Food and Nutrition Programs

12/22/2022 UPDATE: Choking Prevention Policy: Nutrition for Young Children (Under the age of four)

This Choking Prevention Policy supersedes the Choking Prevention Policy distributed by the Office for Food and Nutrition Programs (FNP) on October 15, 2019. This policy is being revised and reissued to reflect feedback from Program operators, FNP staff, and current best practice guidance.

The memo language has been updated to improve clarity and provide additional guidance. An infographic is available to complement this policy memo and provide programs with a tool to share with kitchen and food prep staff to support policy understanding and implementation.

Specific changes to the list of restricted food items are as follows:

• Removal of kiwi fruit from restricted food list: based on feedback and in discussion with other sources of guidance, FNP has determined that kiwi fruit may be served to children under age four (4).

• Addition of bone-in meat/fish: meat or fish which contain bones (such as chicken wings, or whole fish) should not be served to children under age 4. The bone presents a significant choking hazard, therefore meat must be removed from the bone prior to meal service for children under age four (4).

As always, the restricted foods list does not contain all potential choking hazards; instead, it focuses on creditable, commonly served items that pose the greatest risk to children under age four (4). Institutions/SFAs are encouraged to consider their program recipients and modify or remove any other items which they consider to be high risk.

In addition to changes to the restricted items list, FNP has expanded its guidance on specific food preparation methods to ensure safety of foods. This guidance was included to answer questions frequently received by FNP and reflect available guidance from Federal and State agencies.

Choking Prevention: Nutrition for Young Children

Children under the age of four (4) are at high risk of choking while eating, and choking is a leading cause of unintended injury for this age group^{1, 2}. Foods that pose the highest risk for choking are foods that are round, tube-shaped, small, hard, thick and sticky, smooth, slippery, or easily molded to the airway.

There are many food items which meet those characteristics and therefore pose a choking hazard. To mitigate the risk of serving an item which may pose a hazard, institutions are asked to consider the shape, size, and texture of foods and make them safer for young children. Foods can be modified through a variety of methods, including:

• Cooking or steaming an item, such as a carrot, until it is soft enough to pierce with a fork.
• Removing seeds/pits/skins from certain items, like a peach, to ensure a consistent texture for all bites.
• Finely chopping food items so that they can be served in manageable bites, no larger than a nickel in size
• Grating/mashing/pureeing food items to modify the texture and bite-size of an item to make it safer to consume

Please see the Choking Hazard Infographic to provide further instruction on food modification and identifying appropriate sizes and shapes of food.

There are specific food items which pose too great a choking risk to allow for their modification. To align with Massachusetts state licensing and current best practice, FNP restricts serving of the following foods to children under four years of age:

• Hot Dogs, sausages*, sausage links or similar processed food items
• Fish or meat with bones
• Grapes, cherries, melon balls, cherry and grape tomatoes
• Specific berries- kiwi berries, raspberries, blackberries, goji berries
• Peanuts, nuts, and seeds (for example, sunflower or pumpkin seeds)
• Peanut butter and nut/seed butters
• Dried fruit such as raisins or cranberries**
• Shelf stable, dried, and semi-dried meat, poultry, seafood snacks (such as beef jerky)
• Popcorn

*Sausage patties are not restricted by the choking policy, but Institution/SFA must have crediting documentation (CN Label or PFS) for the product

The foods in the above bulleted list are not to be served to children under the age of four, even with alternate food preparation methods. The information about alternate food preparation methods relates only to other foods nor specifically identified. Children should always be supervised during meals and snacks.

Vended Meals or Contracts

Operators that enter into a contract to purchase meals from a food service vendor are responsible for ensuring that meals and snacks comply with FNP choking prevention policy. Please share FNP's policy guidance ensuring that meals received meet the requirements for serving children under the age of four years old.

Implementation Timeframe

CACFP, NSLP and SBP, and SFSP are expected to implement these changes effective immediately in FY2023/SY2022-2023.

The list of foods not to be served to young children will continue to be expanded as the United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) issues additional guidance. As new foods are added to the list, implementation of restrictions should be immediate.

If you have any questions or need further assistance, please contact FNP at 781-338-6480 or email nutrition@doe.mass.edu

May 10, 2018
Revised March 26, 2019
Revised October 15, 2019
Revised December 22, 2022

This institution is an equal opportunity provider.

¹ USDA: Reducing the Risk of Choking in Young Children at Mealtimes

² Mass.gov: Choking Prevention