Drowning Prevention

Drowning is the leading cause of injury death among U.S. children ages 1 to 4 years and the third leading cause of unintentional injury death among U.S. children and adolescents ages 5 to 19 years. 1

In 2017, nearly 1,000 American children drowned. Fortunately, mortality rates from unintentional child drowning have steadily decreased from 2.68 per 100,000 in 1985 to 1.11 per 100,000 in 2017.

Rates of death from drowning vary with age, sex, and race and/or ethnicity, with young children and adolescent males having the highest levels of risk. After one year of age, boys of all ages are at greater risk of drowning than girls.

Overall, African American children have the highest rates of death from drowning, followed in order by American Indians and/or Alaska Natives, whites, Asian Americans and/or Pacific Islanders, and Hispanic children.

For the period 2013-2017, the highest rates of drowning deaths were seen in white male children ages 0 to 4 years (3.44 per 100,000), American Indian and/or Alaskan children ages 0 to 4 years (3 .58), and African American male adolescents ages 15 to 19 (4.06 per 100,000). 1

Drowning is also a major source of morbidity for children. In 2017, an estimated 8,700 children under the age of 20 visited a hospital emergency department for a drowning event, and 25% of those children were hospitalized or transported for further care. 1

Most nonfatal drowning victims recovered completely without neurological deficits, but severe long-term neurological deficits were observed with prolonged submergence times (>6 minutes), prolonged resuscitative efforts, and failure to initiate early cardiopulmonary resuscitation (CPR). by the observer. 2–4

The American Academy of Pediatrics is issuing this revised policy statement due to new information and research regarding: 

1. Populations at highest risk

2. Racial and sociodemographic disparities in drowning rates,

3.  Water competence (water safety knowledge and attitudes, basic swimming skills, and response to a swimmer in trouble), 5.6

4.  When children are in and around water (the need for close, constant, attentive and capable adult supervision and the use of life jackets on children and adults),

5.  When children are not expected to be around water (the importance of physical barriers to prevent drowning), and

6. The chain of drowning survival and the importance of bystander CPR.

In 2002, the World Congress on Drowning and the World Health Organization revised the definition of drowning as “the process of experiencing respiratory failure due to sub-immersion/immersion in liquid.”

The outcomes of drowning are classified as “death,” “no morbidity,” or “morbidity” (later divided into “moderately disabled,” “severely disabled,” “vegetative state/coma,” and “brain death”).

The drowning process is a continuum that can be interrupted by rescue at any point in that process, with consequences varying from no symptoms to death.

Terms such as wet, dry, secondary, active, near, passive and silent drowning should not be used.

The revised definition and classification is more consistent with other medical conditions and injuries and should assist in the surveillance of drowning and the collection of more reliable and comprehensive epidemiological information. 7

Certain populations, due to their behavior, ability, environment, or underlying medical condition, are at greater risk for drowning.

> Young children

For the period 2013-2017, the highest drowning rate occurred in the group from 0 to 4 years old (2.19 per 100,000 inhabitants), with children from 12 to 36 months being at highest risk (3.31 ). Most babies drown in bathtubs and buckets, while most preschoolers drown in swimming pools. 8

The main problem for this young age group is the lack of barriers to prevent unanticipated, unsupervised access to water, including swimming pools, hot tubs and spas, bathtubs, natural bodies of water and stagnant water in homes (buckets, bathtubs, and toilets).

The Consumer Product Safety Commission (CSPC) found that 69% of children under the age of 5 were not expected to be in the pool at the time of a drowning incident. 9

> Adolescents

Adolescents (15–19 years) have the second highest fatal drowning rate . In this age group, just under three-quarters of all drownings occur in natural water sources, and this age group makes up half of child drownings in natural water. 10

In 2016, Safe Kids Worldwide reported that the rate of fatal drowning in natural water in adolescents ages 15 to 17 was more than 3 times higher than in children ages 5 to 9 and twice the rate for children under 5 years. eleven

The increased risk of fatal drowning in adolescents can be attributed to multiple factors, including overestimation of abilities, underestimation of dangerous situations, engaging in impulsive and high-risk behaviors, and substance use. 12

Alcohol is a leading risk factor, contributing 30% to 70% of recreational water deaths among American adolescents and adults . 13

> Epilepsy

Drowning is the most common cause of death from unintentional injury in people with epilepsy, 14 and children with epilepsy are at increased risk of drowning, both in bathtubs and swimming pools. fifteen

The relative risk of fatal and non-fatal drowning in patients with epilepsy varies greatly but is 7.5 to 10 times higher than in children without seizures 15,16 and varies with age, severity of the disease, degree of exposure. to water, and the level of supervision. 15–17

Parents and caregivers of children with active epilepsy should provide direct supervision around water at all times, including swimming pools and bathtubs.

When possible, children with epilepsy should shower rather than bathe 17 and swim only where a lifeguard is present. Children with poorly controlled epilepsy should discuss any swimming activity with their neurologist or pediatrician.

> Autism

Children with autism spectrum disorders (ASD) also have an increased risk of drowning, 18 especially those under 15 years of age 18 and those with a higher degree of intellectual disability. 19 Wandering behavior is the most commonly reported behavior leading to drowning, accounting for nearly 74% of fatal drowning incidents among children with autism. twenty

> Cardiac arrhythmias

Exertion while swimming can trigger arrhythmia among individuals with long QT syndrome. 21 Although the condition is rare and such cases represent a small percentage of drownings, long QT syndrome, as well as Brugada syndrome and polymorphic catecholaminergic ventricular tachycardia, should be considered as a possible cause of unexplained diving injuries among competent swimmers. low risk environments. 22

There continue to be significant racial and socioeconomic disparities in drowning rates among children. For many, cultural beliefs and traditions can prevent children from swimming. 23,24

Additionally, for some religious and ethnic groups, single-sex aquatic environments, 25 and clothing that protects modesty are required according to religious standards which may not be permitted in some pools.

Socioeconomically, the multiple swim lessons required to achieve basic water proficiency can be expensive or difficult given limited access and transportation.

Furthermore, decreasing municipal funding for swimming pools, swimming programs, and lifeguards limited access to swimming classes and recreational sites with safe water for many communities.

These barriers can be overcome through community-based programs targeting high-risk groups to provide free or low-cost swimming lessons, developing special programs to address cultural concerns, as well as developing swimming classes for youth with disabilities. developmental disabilities, changing pool policies to meet the needs of specific communities, using culturally and linguistically appropriate instructors to teach swimming lessons, and working with both health care and faith communities to refer patients and their families to swimming programs. 25–27

Water competence is the ability to anticipate, avoid, and survive common drowning situations. 6

Components of water proficiency include water safety awareness, basic swimming skills, and the ability to recognize and respond to a swimmer in trouble. Swimming lessons and swimming skills alone cannot prevent drowning.

Learning to swim has to be seen as a component of water competence that also includes knowledge and awareness of local dangers and/or risks and one’s own limitations; how to use a life jacket (previously referred to as a "personal flotation device"); and the ability to recognize and respond to a swimmer in trouble, call for help, and perform safe rescue and CPR. 5

Evidence reveals that many children over 1 year old would benefit from swimming lessons. 28 Swimming lessons are increasingly available to a wide range of children, including those with various health conditions and disabilities such as ASD.

A parent or caregiver’s decision about when to start swimming lessons should be individualized based on a variety of factors, including comfort with being in the water, health status, emotional and physical maturity, and cognitive limitations.

Although swim lessons provide 1 layer of protection from drowning, swim lessons do not make the child “drowning-proof,” and parents should continue to provide barriers to prevent inadvertent access when not in the water and to supervise closely watch children in and around water.

In contrast, infants under 1 year of age are maturationally unable to learn the complex movements, such as breathing, necessary for swimming. They can manifest reflex swimming movements underwater but cannot effectively raise their heads to breathe. 29

There is no evidence to suggest that infant swimming programs for children under 1 year of age are beneficial.

Basic swimming skills include the ability to enter the water, float, turn, propel yourself at least 25 yards, and exit the water.30

Importantly, the performance of these water survival skills, typically learned in a pool, are affected by the aquatic environment (water temperature, water depth, water movement, clothing, and distance), and the demonstration of skills in 1 aquatic environment cannot be transferred to another.

There is tremendous variability among swim classes, and not every program will be right for every child. Parents and caregivers should research options for swim lessons in their community prior to enrollment to ensure the program meets their needs and the needs of the child.

High-quality swim classes provide more training experience, including swimming while clothed, with life jackets, in falls, and practicing self-rescue. Achieving basic swimming skills with water proficiency requires multiple lessons, and the acquisition of water proficiency is a prolonged process that involves learning in conjunction with developmental maturation.

There is a need for a broad, coordinated research agenda to address not only the effectiveness of swimming lessons for children ages 1 to 4 years, but also the many components of water competence for the child and parent or caregiver. .

The Haddon Matrix paradigm for injury prevention is used to identify interventions aimed at changing the environment, the individual at risk, and/or the agent of injury (in this case, water). 31

Experts generally recommend using multiple “layers of protection” to prevent drowning because any single strategy is unlikely to prevent drowning deaths and injuries.

The Haddon Matrix reveals examples of interventions before the drowning event, during the drowning event, and after the drowning event at the individual, environmental, and policy levels. Five major interventions are evidence-based: 4-sided pool protection, life jackets, swimming lessons, supervision, and lifeguards (with descending levels of evidence).

Installing 4-sided fences (at least 4 feet high) with self-closing gates that completely isolate the pool from the home and yard is the most studied and effective drowning prevention strategy for the young child. , preventing more than 50% of drownings in swimming pools in young children. 32,33

It is now also well proven that life jackets prevent drowning deaths. Some data reveal that swimming lessons can lower drowning rates in children, 27 including those ages 1 to 4.

Lifeguards and CPR training also appear to be effective. 2,4,34–36 However, data are lacking on the value of other potential preventive strategies, such as pool covers and pool alarms.

Inadequate supervision is often cited as a contributing factor to childhood drowning, especially for younger children. 11,37,38 Adequate supervision, described as close, constant, and attentive supervision of young children in or around any water, is a primary and absolutely essential preventive strategy. 27

For beginning swimmers, appropriate supervision is "tactile supervision," in which the supervising adult is within arm’s reach of the child so that he or she can remove the child from the water if the child’s head goes underwater. .

The interventions evaluated demonstrated that increasing the quality of supervision includes swimming lessons that emphasize the need for continuous parental supervision, 39 and a study in Bangladesh found that adult supervision, in addition to the physical barrier of parks significantly reduced the risk of drowning in children aged 1 to 5 years. 27

Supervision should include being able to recognize and respond appropriately to a child in trouble. Supervision is critical for safety in children with ASD and other disabilities. The National Autism Association’s Big Red Safety Box 40 contains information for parents, schools, and first responders and suggests a safety plan in public places where there is a handover of supervision so that children with ASD and other disabilities do not wander outside .

Although supervision is an essential element of protection when children are expected to be in or around water, barriers should be in place to prevent children’s inadvertent access to the water at times when swimming is not taking place.

Drowning is silent and only takes a minute.

Children at highest risk of drowning are those between 12 and 36 months. Developmentally, they are curious and lack judgment or awareness of the dangers of water, so barriers, such as 4-sided fences and door locks, are critical in preventing access when the caregiver is distracted. with other children, preparing food, etc.

The Model Aquatic Health Code, 41 developed by the Centers for Disease Control and Prevention (CDC), is based on science and best practices to help guide policymakers and aquatic leaders on pool safety. and spas.

The Model Aquatic Health Code provides guidelines and standards for equipment, staffing and training, and monitoring of pools. Similar attention and effort are necessary for open water swimming locations.

The drowning chain of survival refers to a series of steps that, once enacted, attempt to reduce the mortality associated with drowning. The steps in the chain are as follows:

1. Avoid drowning.

2. Recognize the problem.

3. provide flotation.

4. Remove from water.

5. Provide necessary care.

The chain begins with prevention , the most important and effective step in reducing morbidity and mortality from drowning. 42

Rescue and resuscitation of a drowning victim must occur within minutes to save lives and reduce morbidity in non-fatal drownings and underscores the critically sensitive role of the parent or supervising adult.

Immediate resuscitation at the immersion site, even prior to the arrival of emergency medical services (EMS) personnel, is the most effective means of improving outcomes in the event of a drowning incident. 23

Rapid initiation of CPR with a focus on airway and breathing before compressions 43 and activation of prehospital advanced cardiac life support for the pediatric submersion victim has the greatest impact on survival and prognosis. 4.44

Current guidelines recommend that drowning victims requiring any form of resuscitation (including rescue breaths only) should be transported to the emergency department for evaluation and follow-up, even if they are alert with effective cardiopulmonary function at the scene. 43

> Parents and caregivers

1. Parents and caregivers should never (even for a moment) leave young children alone or in the care of another child while in or near bathtubs, swimming pools, spas, or wading pools and when near irrigation ditches. , ponds, or other open stagnant water.

2. Parents and caregivers should be aware of the risks of drowning associated with hazards in the home.

• Baby bath seats can tip over, and children can escape from them and drown in even a few inches of water in the bathtub. Babies should always be with an adult when in a bath seat in a bathtub.

• Water should be emptied from containers, such as buckets, immediately after use.

• To prevent drowning in bathrooms, small children should not be left alone in the bathroom, and bathroom locks may be helpful.

• Parents and caregivers should avoid unsupervised access to the bathroom, pool, or open water.

3. When infants and toddlers (or non-proficient swimmers) are in or around the water, a supervising adult with swimming skills should be within an arm’s length, providing constant contact supervision. Even with older children and better swimmers, the eyes and attention of a supervising adult must be constantly focused on the child.

This “water watcher” should not be involved in other activities that might compromise this attention, including phone use (e.g., texting), socializing, doing homework, or drinking alcohol, and there should be a clear handover of responsibility. from one observer to the next. Supervision must be close, constant, and attentive.

In the event of an emergency, the supervising adult must be able to recognize a child in danger, safely perform a rescue, initiate CPR, and call for help. Parents need to recognize that lifeguards are only 1 stage of protection, and children in and around water require constant caregiver supervision, even if a lifeguard is present.

4. To prevent inadvertent access, families should install a 4-sided isolation fence to separate the pool from the house and the rest of the self-closing yard. Detailed guides for safety barriers for home pools are available online from the CSPC. 46

Families of children with ASD or other disabilities who are at risk for wandering should identify local hazards and work with the community on pool fencing and hazard mitigation.

5. Although data is lacking, families can consider supplemental pool alarms and pool covers as additional protection parts; However, neither alarms nor pool covers are a substitute for proper fencing and adult supervision.

It is important to note that some types of pool covers, such as thin plastic solar covers, should not be used as a means of protection because they can increase the risk of drowning.

6. Parents, caregivers, and pool owners should learn CPR and have a phone and US Coast Guard-approved rescue equipment (e.g., life buoys, life jackets) by the pool. Older children and teenagers should learn CPR.

7. Children and parents should learn to swim and learn water safety skills. Because children develop at different times, not all children will be ready to learn to swim at exactly the same age. There is evidence that swimming lessons can reduce the risk of drowning, even in children aged 1 to 4 years.

Parents’ decisions about starting swimming lessons or water survival training skills at an early age should be individualized based on the child’s frequency of exposure to water, emotional maturity, physical and cognitive limitations, and health problems related to swimming pools.

Parents should be reminded that swimming lessons do not prove that a child of any age will not drown.

It is critical that swim instructors emphasize this message, as well as the need for constant supervision around the water.

Swimming ability should be considered only 1 part of water proficiency and a multi-layer protection plan involves an effective pool fence; close, constant, and attentive supervision; wear a life jacket; training in CPR and the use of an automated external defibrillator and lifeguard.

Children should be taught that they should never swim alone and never swim without adult supervision.

8. Parents should monitor their child’s progress during swimming lessons and continue their lessons at least until basic water skills are achieved. Basic swimming skills include the ability to enter water, float, spin around, propel yourself for at least 25 yards, tread water, and get out of water.

9. Any time a young child visits a home or business where there is access to water (e.g., pool, hot tub, open water), parents and/or caregivers should carefully evaluate the locations to ensure that basic barriers are in place. in place, such as sliding door locks and pool fences with closed doors in good repair, and ensure that supervision will be consistent with the recommendations above.

10. All children and teens should be required to wear U.S. Coast Guard-approved life jackets whenever in the water or on a personal watercraft, and all adults should wear life jackets when boating to model a safe behavior and to facilitate your ability to help your child in an emergency.

Young children and non-swimmers should wear life jackets around water and when swimming. Parents and caregivers should ensure that life jackets are those approved by the United States Coast Guard because many do not meet safety requirements.

Information on how to choose US Coast Guard approved life jackets is available on the website. 47 Parents should not use air-filled swimming aids (such as inflatable armbands, neck rings, or "floats") in place of life jackets. These aids can deflate and are not designed to keep swimmers safe.

11. Jumping or diving into water can lead to spinal injury. Parents and children should know the depth of the water and the location of underwater hazards before jumping or diving or allowing children to jump or dive. The first entry into any type of water should be feet first.

12. When selecting an open water location where their children will swim, parents should select sites with lifeguards and designated swimming areas. Even for the strongest swimmers, it is important to consider the weather, tides, waves and water currents when selecting a safe location for recreational swimming.

Swimmers should know what to do in the event of currents: swim where a lifeguard is present, and if caught in a current, stay calm and either swim out of the current parallel to the shore (do not try to swim against the current) or walk through the water until you are safely out of the current and able to return to shore or signal for help. 48

13. Parents and children should recognize the risks of drowning in cold seasons. Children should refrain from walking, skating or riding on weak or thawed ice on any body of water.

1. Pediatricians should know the main causes of drowning in their location so they can appropriately tailor their prevention guidance to caregivers. Pediatricians can provide messages targeted by age, sex, high risk of drowning, and geographic location.

2. Children with special health care needs should have anticipatory counseling related to drowning risks. Children with epilepsy, ASD, and cardiac arrhythmias are at particular risk. When swimming or taking a bath, children of any age with epilepsy should be closely supervised by an adult at all times. 15 Children with poorly controlled seizures should discuss water safety with their doctors before swimming activities.

3. Counseling parents and teens on water safety provides an opportunity to address problems related to alcohol and drug use during any activity. Specifically, the discussion should include a warning about the increased risk of drowning when using alcohol or illicit drugs while swimming or boating. Because adolescent boys are at high risk of injury in aquatic environments, they warrant extra counseling.

4. Pediatricians should help facilitate a conversation between caregivers and their children about water competence levels to decrease the frequency with which children or parents overestimate swimming skills and equip older children with the ability to make informed decisions. when they are not in the presence of their parents or caregivers.

5. Pediatricians should support the inclusion of CPR training in high school health classes.

> Pediatricians

1. Pediatricians should work with legislators and serve as a voice for children to institute policies that reduce the risk of drowning, including but not limited to fencing policies, boating, life jackets, aquatic safety, and safety systems. SME. Pediatricians should partner with public health and policy leaders to address the issue of childhood drowning by implementing effective evidence-based interventions.

2. Pediatricians should use the term “nonfatal drowning” (rather than “near drowning”) when speaking to families and the media to avoid confusion and misconceptions associated with other terms previously used. There has been a lot of misinformation in recent years regarding dry drowning and secondary drowning. 49

Pediatricians should educate caregivers that dry drowning and secondary drowning are not medically accurate terms. Pediatricians can address parental concerns by providing reassurance that nonfatal or fatal drownings do not occur later in patients without prior symptoms.

3. Pediatricians should partner with community groups to increase access to life jackets through vest lending programs at swimming and boating sites.

4. Pediatricians should work with the community to provide access to programs that develop swimming skills for all children, especially those from low-income and diverse families and those with developmental disabilities. Pediatricians can identify and support programs to increase access to high-quality, culturally sensitive, and affordable programs. 26

> Pool operators

1. Community pools must have certified lifeguards with current CPR certification.

2. Pool owners and operators should adopt the Model Aquatic Health Code to ensure that best practices are being used to maintain a safe pool and spa environment.

3. Owners of private pools and spas and managers of public pools should be aware of the risks of entrapment and/or entanglement and of laws requiring drain covers and filter pump equipment necessary to prevent these injuries that primarily involve children. 50.51

> Political leaders

1. Policymakers should pass legislation or make codes to mandate 4-sided fencing for new and existing residential pools at the local and state level. Local governments should inspect and strictly enforce pool fencing requirements because this has been shown to be effective in reducing drowning. 52

2. Policymakers should work with recreation and boating agencies to support legislation mandating that teens and child caregivers wear life jackets when boating. 53 When adults model appropriate behavior by wearing life jackets, children and teens are more likely to do so as well.

3. States and communities should pass legislation and adopt regulations to establish basic safety requirements for natural swimming areas and for public and private recreational facilities (for example, requiring the presence of certified lifeguards in designated swimming areas). 54

4. States and communities should enforce laws prohibiting alcohol and other drug use by all boat occupants, not just operators.

5. State and local EMS personnel, physicians, health departments, and child death review teams must use consistent systematic reporting of information about the circumstances of drowning events. Periodic review of this data is critical in developing drowning prevention strategies appropriate for the geographic area.

6. Local government agencies should adopt the Model Aquatic Health Code for swimming pools, with improved inspection and enforcement of pool safety standards.

7. Due to the lack of robust evidence, a coordinated research agenda must be established to inform future policy, and federal funding must be secured to advance this research.

The present review emphasizes the importance of the commitment of caregivers, teachers, lifeguards and decision makers in knowing and implementing appropriate drowning prevention measures.

The groups and ages most vulnerable to drowning events are highlighted, and the measures that are proven to reduce the risk: constant, adequate and trained supervision, swimming classes adapted to ages and special needs, safe environment, protection of swimming pools and other water sources. , and CPR training for the community.

It also points out the need to be aware of potentially dangerous exposures for young children such as buckets, bathtubs and other sources of stagnant water in the home.