My Toddler Aspirated a Pistachio. Here's What Happened.
On Halloween, 2019, my 18-month-old son Holden was chewing a small piece of pistachio and he started coughing. He had a cold that was on its way out and a lingering cough. He’s never choked on anything and we became over-confident in his abilities, allowing him to eat smaller, harder foods like nuts. Starting this story, I feel myself becoming defensive. I want to tell you how much I love him and how careful we are with food and how good at eating he is. I feel defensive because I’m his mama and I feel responsible for the accident.
When he coughed he blew air out, then his bodies’ instinct was to quickly inhale air. When he inhaled, he forcefully inhaled tiny pieces of chewed up pistachio into his lungs. This is known as foreign body aspiration. He coughed and I gave him the Heimlich and several small pieces came out. He didn’t stop breathing. He didn’t turn blue. He quickly returned to his normal, happy self. He could talk and cough and wanted to nurse and he was able to suck and swallow normally. I listened to his lungs with my stethoscope, he sounded clear. We talked to our neighbor, who’s a doctor, and he told us to keep an eye on him for any changes. We did.
I took Holden upstairs for his nap and sat with him in his room and watched him breathe while he slept. After about an hour and a half, his cough woke him up. He coughed and coughed, and when he stopped coughing I heard an expiratory wheeze. I knew what the wheeze meant. We packed up our bags and headed to the ER.
On the way to the ER, I read a few case studies about foreign body aspiration in children. It turns out, it’s pretty common for kids to aspirate and have an initial coughing incident and then become asymptomatic. Sometimes these foreign body aspirations are missed by caretakers. When this happens, kids might be treated for other illnesses like asthma, pneumonia or given antibiotics in response to their symptoms that can slowly worsen over days or weeks. X-rays don’t show organic foreign matter, but they can show issues with the lungs that develop secondary to the foreign body. Holden’s x-rays were completely clear. His oxygen saturation was perfect. He showed no signs or symptoms other than a wheeze that you could just barely hear when he exhaled.
We sat in the ER for five or six hours waiting to figure out the plan. We needed to find a pediatric doctor in the area who performed rigid bronchoscopy. Bronchoscopy is a procedure where a doctor inserts a thin tube with a light and camera into the lungs. For children who may have objects in their lungs, it is necessary to use what is called rigid bronchoscopy to examine the lungs and remove the foreign matter. I’ve seen plenty of flexible bronchoscopy’s performed on adults when I worked in the cardiac ICU. Doctors performed the procedure on patients who were under conscious sedation at the bedside, meaning we blocked pain and gave relaxants, but the patients were not under general anesthesia. These procedures I witnessed were quick, maybe 20 minutes or less.
We tried to keep our energy up and calm in the hospital. We played and talked to him gently about what was happening. My breakdowns were reserved for the times when I was waiting.
For children, it is necessary to go under general anesthesia. After many hours of trying to find a solution to this problem of no pediatric providers, our incredible ER doctor got ahold of the one woman in town who could perform the procedure. We headed to the OR. She had performed this procedure many times. Depending on what was in there, she’d probably take about 30 minutes to 1 ½ hours. Most kids did great and didn’t end up intubated.
We handed Holden off to the OR nurses and his scream filled the hallways. For the first time that day, I felt the full weight of the moment and it felt like a piece of me was dying. We went to the waiting room. A half hour passed. An hour passed. An hour and a half passed. A pediatrician came to talk to us. He told us that anytime you suspect foreign body aspiration you need to address the problem with rigid bronchoscopy within 24 hours. He told us that if the doctor performing the rigid bronchoscopy hadn’t come in, he would have flown us to Stanford.
He went in to check on Holden’s progress. When he came out, he told us there were multiple small pieces of pistachio in his lungs and that they were still working. After another hour and a half, the doctor performing the bronchoscopy finally came out. The pistachio pieces had traveled all the way down into his left lung, obstructing his tiniest airways. It was an ordeal and his lungs were scraped and swollen. They were going to try to extubate him, but there was a chance he would be intubated overnight.
They ended up keeping Holden’s breathing tube in. During his procedure, as we waited and waited, I felt like I didn’t have the capacity to withstand the stress I felt. I was overwhelmed and anxious and in physical pain. Why is this happening? This isn’t real. I was so mad and trapped and powerless. Max and I paced and I cried and we waited and waited.
When the anesthesiologist came out, I knew Holden would be intubated overnight. Before I even saw him, I could picture his small body with a breathing tube in his throat hooked up to a machine that was breathing for him. I thought, why isn’t this happening to me instead, why him?
We headed to the pediatric ICU and when I saw him he looked so peaceful and beautiful and the machine looked like an offensive intruder. I stroked his head and cried and rubbed his legs and I wanted to pick him up and run away with him. He was sedated with morphine, but he was fighting through the medication even as it was slowly increased. We ended up holding his head in place all night so he wouldn’t pull his tube out. When the nurses were in the room, I could lay down for a few minutes and try to rest, but then they would leave and I’d hop up in time to make sure he didn’t pull his tube out. My stress and exhaustion combined into a kind of focus that has left me with some amnesia.
Sometime around 7 in the morning, after a horrible night, the nurses were out of the room for a long time. Holden was still thrashing. Max was holding his head and I was holding his arms and telling him it was ok, we were here.
Gently and quietly, Max said, “Amy, can you come here for a moment and hold his head?” I came around to his side of the bed and just as I slipped my hands under Holden’s head, Max fell straight back and crashed his head into the hospital floor. He had passed out. The empty room flooded with people. Several nurses started helping with Holden. Max’s head was bleeding on the floor. His vitals were taken, they wanted him to go to the ER. I saw that his vitals were stable and said, he’s not going to the ER, we’ve just had the worst, most stressful night of our lives. He needs food, water and sleep. I passed him a coconut water, he rested and hydrated and my life felt a little scarier and more uncertain.
Max’s incident brought in the full team including the pulmonologist who looked at Holden and said, lets extubate him this morning ASAP. After turning off his sedation and ensuring he was breathing on his own, they pulled out his tube. For a few hours, he was on a low amount of oxygen. He was so tired he couldn’t keep his eyes open. His cry was a silent scream since his throat was sore and raw. He slept all day, waking only to eat midday, then slept again. He nursed and slept all day and all night and into the next morning.
When he woke up after the second night in the hospital, he was suddenly himself again. He wanted to nurse more, but he was talking and playing and making fart noises. Fart noises are the sound of hope. They are what I want to hear from my boy. We came home and he continued recovering. We are still scared every time he eats and every time he coughs. I wonder now if I’ll be scared of him choking for years. I think about how much there is to fear, how little control we have, but how resilient Holden is and how lucky we are that he’s ok.
I wrote this story as an act of integration and healing of my own trauma and to let parents know that accidents happen and it is really hard not to feel the incredible weight of regret and self-hatred as a parent. if you suspect foreign body aspiration, you need to push for a rigid bronchoscopy within 24 hours. The top ten foods children aspirate or choke on are seeds and nuts, popcorn, hotdogs, hard candy, raw vegetables and round foods like grapes and beans. It was a mistake for us to give Holden a tiny, bitten in half piece of pistachio. He hasn’t had trouble with choking before, but his cold made him vulnerable.
After we came home from the hospital, Holden wanted to nurse. He was sleepy and only wanted to be with me for a few hours. He nursed and I held him and figured this might be how we spend the day, perhaps a few days. Then out of nowhere, he said, done, bye milk, and jumped up and started galloping around the house like a horse. He did his lady ballerina dance and his man ninja kicks. He sang and danced and did all of his party tricks. The marks on his cheeks and body that were rubbed raw by tape healed in a day. He is helping us all get back to normal the way kids do best, through play and long naps, fart sounds and warm baths.
Aspiration: Facts and Prevention
Aspiration is when food, material, or drink enters the lungs or airway. It is more likely to happen in children who have trouble swallowing due to medical conditions and those with GERD. It can also happen in children and adults without medical conditions. Aspiration is most common in children under 3 and adults over 50. Anytime your child chokes on food and has excessive coughing, choking, or turns red or blue, there is a chance they aspirated material into their lungs.
The signs and symptoms of aspiration in babies and toddlers include wheezing, choking or coughing while feeding, faster breathing while eating, lungs and voice that sound wet after eating, slight fever and repeated airway or lung infections (when the aspiration event is missed and left untreated). Some children have no signs or symptoms and this is known as silent aspiration.
If aspiration is suspected, doctors may order a chest X-ray or CT scan or do some swallowing tests. Rigid bronchoscopy is required for visualization of the airway and retrieval of foreign matter and is ideally performed within 24 hours.
In the event of choking or aspiration, the Heimlich maneuver is performed in children over 1 and back blows and chest thrusts are used in babies younger than 1. If you don’t know how to do these, take a child CPR class.
According to Dr. Julie Wei, children under age 5 or 6 shouldn’t be offered any nuts or seeds because they don’t do a good enough job chewing these foods. She also advised that parents with infants and toddlers avoid popcorn, hotdogs, hard and gummy candies, raw chunks of vegetables like carrots and broccoli, round foods and beans. Cooking vegetables until they are soft and cutting grapes in half makes these foods safer for toddlers. Mindful eating, while seated, helps prevent aspiration. Keep gum, chunks of peanut butter, chips, pretzels and other crunchy snack foods, balloons, marbles, small balls, pen caps, batteries and pins out of reach.
Safe foods and habits: sit upright, eat in a quiet area without distractions (like TV) and take slow, small sips of water. Always watch kids while they eat. Offer cooked food in small cut up pieces, shredded or crumbled cheese and ground meat.
The reality of parenting is that you can take preventative steps but you can’t prevent all bad things from happening. On the day Holden aspirated, we were having an amazing, fun day and we were just confident in Holden’s abilities and made a mistake by giving him an unsafe food. He probably would have been OK if he didn’t have a cough from his cold, but maybe not. The aspiration was an accident. I’ve met many parents who give their young toddlers these foods without a problem and kids put stuff in their mouths all the time. And while I know now that thousands of kids choke and aspirate each year, I feel so guilty and angry with myself. Parent guilt is a real thing. I’m trying to shape my guilt into a story, improve our safe eating practices and share our experience with other parents. Max reminds me daily that accidents can happen, but our reactions to those accidents, how we move forward and the stories we tell are powerful and have the capacity to shape our experiences into memories we can learn from. I hope this story fills you not with fear, but with a little more information about safe eating and gentleness toward yourself as a parent.