What is the appropriate emergency choking relief technique (Heimlich maneuver/abdominal thrusts) for a child who cannot cough, speak, or breathe, including infants under 1 year and children aged 1 year to puberty?

Pediatric Heimlich Maneuver Technique

For infants under 1 year old, never use abdominal thrusts (Heimlich maneuver)—instead use 5 back blows followed by 5 chest thrusts in repeated cycles; for children over 1 year old, use 5 back blows followed by 5 abdominal thrusts (Heimlich maneuver) until the obstruction clears. 1, 2, 3

Age-Based Algorithm

Infants (Under 1 Year Old)

Critical Warning: Abdominal thrusts are contraindicated in infants because they can rupture abdominal viscera. 1, 2, 4

Positioning

• Hold the infant face down (prone) along your forearm with the head lower than the trunk, supporting the head and jaw. 1, 2, 3
• The head must remain lower than the chest throughout the entire procedure to facilitate gravity-assisted expulsion of the foreign body. 2

Step-by-Step Sequence

1. Deliver 5 back blows: Strike firmly to the middle of the back between the shoulder blades using the heel of your hand. 1, 2, 3

2. Turn infant supine: Flip the infant to their back while keeping the head lower than the trunk. 1, 2

3. Deliver 5 chest thrusts: Place two fingers on the sternum one finger's breadth below an imaginary line joining the nipples, compress approximately 3 cm deep (one-third of the anteroposterior diameter of the chest). 1, 2

4. Chest thrusts should be sharper and more vigorous than CPR compressions, at approximately 20 per minute. 1, 2

5. Check the mouth: Look for visible foreign bodies and remove only what you can see. 1, 2, 4

6. Repeat the entire cycle (5 back blows + 5 chest thrusts + mouth check) until the airway clears or the infant becomes unresponsive. 2, 3, 4

Children (1 Year to Puberty)

For Conscious Children

1. Deliver 5 back blows first: Position the child leaning forward (across your thighs if kneeling, or bent at the waist if standing), with the head lower than the chest, and deliver 5 sharp blows to the middle of the back. 1, 3

2. Deliver 5 abdominal thrusts (Heimlich maneuver): Stand or kneel behind the child, make a fist and place it between the navel and xiphoid process, grasp with the other hand, and deliver 5 quick upward thrusts. 1, 3, 4

3. Check the mouth for visible foreign bodies after each cycle. 1, 4

4. Repeat alternating cycles of 5 back blows and 5 abdominal thrusts until the obstruction clears. 1, 3

For Unconscious Children

• Lay the child supine and place the heel of one hand in the middle of the upper abdomen, directed upward toward the diaphragm, delivering 5 sharp upward thrusts. 1
• If the child becomes unresponsive at any point, immediately begin CPR starting with 30 chest compressions without checking for a pulse first. 3, 4

Critical Warnings: What NEVER to Do

• Never perform blind finger sweeps in the mouth—this can push the foreign body deeper into the larynx or cause oropharyngeal injury. 1, 2, 3, 5
• Never use abdominal thrusts on infants under 1 year—risk of liver and visceral rupture. 1, 2, 3, 4
• Never hang an infant upside down by the feet—no evidence of benefit and can cause injury. 2
• Never interfere with a child who can still cough effectively—their own cough is more effective than any intervention. 3

When to Attempt Rescue Breathing

• After each cycle of back blows and chest/abdominal thrusts, if the airway remains obstructed, attempt rescue breathing. 1, 2, 4
• For infants, cover both the mouth and nose with your mouth when ventilating. 2
• Partial obstruction may allow ventilation even when complete clearance hasn't occurred. 1

Activation of Emergency Services

• Call for help immediately upon recognizing severe choking (inability to cough, speak, or breathe). 3
• If alone with an infant or small child, perform 1 minute of maneuvers first, then carry the child to the phone to activate emergency services. 1
• If someone else is present, have them call while you continue maneuvers. 2

Recognition of Severe vs. Mild Obstruction

Severe obstruction requires immediate intervention: 3

• Inability to cough or make any sound
• Universal choking sign (hands clutching throat)
• Cyanosis developing

Mild obstruction—do not interfere: 3, 4

• Child can still cough forcefully
• Can make sounds or speak
• Allow the child to clear the airway by coughing while monitoring for progression

Common Pitfalls

• Do not assume resolution means no medical evaluation is needed—foreign body aspiration can be present even without evident respiratory symptoms, and medical evaluation is mandatory. 2
• A normal chest radiograph does not rule out foreign body aspiration—clinical history takes precedence. 2
• Liquids are the most common choking cause in infants; solid foods (hot dogs, grapes, nuts, round candies) and small objects are most common in children over 1 year. 3, 6