Recent accidents involving children choking on fruit served at Japanese day cares have raised concerns that the government fails to take the issue seriously through active involvement.

On April 18, a 6-month-old infant was fed an uncooked grated apple at a preschool in Aira, Kagoshima Prefecture, southwestern Japan, and fell unconscious.

The girl, whose face turned pale, was taken to hospital but never awoke and died on May 28. It was later discovered that a small piece of the fruit had lodged in her throat, choking off her airway.

A child in an infant class is fed at a certified day care center in Aira, Kagoshima Prefecture, in September 2023. (Day care not related to nursery in the same city where fatal accident occurred)(Kyodo)

"This is a place where we entrust you with our children's lives. We ask it to reconfirm the government guidelines," the father of the girl said, referring to the preschool, at a press conference in Aira in early October.

According to a document released in June by the family, they had explained to the nursery staff in a meeting before the girl joined the preschool that they always heated fruit and mashed it up before giving it to her. The staff replied that the nursery would "try not to give her uncooked fruit."

The same month, the Aira city office set up an inspection committee, including experts, and conducted a survey of preschools in the city in September. The committee, which plans to release its findings in a report, asked the nurseries about their apple cooking methods, among other practices, and their understanding of government guidelines.

"We knew that guidelines existed but overlooked some aspects of them," admitted the principal of another nursery, adding that the day care has stopped offering apples until the inspection committee issues the findings of its report.

National guidelines established in 2016 call for apples to be served heated until an infant has been completely weaned and started eating food, as they can easily choke on the fruits or accidentally breathe them into their lungs.

File photo shows an inspection committee meeting being held in Aira, Kagoshima Prefecture, in June 2023 in response to the death of a girl at a private licensed nursery school. (Kyodo)

Pears and persimmons are also dangerous for children up to around 5 years old, as clumps can be hard to swallow even if the food is broken down in the chewing process. The guidelines further state that nurseries should avoid using grapes and cherries in meals because the spheres and skins can block a child's airway if inhaled.

Even so, the guidelines are still only recommendations and lack a sense of urgency, experts say.

An infant's airway is less than 1 centimeter in diameter, which can easily lead to food aspiration.

According to the Consumer Affairs Agency, from 2014 to 2019, 80 children under the age of 14 died from choking due to food aspiration, with 73 children under the age of 5 accounting for about 90 percent of the deaths. For the 51 people for whom the foods that caused choking was clear, six ate fruits such as apples or grapes.

In 2020, a 4-year-old boy choked to death on a grape at a preschool in Hachioji, western Tokyo.

And in Niihama, Ehime Prefecture, western Japan, an 8-month-old boy fell unconscious and was left in critical condition after eating an uncooked chopped apple in May of this year. An inquiry by the prefecture and city later concluded that the nursery had not followed the guidelines for serving the fruit.

A day care worker feeds a child in an infant class at a certified nursery in Aira, Kagoshima Prefecture, in September 2023. (Day care center not related to one in the same city where fatal accident occurred)(Kyodo)

An official at the Children and Families Agency said the guidelines are "technical advice." Because there are different types of fruits and the heating facilities differ at each day care, "it is hard to mandate a uniform method of serving them," the official added.

Tatsuhiro Yamanaka, chairman of Safe Kids Japan, a nonprofit that works to prevent accidents involving children, pointed out that "grating apples alone can still leave clumps."

In particular, he said that apples provided to infants who have not fully developed their back teeth must be heated to a mushy consistency, lest it result in aspiration. "So we need to be very careful about how fruit is served."

Yuichi Murayama, director of a day care research organization, who himself operates a preschool, said that "it is not enough for the government to simply notify nurseries of the guidelines."

Active government involvement, he said, is paramount, such as increasing the number of preschool staff trained in how to serve baby food and reviewing the staffing standards so that they can notice any changes in children's behavior that might be concerning or out of the ordinary.

"It is necessary to create an environment that prevents accidents from occurring in the first place," Murayama said.

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