Baby and Toddler Gagging: One Mom’s Story

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Fear of choking and misinformation about the differences between gagging and choking in babies are among the biggest barriers to baby-led weaning (BLW) that I see in my private practice as a pediatric dietitian working in infant and toddler feeding.

Studies actually show that BLW does not increase choking risk when parents and caregivers know how to offer appropriately sized foods at the right texture for babies. In fact, a 2017 study in the Journal of Human Nutrition & Dietetics found that infants who were given finger foods the least often had the highest frequency of choking episodes.

Another 2016 study in Pediatrics found that by the age of 8 months, BLW babies gagged less frequently than conventionally-fed (spoon-fed) infants of the same age. If I had to guess why this is the case, I’d say these studies highlight how important it is that babies are given opportunities to practice eating finger foods of different textures, since learning how to eat is a process with many different skills to learn and master.

In any case, gagging is a normal, natural, noisy, built-in safety mechanism that can seem alarming, but is actually nothing more than the process of coughing up food that a baby is not quite yet ready to swallow. Early in infancy, the gag reflex is strong, but in most cases, it shifts further back into the mouth over time and is similar to that of an adult by the time baby reaches about 9 months of age. 

Most babies gag during the process of learning to eat. If the gagging doesn't seem to bother the baby, and if baby is gaining weight appropriately and following his or her growth curve, gagging is not usually a cause for concern. The best way parents and caregivers can help a baby during a moment of gagging is to stay calm and positive and encourage baby to chew and swallow. 

I’m often asked by parents how they can reduce their own stress and fear about gagging and choking during infant feeding. In all cases, parents, grandparents, nannies, caregivers, and anyone who will be taking care of your baby should be trained in infant CPR and first aid. This not only helps everyone be prepared, it also reduces our stress around food and feeding which makes mealtimes more pleasant, positive and successful for everyone.

You can get trained at home on your own time by a nationally certified Red Cross and Lifesaving Society First Aid Instructor using this EXCELLENT, 2-hour, self-paced online course from Safe Beginnings* that teaches you everything you need to know to prevent and manage infant and child choking, CPR and first aid-related emergencies. Use my code for 20% off: MALINA. This course is perfect for parents, grandparents, babysitters, nannies and anyone else who will be caring for babies and kids.

But what do you do when gagging seems to be getting in the way of normal growth and development? Start by talking to your pediatrician. Interventions by pediatric feeding therapists, occupational therapists and speech therapists can make all the difference when excessive gagging is happening as a result of issues like physical or developmental delays.

It can sometimes help to hear how other parents have navigated feeding difficulties in their babies and kids. Here is one brave mom’s story. She is a client of mine who volunteered to tell her story anonymously in the hopes that it would help others experiencing something similar. 

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“My three-year-old son sat at the table, wary of the banana I had put in front of him. He was obviously nervous, but he was also determined. He had seen his favorite character eat a banana while pretending to be a monkey, and he wanted to try. However, for most of his life so far, bananas would easily cause him to gag and sometimes vomit; he avoided them like the plague, even gagging when he simply saw one. Nevertheless, with a little encouragement, he gingerly took a tiny bite. His eyes lit up. “I like it, Mommy! Bananas are yummy!”

That moment was such a win for our family. While so many other children would reach for a banana in a heartbeat, fruit in general was a source of fear for my little boy. Most foods that did not consist of crackers or ground meats were sources of fear. 

My son had a combination of some general muscle weakness from birth as well as a very cautious personality. This led to a sensitive gag reflex that made him afraid to eat. At each meal, he would take a few bites, gag, and then refuse to try that food again. Sometimes the food would simply stick to the roof of his mouth as he gagged and panicked, as in the case of soft bread or bananas. Other times, my husband and I had no clue why he was gagging. We tried everything to get him to eat, with very little luck. At the age of 15 months, his pediatrician declared that he was not gaining enough weight and had truly fallen off the curve. After some tests to rule out serious underlying causes of his Growth Deceleration diagnosis, he was referred to our state’s early intervention program which gave us the tools we needed to help desensitize his gag reflex and bring his weight back to the curve of the 2nd percentile. I used to laugh; many parents are worried if their child dips below the 10th percentile, but we were aiming for the 2nd percentile.

Two years later, our daughter was also referred to our state’s early intervention program at nine months old. She was still having trouble sitting up without falling, but something else concerned me even more; she was gagging, retching, and vomiting while trying to eat even those meltable baby puffs. Thankfully, she was a healthy weight, but the process of eating was a stressful one. 

Most meals, she would stick a bite in her mouth, move it around a little, and then it would touch the back of her tongue. Immediately she would gag with her mouth wide open, squeeze her eyes shut, and lean forward. The bite would sit on the back of her tongue, not moving; I could easily see it with her mouth open. She would cough forcefully, but it usually wouldn’t help. Often, she would end up vomiting in order to push that little bite forward and off of the back of her tongue. We’d end the meal with a bath, tear-stained eyes, and a little tummy that was more empty than when we had started. It wasn’t just baby puffs. Any piece of bread or cracker would do it. Most foods with a thin shape would do it too, such as tortillas, pepperoni, pizza, and even thin slices of fruit.

Although both of our children have had gagging problems, I am so thankful that neither one has ever truly choked. The gagging has been stressful, but I’ve learned throughout our experiences that a sensitive gag reflex is still just a natural choking prevention mechanism. True choking is usually silent or consists of a high pitched sound, as described here. Coughing, talking, or loud guttural noises, no matter how distressing they sound, mean that kids are effectively working to clear their airways on their own. In fact, intervention such as patting the back or trying to sweep the mouth with a finger can actually cause choking.

We received physical, speech, occupational, and nutrition therapy home visits. The dietitian who came gave us tips on how to increase his caloric intake, and she worked hard to ensure he was gaining well. The occupational therapist worked with us on desensitizing his gag reflex. With her help, we realized that our son had both oral motor weakness and sensory aversions. He gagged on any soft or mixed-texture food, and he would usually only tolerate crunchy foods and some meats. Crunchy foods helped him to know the location of the food in his mouth because of the sensory input. However, when he took a bite of something soft, he would find it difficult to keep track of, and the food would make its way to the back of his throat before he was ready to swallow.

Initially, our solution to our children's problems eating was to eliminate the offending food from their diets. However, by doing this, we learned that we were just teaching our kids that they were right to be afraid. Instead, our speech and occupational therapists showed us that the solution was to continue exposing them to a variety of foods but also to “wake up” their mouths with increased sensory input before a meal. Before a meal, the therapist would give them icy teethers to chew on, “brush” their mouths with something bumpy, or give them a taste of something sour. Eventually, at 2 ½ years old, our son’s aversions started to relax. He started trying foods a second or third time, even after he had gagged on them. He expanded his palate to include some different textures, although he still finds most fruits difficult even though he’d older. Our daughter still has some trouble with mixed/tough textures and overstuffing now at 2 ½ years old, but she'll try anything if it's on my plate!

Of course, if you are at all worried about your child's eating, it's a good idea to bring the topic up to your child's pediatrician. When I showed the doctor a week-long food diary of what our son was eating, she changed our approach from testing for various disorders to referring to an early intervention program.

Ultimately, I learned to stay calm when my kids start gagging, and I became more comfortable with the knowledge that gagging is a normal part of learning to eat table foods. As long as your kiddos are gaining weight and getting energy, stay positive and keep trying different textures so they can learn to manage these foods.”