Policy Statement

Drowning in Infants, Children, and Adolescents (RE9319)

AMERICAN ACADEMY OF PEDIATRICS

Committee on Injury and Poison Prevention

        Drowning and near-drowning are major causes of childhood mortality and morbidity from injury. From 1980 to 1985, drowning was the second leading cause of injury death of infants and children younger than 15 years of age in the United States. [1] In 18 of the 50 states, drowning was the number one cause of unintentional injury death of children 1 to 4 years of age. [1] Children less than 5 years of age and young people aged 15 to 24 years have the highest drowning rates. [2] Drowning, by definition, is fatal; near-drowning is sometimes fatal. Drowning has been defined as a death resulting from suffocation within 24 hours of submersion in water; victims of near-drowning survive for at least 24 hours. [3] For every child who drowns, four children are hospitalized for near-drowning. [4] One third of those who are comatose on admission but survive suffer significant neurologic impairment. [4] The annual lifetime cost attributable to drowning and near-drowning in children less than 15 years of age is $384 million. [3] The annual cost of care per year in a chronic care facility for an impaired survivor of a near-drowning event is approximately $100 000. [4]
        There is no national surveillance system that defines the circumstances surrounding a drowning event well enough to enable the development of effective preventive strategies for children. A need exists to establish uniform state or local surveillance systems that consider developmental age groupings and geographic location and that account for environmental and behavioral factors that place children at risk. To design preventive strategies aimed at specific risk factors, such surveillance systems must define in sufficient detail the circumstances under which the drowning event occurred, preventive measures used, rescue efforts made, and the outcomes.
        Some local and state limited surveillance systems have identified for each age category both the location of the drowning (eg, pool, river, lake, canal) and the activity performed (eg, swimming, boating). [5] These databases and special studies have demonstrated that children less than 1 year of age most frequently drown in bathtubs and buckets; children aged from 1 to 4 years most often drown in home or apartment swimming pools; and children and adolescents aged from 5 to 19 years most frequently drown in lakes, ponds, rivers, and pools. [6-8] About 8% of drowning of victims younger than 15 years of age occur in bathtubs, whereas about 5% are related to boats. [1] The relationships among age groups, drowning locations, and activity are not uniform, however. Variation exists by gender, geographic region, community, season, race, and economic status (eg, circumstances of immersion events differ in Alaska and California, even though both states have high drowning rates).
        Existing surveillance systems for drowning are most fully developed for pool settings. A recent multistate study conducted by the US Consumer Product Safety Commission revealed that most children less than 5 years of age drowned or nearly drowned by entering the pool from their home through the unprotected side of the pool (the side of the pool that directly faces the house, with no intervening fence). Most children were last seen in the home, but were out of eye contact for only a moment, and the immersion was silent (no screams or splashing heard). [8]

PREVENTION

        Because systematic information is lacking about the factors involved in drowning incidents, other than those in residential pool drowning, few preventive interventions have been implemented and evaluated. Only one environmental preventive strategy has demonstrated its effectiveness in reducing drowning in children aged 1 to 4 years. Installation of four-sided fencing that isolates the pool from the house and the yard has been shown to decrease the number of pool immersion injuries by more than 50%. [8-10] The US Consumer Product Safety Commission study showed that households with pools in which a child drowned were significantly less likely to have isolation fencing than matched control households. [8] Pool alarms and pool covers have not been shown to be reliable preventive measures for very young children. The effectiveness of swimming instruction at different ages for the prevention of child drowning has not been determined. The American Academy of Pediatrics does not endorse swimming instruction for infants and toddlers. The use of an approved personal flotation device, although not well evaluated, appears likely to reduce drowning mortality and morbidity in older children when boating or playing beside streams, rivers, or lakes. Close supervision of young children around any water is an essential preventive strategy, but inevitable lapses make supervision alone insufficient. [6] The performance of cardiopulmonary resuscitation (CPR) at the incident site, rapid reestablishment of effective oxygenation and ventilation, and transportation of severely compromised children to pediatric critical care centers should improve outcome once an immersion injury has occurred.

RECOMMENDATIONS

For Infants and Children Newborn Through 4 Years of Age

        Pediatricians should alert parents to the dangers that standing water presents to children.
        Parents need to be advised that

1. They should never--even for a moment--leave children alone in bathtubs, spas, or wading pools, near irrigation ditches, post holes, or other open standing water. They should remove all water from containers, such as pails and 5-gallon buckets, immediately after use. To prevent drowning in toilets, young children should not be left alone in the bathroom.
2. Swimming lessons for children less than 4 years of age will not provide "drown proofing" and may lead to a false sense of security.
3. Rigid, motorized pool covers are not a substitute for four-sided fencing, because pool covers are not likely to be used appropriately and consistently.
4. They should learn CPR; and they should keep a telephone and equipment approved by the US Coast Guard (eg, life preservers, life jackets, shepherd's crook) at poolside.

        Pediatricians are encouraged to

1. Identify families who have residential swimming pools and then schedule periodic counseling beginning in the perinatal period to ensure that parents remain aware of the risk of drowning and near-drowning. Families (and extended families and others that are visited by children) should be advised to install a fence that separates access to the pool from access to the house. The fence should be at least 4 feet high and climb-proof. No opening under the fence or between uprights should be more than 4 inches in diameter. The gate is the single most important component of the fence. It should be self-latching and self-closing, should open away from the pool, and should be checked frequently to ensure good working order.
2. Work in their communities to pass legislation to mandate isolation pool fencing for new and existing residential pools. They should also support efforts to ensure that community pools have lifeguards with current CPR certification.

For Children 5 to 12 Years of Age

1. Pediatricians should counsel parents on the risks of drowning for children in this age group and the need for children to learn about water safety. Counseling should include the following topics:
a. Children need to be taught to swim. Knowing how to swim well in one body of water, however, does not always make a child safe in another. In addition to rules for safe swimming in pools, parents and children need to know the various safety requirements for swimming in natural bodies of water, such as lakes, streams, rivers, and oceans. Increased drowning risk arises from changing environmental conditions (eg, depth, water temperature, currents, and weather), hazards concealed in murky water, and inaccessibility of emergency medical services. [11]
b. Children need to be taught never to swim alone or without adult supervision.
c. Children should be required to use an approved personal flotation device whenever riding on a boat or fishing, and preferably while playing near a river, lake, or ocean.
d. Children need to understand why jumping or diving into water can result in injury. Parents should know the depth of the water and the location of underwater hazards before permitting children to jump or dive.
e. Parents and children need to recognize the drowning risks in cold seasons. Children should refrain from walking, skating, or riding on weak or thawing ice on any body of water.

2. Pediatricians are strongly encouraged to support efforts in their states to pass legislation and adopt regulations to establish basic safety requirements for natural swimming areas and public and private recreational facilities (eg, mandating the presence of lifeguards in designated swimming areas).

For Adolescents 13 to 19 Years of Age

1. Pediatricians should counsel adolescent patients about other risks of drowning. While including the five topics listed above for children aged 5 to 12 years, teenagers also need counsel about the dangers of alcohol and other drug consumption during aquatic recreation activities (eg, swimming, diving, and boating). Because boys are at much higher statistical risk of water-based injuries than girls, they warrant extra counseling.
2. Teens should learn CPR. Pediatricians should support the inclusion of CPR training in high school health classes.
3. Pediatricians should support state and community efforts to enforce laws that prohibit alcohol and other drug consumption by teens and boat operators.

Community Interventions

1. Data collection should be established with uniform local, state, and national surveillance systems.
a. Pediatricians should work with emergency medical personnel to encourage systematic reporting of information on the circumstances of the immersion event.
b. Local and state surveillance systems should be established to define the circumstances of the immersion event and the preventive strategy appropriate for the geographic area.
c. These data should be linked with morbidity and mortality to design specific regional preventive strategies.
d. At the national level, data should be collected on near-drowning as well as drowning incidents.

2. Adequate funding for drowning surveillance, prevention program implementation, and injury control evaluation should be provided by national and state public health agencies.
3. Pediatricians should work in their communities to develop emergency medical care systems that meet the needs of children, including those who nearly drown.
4. Research on behavioral and environmental risk factors should be conducted including research on effective pool barriers and other technology for water safety. Continuing research on acute care and rehabilitative care of patients who nearly drowned should be supported.
5. Supportive counseling services should be available to relatives and friends of drowning victims.

COMMITTEE ON INJURY AND POISON PREVENTION, 1993 TO 1994
William E. Boyle, Jr, MD, Chair
Marilyn J. Bull, MD
Murray L. Katcher, MD, PhD
S. Donald Palmer, MD
George C. Rodgers, Jr, MD, PhD
Barbara L. Smith, MD
Joseph J. Tepas III, MD

LIAISON REPRESENTATIVES
Jean Athey, PhD, Maternal and Child Health Bureau
Katherine Kaufer Christoffel, MD, MPH, Ambulatory Pediatric Association
Peter Scheidt, MD, MPH, National Institute of Child Health and Human Development
Richard Schieber, MD, Centers for Disease Control and Prevention
Milton Tenenbein, MD, Canadian Paediatric Society

SECTION LIAISONS
James Griffith, MD, Section on Injury and Poison Prevention
Susan B. Tully, MD, Section on Pediatric Emergency Medicine

DESIGNATED REPRESENTATIVE
Deborah Tinsworth, US Consumer Product Safety Commission

REFERENCES

1. Baker SP, Waller AE. Childhood Injury State by State Mortality Facts. Baltimore, MD: The Johns Hopkins Injury Prevention Center; 1989
2. Gulaid JA, Sattin RW. Centers for Disease Control. Drowning in the United States, 1978-1984. MMWR. 1988;37:27-33
3. Rice DP, MacKenzie EJ, et al. Cost of Injury in United States: A Report to Congress. San Francisco, CA: Institute for Health and Aging, University of California; Baltimore, MD: Injury Prevention Center, School of Hygiene and Public Health, The Johns Hopkins University; 1989
4. Wintemute GJ. Childhood drowning and near drowning in the US. AJDC. 1990;144:663-669
5. Wintemute GJ, Kraus JF, Teret SP, Wright M. Drowning in childhood and adolescence: a population-based study. Am J Public Health. 1987;77:830-832
6. Quan L, Gore EJ, Wentz K, Allen J, Novack AH. Ten-year study of pediatric drowning and near-drowning in King County, Washington: lessons in injury prevention. Pediatrics. 1989;83:1035-1040
7. O'Carroll PW, Alkon E, Weiss B. Drowning mortality in Los Angeles County. JAMA. 1988;260:380-383
8. Present P. Child Drowning Study: A Report on the Epidemiology of Drowning in Residential Pools to Children Under Age 5. Washington, DC: Directorate for Epidemiology, US Consumer Product Safety Commission; 1987
9. Milliner N, Pearn J, Guard R. Will fenced pools save lives? A 10-year study from Mulgrave Shire, Queensland. Med J Aust. 1980;2:510-511
10. Pearn J, Nixon J. Prevention of childhood drowning accidents. Med J Aust. 1977;1:616-618
11. Centers for Disease Control. Drowning in a private lake--North Carolina, 1981-1990. MMWR. 1992;41:329-331
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This statement has been approved by the Council on Child and Adolescent Health.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright (c) 1993 by the American Academy of Pediatrics.
No part of this statement may be reproduced in any form or by any means without prior written permission from the American Academy of Pediatrics except for one copy for personal use.