baby’s lips and allow them to position and comfortably move the teat into his mouth.
- If they begin to choke or gag, remove the bottle from their mouth immediately and slowly them him up.
- If your baby stops sucking on the teat or spits out the formula or milk, remove the teat from their mouth. Allowing it to remain could cause the liquid to fill your baby’s mouth, which can lead to choking.
- Do not leave your baby drinking from a bottle unattended.
- Try to keep your baby in a vertical position after feeding them, so that when reflux occurs, your baby can vomit or cough without being at risk of choking.
- Let baby sleep next to you in their crib – at least for the first six months. This way, you will be very close to monitor baby. If you do move them out to their own room, make sure you invest in a good baby monitoring system.
First aid training for parents, nannies and childminders
First aid training for all baby and child caregivers are imperative for obvious reasons. Make sure to ask your childbirth educator if their training covers first aid and if they don’t, take a specific child emergency first aid class from a reputable organisation. It is always good to be empowered with more knowledge regarding any emergency, so doing a supplementary paediatric first aid course will give you the confidence to know what to do should your baby choke.
Bridgitte Fraser from FED Training says: “We know most parents and even some preschools and schools do not know how to handle many emergency situations. It would absolutely be in the parents’, and of course their child’s, best interest to receive proper training – also for a situation where a child chokes on fluids. It is so important that all child caregivers are fully equipped to handle this life-threatening situation.
“In general, choking on liquids is temporary and harmless. However, in cases such as ‘bottle propping’, the baby can turn blue, become limp or pass out, which indicates an emergency.”
We offer training for these specific situations and as a grandmother of a lovely little girl myself, I want to encourage parents to do this course. It could mean the difference between heartache or great relief. Also, it is always a good idea to enquire of your child’s caregivers if they are trained in an emergency fluid choking situation. If your child is cared for by a nanny, it is imperative for her to receive first aid training as well. Parents are encouraged to attend an additional paediatric-specific first aid course, like the specialised one offered by FED Training* countrywide.”
The legal implications for day mothers, crèches, nursery schools and other childcare facilities when a choking incident occurs
When children are placed in the care of any person or institution, it holds that a greater measure of care, protection and supervision must be applied to ensure that the baby or child does not get injured. The courts have over the years stood by the principle that increased pre-emptive actions must be taken by persons responsible for infants and children. It is the duty of persons responsible for the babies or children to ensure that no danger or potential danger exists in any instance where children could possibly fall in harm’s way.
When it is determined if a danger or a possible danger exists, the courts apply a test to establish if a reasonable person responsible for the baby or child would have foreseen that a danger or possible danger exists and that a reasonable person would have removed the danger.
In the case of a baby choking on a bottle of milk due to bottle propping, the reasonable person responsible for this baby would most likely have known, or have foreseen, that by propping a bottle that contains liquid could represent a substantial danger should that baby choke. It would also be expected that the reasonable person would have ensured that this danger was removed or that measures were taken which would make it unnecessary for a bottle propping situation to arise.
Even though the caregiver did not try and hurt the baby on purpose, it can likely be said that they were negligent and should not have used the bottle propping method to feed the baby and they should have realised that their failure to keep constant supervision could be the direct cause of a catastrophic event.
However, the police would most likely see this as an accident and thus it is not a criminal matter (unless intent can be proven). The matter will then be handled as a civil one should the parents decide to take the matter further. Usually day mothers, crèches and other childcare institutions have liability insurance for these incidents, but it is not compulsory in South Africa. In other words, if an accident happens, for example, at a day mother and she does not have liability insurance or any personal assets, no financial claim can be laid against her.
What to do when your baby chokes
So, what should a parent do in such a situation? Do you first call paramedics? Jump in your car and rush for help? Or do you try to help the baby yourself? While choking in children is not something you can necessarily prevent, knowing what action to take during a choking incident could save a life.
“Witnessing a child choking can be very distressing, causing many parents or caregivers to panic and in some instances completely freeze up if they don’t know what to do. That is why it is always a good idea to familiarise yourself with what actions to take should you be present during a choking incident,” says Dr Hennie Smith, Netcare Krugersdorp Hospital.
When advising on what to do when a young child is choking, David Stanton, Head: Clinical Leadership at Netcare 911, emphasises the importance of keeping calm and acting quickly. “Speed is of the essence in any choking situation. Being able to dislodge a blockage quickly greatly minimises the risk of further complications. However, never try to remove a foreign object unless you can actually see it, as you can run the risk of pushing it further into the airway.”
Therefore, as soon as you notice a baby or younger child is unable to cry, cough or talk, it is likely that something is blocking their airway. They may even turn bright red or blue. It is important to keep calm and think rationally about what you will need to do to best assist the child.
Below is Netcare 911’s guide to assisting a child or baby that may be choking:
“Remember, it is essential that emergency medical services are summoned as soon as possible when someone is choking because if these steps do not work, choking can very quickly result in the person losing consciousness and suffocating. The sooner paramedics are called, the sooner they will arrive on scene and the greater the chance of a positive outcome,” says Mr. Stanton.
What to do if a baby is choking on an object:
- Lay the infant face down along your arm, with the head lower than the rest of the body.
- Give five hard slaps on the baby’s back. You should do this with the intention of shaking the object loose, so don’t be too gentle.
- If the object doesn’t come out, turn the baby on their back. While supporting the entire baby, place two fingers on the middle of the chest. Give up to five hard chest thrusts.
- Keep repeating black slaps and chest thrusts until the object comes out or keep checking in the mouth to see if you can see the object. If you can see it, pull it out.
- If the object does not come out in the first few seconds (or if a baby choked on fluids), it is essential to call for professional help. If at any time, the baby or child becomes unresponsive, place them gently onto the floor. Begin cardiopulmonary resuscitation (CPR). When giving breaths, take a moment to look in the mouth and see if you can see the object, and remove it if possible. You will need to continue CPR until help arrives.
What to do if a baby is choking on fluids:
- Place infant facedown over your forearm (or legs) with the head lower than the chest.
- Give five back blows between the shoulder blades with your hand.
- If breathing has not resumed, turn the infant over, again keeping the head lower than the chest. Give five chest thrusts over the centre of the chest just below the nipple line. Use two fingers and depress the breastbone at least one inch (one third of the way to the back).
- Alternate back blows and chest thrusts until breathing returns, or help arrives.
Lastly, check with your child’s day mother or nursery school what their policy around ‘bottle propping’ is. Gracie, mother of Memphis (six months) says, “You will be amazed at how many childcare facilities do not have any feeding policies on paper – in other words, nothing stops an employee from feeding your baby any way they see fit. I was shocked to find out that Memphis’ school had no policy about bottle propping!”
Choking is a very real risk, so make sure that you and anyone who cares for your child are prepared for any emergency. Time is of the essence in a choking situation and if it is wasted, it could mean death or serious brain injury for your baby.
Verna concludes: “Mienke’s incident changed our lives forever. But it has also made us stronger and we have learned to never stop believing in hope, as miracles happen every day. We are trusting for a miracle for Mienke.” Mienke Mulder Support Group: https://www.facebook.com/groups/501325500211612/
*For information on the FED Training (Level 4 BEE Contributor) – HWSETA Aligned Child & Infant First Aid Course, contact Bridgitte Fraser on 072 684 6503 or email: firstname.lastname@example.org