TECHNICAL REPORT

Prevention of Sarah A. Denny, MD, FAAP,a Linda Quan, MD, FAAP,b Julie Gilchrist, MD, FAAP,c Tracy McCallin, MD, FAAP,d,e Rohit Shenoi, MD, FAAP,f Shabana Yusuf, MD, Med, FAAP,f Jeffrey Weiss, MD, FAAP,g,h Benjamin Hoffman, MD, FAAP,i COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION

Drowning is a leading cause of injury-related in children. In 2018, abstract almost 900 US children younger than 20 years died of drowning. A aNationwide Children’s Hospital and College of Medicine, The Ohio State number of strategies are available to prevent these tragedies. As University, Columbus, Ohio; bPediatric Emergency Medicine, Seattle Children's Hospital, University of Washington School of Medicine, educators and advocates, pediatricians can play an important role in Seattle, Washington; cUS Public Health Service (Retired); dChildren’s prevention of drowning. Hospital of San Antonio, San Antonio, Texas; eBaylor College of Medicine, Houston, Texas; fSection of Emergency Medicine, Department of , Baylor College of Medicine, Houston, Texas; gPhoenix Children's Hospital Medicine, Phoenix Children's Hospital, Phoenix, Arizona; hUniversity of Arizona College of Medicine-Phoenix, Phoenix, INTRODUCTION Arizona; and iDoernbecher Children’s Hospital and Oregon Health and Science University, Portland, Oregon Background This document is copyrighted and is property of the American Drowning is the leading cause of unintentional injury–related death in Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of US children 1 through 4 years of age and, as of 2018, has surpassed Pediatrics. Any conflicts have been resolved through a process birth defects as the most common cause of death among this age group. approved by the Board of Directors. The American Academy of – Pediatrics has neither solicited nor accepted any commercial Drowning is the third leading cause of unintentional injury related involvement in the development of the content of this publication. death among US children and adolescents 5 through 19 years of age.1 Technical reports from the American Academy of Pediatrics In 2018, almost 900 US children and youth under 20 years died of benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the drowning and more than 7200 were seen at a hospital emergency American Academy of Pediatrics may not reflect the views of the department (ED) for a drowning event, with 35% of those children liaisons or the organizations or government agencies that they represent. either hospitalized or transferred for further care.1 Rates of drowning death vary with age, sex, and race; those at greatest risk are The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, and male adolescents. Underlying medical conditions, such as seizures taking into account individual circumstances, may be appropriate. and autism, also increase risk. Fortunately, childhood unintentional All technical reports from the American Academy of Pediatrics drowning fatality rates have decreased steadily from 2.68 per 100 000 automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. in 1985 to 1.09 per 100 000 in 2018. Most victims of nonfatal drowning DOI: https://doi.org/10.1542/peds.2021-052227 do well, but severe long-term neurologic deficits are seen with Address correspondence to Sarah Denny, MD, FAAP. E-mail: extended submersion times, prolonged resuscitation efforts, and lack of [email protected] early bystander-initiated cardiopulmonary resuscitation (CPR).2–4 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics The American Academy of Pediatrics (AAP) has revised this technical FINANCIAL DISCLOSURE: The authors have indicated they have no report because of new information and research regarding (1) financial relationships relevant to this article to disclose. populations at increased risk; (2) racial and sociodemographic disparities in drowning rates; (3) water competency (water safety knowledge and attitudes, basic swim skills, and response to a swimmer To cite: Denny S A, Quan L, Gilchrist J, et al; AAP Council on 5,6 Injury, Violence, and Poison Prevention. Prevention of in trouble) ; (4) the need for close, constant, attentive, and capable Drowning. Pediatrics. 2021;148(2):e2021052227 supervision when children are in and around water as well as life

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 148, number 2, August 2021:e2021052227 FROM THE AMERICAN ACADEMY OF PEDIATRICS jacket use among children and group (2.26 per 100 000 individuals have the lowest ; (5) the importance of population), with children aged 12 drowning risk of all races and physical barriers to prevent access to 36 months being at highest risk ethnicities in pools but to water when children are not (3.38 per 100 000). There is a the highest in natural water settings expected to be around water; and second peak incidence in (1.22 per 100 000 among AI and AN (6) the Drowning Chain of Survival (1.90 per 100 000 versus 0.63 per 100 000 among and importance of bystander CPR among boys aged 15 to 19 years), Black and 0.42 per 100 000 among (Table 1). attributable largely to a high white individuals). AI and AN number of male drowning . individuals could not be included in In 2002, the World Congress on Approximately 75% of childhood additional analyses of race and Drowning and the World Health drowning victims are boys,1 and, ethnicity (eg, white, Black, Hispanic) Organization revised the definition after the first year of life (during by single year of age because of “ of drowning to be the process of which risks are often similar), boys small numbers. When considering experiencing respiratory impairment are at greater risk of drowning than race and ethnicity as a risk factor, from submersion/immersion in are girls at each age. Among age dramatically influences ” liquid. Drowning outcomes are children and preteens, drowning drowning disparities. The highest classified as death, no morbidity, or death is roughly twice as common in rates were among children aged 1 morbidity (further divided into boys as in girls, but among year, with rates for white children moderately disabled, severely adolescents, the rate is almost 10 (5.22 per 100 000) higher than 1 disabled, vegetative state/coma, and times higher among boys (Table 2). those for Hispanic (4.14 per brain death). Terms such as wet, The higher drowning rate for boys 100 000) and Black (2.98 per dry, near, secondary, active, passive, has been explained by greater 100 000) children. Between the ages and silent drowning should not be exposure to aquatic environments, of 1 and 5 years, drowning rates used. The 2002 revised definition overestimation of swimming ability, decreased significantly for each and classification is more consistent higher risk taking, and greater racial and ethnic group but 9,10 with other medical conditions and alcohol use. decreased less among Black injuries and should help in children. However, the drowning drowning surveillance and collection Among children aged 0 to 19 years rates for Black children were of more reliable and comprehensive overall, drowning rates from 2014 significantly higher than those for 7 to 2018 are highest among Black epidemiological information. white and Hispanic children at every (1.79 per 100 000) and American age from 5 years to 18 years, and Sociodemographic Factors Indian (AI) and Alaska native (AN) this difference persisted when Rates of drowning vary by (1.49 per 100 000) individuals; examining drowning in swimming sociodemographic factors, such as drowning rates are lower among pools and natural water settings. An age, sex, race and ethnicity, and the white (1.06 per 100 000), Asian analysis that was focused presence of neurodevelopmental American and Pacific Islander (0.85 specifically on swimming pool disorders such as epilepsy, autism per 100 000), and Hispanic (0.82 per drowning deaths in the 5- to 24- spectrum disorder (ASD), and 100 000) individuals.1 One analysis year age group demonstrated that intellectual disability. Drowning of 11 years of fatal drowning data Black males had higher drowning rates are reported on the basis of among people younger than 30 rates than either white or Hispanic the population under examination, years reveals that AI and AN males, even when adjustments were not on the basis of the group’s individuals have the highest rates of made for income. Although the exposure; exposure-based rates fatal drowning (2.57 per 100 000), majority of white children drowned might increase disparities among higher than both Black (1.90 per in residential pools, Black children groups.8 The highest rate of 100 000) and white (1.32 per were more likely to die in a public drowning is in the 0- to 4-year age 100 000) individuals. AI and AN pool, often at a motel or hotel.11 In swimming pools, Black children TABLE 1 Key Evidence-Based Strategies aged 5 to 19 years were 5.5 times Assess all children for drowning risk on the basis of risk and age, and prioritize evidence-based strategies: more likely to drown than white 12  Barriers children of the same age. With no  Supervision physiologic differences to explain  Swim lessons the difference in drowning risk, race  Life jackets and ethnicity are likely a proxy for  CPR social and cultural differences

Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Unintentional Drowning Deaths, United States, 2014–2018 The role of socioeconomic status Average Annual (Crude Rate No. Deaths Per 100 000) and income on drowning rates, independent of race, is not well Age Group, y Boys Girls Totala known. Worldwide, drowning rates <1 19 (0.93) 17 (0.90) 36 (0.91) are much higher in low-income, – 1 2 175 (4.32) 93 (2.40) 269 (3.38) resource-limited countries, possibly 3–4 104 (2.55) 41 (1.05) 145 (1.81) 0–4 298 (2.93) 152 (1.56) 450 (2.26) because of the increased exposure 21,22 5–9 95 (0.91) 36 (0.36) 131 (0.64) to natural bodies of water. In 10–14 71 (0.68) 27 (0.26) 98 (0.47) contrast, a study of pool drowning 15–19 205 (1.90) 21 (0.21) 226 (1.07) conducted in California found that 0–19 670 (1.60) 236 (0.59) 906 (1.10) among children younger than 10 Source: Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System. a Totals may not add up because of rounding. years, drowning rates were actually associated with higher family between the groups. The reasons persist after controlling for income and parental education. This that Black children and teenagers socioeconomic status, cultural and association was attributed to are at higher risk of drowning have historical factors, and access.11 increased exposure to residential not been thoroughly studied, but Finally, the role of race and ethnicity swimming pools in more affluent 23 poor swimming skills in both as a risk factor may vary at the local communities. In the Netherlands, children and their parents, lack of level, necessitating examination of individuals of ethnic minorities were early training, and lack of lifeguards risk at the level of individual more likely to drown than those of at motel and hotel pools may be communities.18 Dutch heritage, even after adjusting important factors.11,13–15 for age, sex, income, and 24 Further research is imperative to urbanization. Among Black males Risks related to race and ethnicity learn more about racial and ethnic in the United States, swimming pool are likely related to differences in disparities in drowning and guide drowning risk remained higher even exposure, behavior, knowledge, and effective prevention interventions. A after controlling for income,11 and skills. In Ontario, Canada, African, study performed in Alaska to among urban youth, Black children Hispanic, and Asian people have decrease injury in AN territories reported lower swimming ability higher age-adjusted drowning rates successfully increased the use of after controlling for income.13 compared with those of European float coats (summer-weight coats Underlying reasons are not well descent.16 In a survey targeting poor that doubled as personal flotation understood but may include children of color, approximately devices) by using an aggressive cultural, historical (such as 57.5% of Black youth and 56.2% of education campaign, increased segregation and lack of access), and Hispanic youth reported being enforcement, and increased environmental influences. unable to swim or being availability of float coats. This Temporal and Geographic Variation uncomfortable in the deep end of project was successful because of the pool. 14 Black females report partnership with tribal elders in Among all causes of unintentional fear of drowning; this negatively developing culturally appropriate injury death in the United States, affects seeking swimming messaging.19 In addition, drowning shows the greatest instruction and swimming understanding the historical seasonal variation.25 For drowning abilities.15 Certain religious beliefs relationships that affect risk victims younger than 15 years, 70% may prevent children from taking perception around water safety of deaths occurred from May to swimming lessons because of lack of helps inform aquatic risk August; the risk of drowning single-sex aquatic settings or type of communication to different cultural significantly increased (up to 69%) clothing restrictions.17 and ethnic groups.20 The drowning when the outside temperature Socioeconomic disparities account research agenda should include exceeded 30C (86F).26 Drowning for some, but not all, of the understanding the disparities also occurred disproportionately on disparities. Inadequate funding for affecting immigrants, refugees, and Saturdays and Sundays. In 2016, in pools, swimming programs, and various ethnic and racial Maricopa County, Arizona, 47% of lifeguards, as well as the cost populations and establish evidence- the 131 life-threatening pool-related associated with swimming lessons, based interventions to improving incidents among children aged 0 to may affect water competency and water competency and decreasing 4 years occurred on the weekend. community resources for low- drowning rates in these The peak time of day was 6 PM to income populations. Differences disproportionately affected groups. 8 PM, with 75% of all incidents

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 3 27 occurring between noon and 9 PM. occurred in bathtubs, and 8% were (rivers, creeks, lakes, ponds, canals, In another report, approximately unspecified.32 and quarries).29 In children younger one-half of occurred than 5 years, the largest numbers of between 4 PM and 6 PM, coinciding Most drowning deaths occur natural water drownings occur in – with the busiest swim times as well in bathtubs (62% 71%) and large ponds, whereas older children more 25,29 39 as distractions secondary to meal buckets (16%). Almost all commonly drown in lakes. preparation.28 parents report believing a should be at least 6 years old before Although children aged 5 to 14 33 For the period 2014–2018, the 3 US being allowed to bathe alone. years are slightly more likely to states with the highest number of However, approximately 15% to drown in a natural body of water drowning deaths in the 0- to 19- 30% of caregivers have reported than in a swimming pool, a high year age group were California (419 leaving their children younger than proportion (69%) of adolescents 2 years unsupervised in the bath for aged 15 to 19 years drowned in per 100 000), Florida (489 per a period ranging from 1 minute to natural bodies of water.29 More than 100 000), and Texas (516 per slightly over 5 minutes.34,35 In fact, one-half of natural water drownings 100 000). For the same age group, in this study, 33% of parents occur in children younger than 14 the states with the highest rates of reported leaving children younger years, and a greater proportion of drowning deaths per 100 000 than 2 years for a little over 1 these occur in urban settings with population aged 0 to 19 years were minute and 24% for more than 2 populations of more than 1 Louisiana (2.3), Florida (2.1), and minutes but less than 5 minutes.34 million.39 Mississippi (2.0). The lowest The caregivers were distracted by a drowning death rates were reported phone, getting diapers or clothes for In-ground Pools in some of the New England and the child, or completing household As opposed to open bodies of water, 25 mid-Atlantic states. chores.34 Of note, first-time parents swimming pools have fewer Setting were less likely to leave children in drowning hazards, such as unknown the bathtub when compared with depths, undefined areas, and Age is an important determinant of parents with an older child.36 The presence of currents and waves.12 drowning location. Most association of unsupervised bathtub However, swimming pools can pose drown in bathtubs and buckets, drowning deaths with the use of a serious risk to toddlers and young whereas the majority of preschool- bathtub seats and rings was children and older children who do aged children drown in swimming recognized more than 2 decades not know how to swim. There are pools. Older children and ago.37 The bath seat and ring are an estimated 6700 pool- or spa- adolescents are more likely to designed to position the infant in a related, hospital ED-treated, nonfatal drown in natural bodies of water. In sitting position with 3 to 4 legs and drowning injuries and 379 pool- or a large national study of 1420 suction cups at their base. Three spa-related fatal drownings each drowning deaths in children hazard scenarios have been year involving US children younger 40 younger than 20 years, 47% of described with these devices: (1) than 15 years. Of these, 75% drownings in all age groups the seat tipping over from suction involve children younger than 5 occurred in fresh water, 32% in cup failure, (2) the child becoming years. The recurring drowning artificial pools, 9% in the home entrapped in leg openings that are scenario in pools and spas for young too big, and (3) the child climbing children includes unexpected, (bathtubs, buckets), and 4% in salt 37 29 out of the seat. Additionally, infant unsupervised access to the water. water. In a study from Washington tubs pose another risk contributing Only 17% had been last seen in or state, natural bodies of water were to bathtub drownings. Between near the pool or spa before the the setting in 35% of drownings in January 2004 and December 2015, a incident and 10% had compromised the 0- to 4-year age group, 69% of total of 247 incidents were reported or circumvented a pool or spa the drownings in the 5- to 14-year to the Consumer Product Safety barrier.40 age group, and 95% of the 30 Commission (CPSC) involving infant drownings of adolescents. Similar tubs, 31 fatal and 216 nonfatal.38 Pediatric swimming pool drownings findings were found in another occur in single-family and 31 study conducted in Massachusetts. In a national study, 56% of multifamily residences or public In contrast, for nonfatal drowning drownings in children aged 0 to 4 pools. Pediatric swimming pool involving children and adults, 57% years occurred in swimming pools, drownings in single-family and occurred in pools, 25% occurred in but a sizable portion (26%) multifamily residences are best natural bodies of water, 9% occurred in fresh bodies of water predicted by the number of pools by

Downloaded from www.aappublications.org/news by guest on September 30, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS housing type and the number of surrounded by a barrier to prevent Drain Entrapment 42 children aged 0 to 17 years by access when the pool is not in use. Entrapment and hair entanglement 41 housing type. The risk of a The American Society for Testing remain causes of injury and submersion is 2.7 times higher for a and Materials (ASTM) has published drowning in the pediatric child at a multifamily than a single- a standard (F 2666-16) for population. The CPSC reported 11 family residence and 28 times more aboveground pools for residential victims of circulation entrapment likely in a swimming pool at a use that addresses structural from 2014 to 2018 (4 pool and 7 multifamily property than a pool at integrity, sanitation, electrical safety, spa), including 2 fatalities, all in 41 and safety message labeling.44 a single-family residence. children aged 0 to 14 years, with the peak in the 5- to 9-year age group.48 Fixed and Portable Aboveground Unfortunately, many parents do not A circulation entrapment is defined Pools consider fencing for an inflatable or as an entrapment involving the Aboveground pools can be fixed or portable pool, and such pools often water circulation system of the portable. Aboveground pools can fall outside of local building codes product. Hair entanglement typically vary in size and height from small that require pool fencing. Because involves girls with long hair who are inflatable pools to larger versions they contain such large amounts of underwater near a suction outlet. that can hold thousands of gallons of water, these pools are often left The water flow into the drain water.42 A portable pool is any filled for weeks at a time, presenting sweeps the hair into and around the movable structure intended for a continuous danger. The soft sides drain cover, where it becomes swimming or other water of some models allow children to entangled in the holes and recreation, including wading pools, lean over and easily fall into the protrusions of the cover. Other inflatable pools, and “soft-sided, self- pool headfirst. Ladders supplied types of entrapment involve a limb rising” pools. Portable pools are with inexpensive aboveground pools or body part. This scenario often increasingly popular compared with generally cannot be locked to block fixed aboveground pools because access and are cumbersome to involves a child playing with an they can be set up and taken down remove from the pools. Whether open drain, inserting a hand or foot or moved to another location with portable or fixed, children may be into the pipe, and then becoming relative ease. Portable pools in able to gain access to the water trapped by increasing suction and residential settings also pose a risk more easily than parents and resulting tissue swelling. Deaths of submersion-related morbidity and caregivers intend. Children can enter occur from drowning. mortality to children. the pool using the pool ladder (68%) or by climbing on a nearby Entrapment and entanglement can From 2014 to 2016, there were, on object (20%).45 In a study of be prevented by the use of special average, 363 fatalities each year aboveground pools, children drain covers, safety vacuum release associated with pool or spa between 42 and 54 months of age systems (SVRSs), filter pumps with drownings involving children were shown to be able to climb into multiple drains, and a variety of younger than 15 years. a pool with a 48-inch wall, even if other pressure-venting filter 49 Aboveground pools accounted for the ladder was removed.46 construction techniques. 19% and portable pools accounted Unfortunately, many parents and for 5% of these fatalities.43 It is important to stress that no pool and spa owners are not aware single intervention is fully protective. of the risk of entrapment and The CPSC recommends that all Rather, multiple layers of protection entanglement; only 15% have pools, in-ground and aboveground, are recommended. Industry is installed antivortex drain covers, have a barrier, optimally 4-sided advised to develop affordable and only 14% have multiple drain isolation fencing. The pool structure effective products that include systems, and only 12% have SVRSs can serve as a barrier if the walls of isolation fencing, safety covers, and in their pools or spas.50 In 2007, the pool are high enough to meet alarms for portable pools. Extensive Congress passed the Virginia the recommended 4-foot height for public education should stress that Graeme Baker Pool and Spa Safety barrier fencing. Alternatively, a children can drown in portable pools. Act, which requires drain covers, barrier can be mounted onto the top These efforts should be combined unblockable drains, and SVRSs for of the pool structure. The CPSC also with strategies that reduce drowning all public pools and spas in the recommends that, if the pool walls risk, such as close supervision, CPR United States.51 The act markedly are not high enough, the steps or education, and methods to prevent reduced the number of injuries and ladder leading to the pool be unsupervised children from gaining deaths attributable to drain secured, locked, or removed or access to these pools.47 entrapment.52 Although the act does

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 5 not apply to private pools, children compared with matched, over 8 months, as parents’ residential pool owners can protect alive children.22 Among 127 perceptions of their child’s swim against entrapment by implementing drowning deaths in children skill increased, their belief in the the recommendations reflected in examined by a state’s child death child’s ability to keep themselves the legislation. review teams, 38 (30%) were not in safe in the water increased and their the care of an adult (4% perception regarding the need for Lapses in Adult Supervision 59 unsupervised entirely, 25% with parental supervision decreased. Although poor supervision is often other children or friends, 4% at a The sociocultural norms and cited as a contributing factor for location with lifeguards present). In environment of a community can childhood drowning, especially for deaths occurring among children also influence parental perceptions younger children,18,53,54 an accepted younger than 5 years, teams and resultant supervisory behavior definition for adequate supervision identified inadequate supervision that is deemed appropriate.60 is lacking.55 Supervisory behavior and isolated neglect as a factor in has been described as being 68% (21 of 31) of cases.18 When Alcohol composed of 3 components: responding to an online Alcohol plays a significant role in proximity, attention, and questionnaire, parents admitted that drowning risk related to boating, continuity.56 Attention and they talked to others (38%), read swimming, and supervision. A meta- continuity are related to awareness, (18%), ate (17%), and talked on the analysis found that 30% to 70% of and proximity is related to the phone (11%) while supervising their swimming and boating fatal ability to intervene if needed. child near water.57 In a study of 496 drowning victims had a measurable Proximity might be particularly drowning deaths in children blood alcohol concentration (BAC) important for young children and/or younger than 14 years that were and that 10% to 30% of these nonswimmers. For beginning reviewed by state child death deaths could be attributed swimmers, adequate supervision review teams, only 10% were specifically to alcohol use.61 In should include “touch supervision” completely unsupervised at the time boating, there is evidence that the in which the supervising adult is of the drowning.57 A more recent relative risk of drowning death is within arm’s reach of the child so examination of national child death directly related to BAC, with a 16- they can pull the child from the review data found that supervision fold greater risk when BAC was water if the child’s head becomes was assessed to be lacking in 49% greater than 0.10 (100 mg/dL).62 submerged. High levels of all 3 of incidents involving children Boat passengers are at risk for components are likely necessary to drowning in pools. Caregivers often alcohol-related drowning regardless keep children safe when around provided inadequate supervision of the alcohol use of the boat water. When children are not because of drug or alcohol operator.63 Most drownings intended to be in or around the impairment, injury or illness, or associated with alcohol occur during water, differing levels of the distraction. Necessary supervision recreational periods, over weekends, components may be appropriate, was noted to be lacking more often and in the afternoon. A longitudinal but the inevitable decreases in among drowning deaths involving study showed that a decrease in attention and proximity and lapses younger children compared with regional unintentional drowning in continuity highlight the need for older children.54 Similarly, in an rates was associated with a decrease barriers to prevent water entry. It is Australian study of 339 in deaths attributable to alcohol important to note that supervision unintentional drowning deaths use.64,65 cannot replace barriers, and barriers among children aged 0 to 14 years, cannot eliminate the need for coroners identified lack of Alcohol may increase the risk of supervision; they should work in supervision as a contributory factor drowning not only by impairing conjunction with each other. in 72% of cases.53 judgment and performance but also through physiologic effects (eg, poor Drowning most often occurs quickly Parental perceptions regarding balance, impaired orientation, and quietly during periods of necessary levels of supervision ) that affect survival inadequate supervision. In change as children progress through once submersion occurs.62 Alcohol Bangladesh, a case-control study of swim training, potentially to the use while boating is also unintentional injury deaths among detriment of the child’s safety.58,59 significantly associated with low or children younger than 5 years found In a survey of parents of children no life jacket use.66 Little that fatalities were 3 times more aged 2 to 5 years enrolled in information is available regarding likely to occur in unsupervised community swim lessons 4 times the association of drug use and

Downloaded from www.aappublications.org/news by guest on September 30, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS drowning. In a 10-year retrospective 10 to 18 months can climb into a contributing to 30% to 70% of study from Ohio, researchers found bathtub.70 recreational water deaths among US that only 3% of 141 accidental adolescents and adults.76 Providing drowning deaths were associated Therefore, the primary problem for drowning prevention anticipatory with illicit drugs.67 this young age group is lack of guidance to adolescents and their barriers to prevent unanticipated, caregivers, especially relating to Studies examining the relationship unsupervised access to water, alcohol use, can help address of caregiver alcohol use and including swimming pools, hot tubs reported low rates of water safety unintentional childhood injury and spas, bathtubs, natural bodies of knowledge in this age group.77 indicate that caregiver-reported water, and standing water in homes number of drinks predicted (buckets, tubs, and toilets). The Boaters decreased caregiver supervision and CPSC found that 69% of children In 2019, the US Coast Guard a higher likelihood of children younger than 5 years were not reported 46 boating deaths in sustaining injury.68,69 Avoidance of expected to be at or in the pool at individuals aged 19 years and 71 alcohol and drug intake positively the time of a drowning incident. younger, with 59% attributed to affects caregivers’ prevention of and drowning; the remainder were Adolescents recognition and response to a child mostly attributable to trauma. The struggling to swim in water, Older adolescents (aged 15 to 19 majority (78%) of the boating resulting in better drowning years) have the second-highest fatal deaths in this age group occurred surveillance. Alcohol and other drug drowning rates. In this age group, while riding in an open motorboat use should be avoided when approximately one-half of all (39%) or canoe or kayak (39%). swimming, boating, or supervising drownings occur in natural water Analysis of all fatal boating incidents 72 children in and around the water. settings. In 2016, SafeKids revealed that 70% of the operators Boaters should be educated about Worldwide reported that the natural had not had boating safety water fatal drowning rate for the dangers of consuming alcohol instruction, and 23% of the adolescents aged 15 to 17 years was when operating or riding in a incidents cited alcohol as a leading more than 3 times higher than that 78 watercraft, and authorities should factor. for children aged 5 to 9 years and enforce local Boating Under the twice the rate for children younger Most boating-related drowning Influence legislation. than 5 years.54 Adolescence is a deaths (86%) occur among At-Risk Populations formative period, often involving individuals who are not wearing a seeking high-intensity and exciting life jacket.78 In children younger Certain populations are at increased experiences and sensations.73 than 14 years, nearly 45% of those risk of drowning because of During this time, adolescents are who died in a boating-related behavioral, skill, or environmental especially vulnerable to the incident were not wearing a life factors as well as underlying presence of peers. The mere jacket.57 Federal law requires life medical conditions. presence of peers promotes risk- jacket use for children younger than Toddlers taking activity, especially if the 13 years on recreational boats in the adolescent has experienced previous United States. In an observational – For the period 2014 2018, the social isolation.74 This behavioral study of small boats, researchers highest rate of drowning occurred in psychology plays a role in found that 90% of children younger the 0- to 4-year age group (2.26 per vulnerable teenagers, especially than 5 years wore life vests, but 100 000 population), with children adolescent boys of racial and ethnic only 13% among those aged 14 aged 12 to 36 months being at minorities, in social aquatic years or older wore life vests.79 highest risk (3.38 per 100 000). activities. The increased risk for Trends in life jacket use from 1999 Most infants drown in bathtubs and fatal drowning in adolescents can be to 2010 showed an increase in life buckets, whereas the majority of attributed to several factors, jacket use across all pediatric age preschool-aged children drown in including overestimation of skills, groups in all boat types, but only an swimming pools.29 These children underestimation of dangerous increase among adult boaters in are developmentally curious and situations, engagement in high-risk sailboats.80 Another observational drawn to water but lack the and impulsive behaviors, and study of swimmers and waders in awareness of its dangers. For substance use.75 Alcohol remains a designated swim areas revealed that instance, as many as 35% of leading factor in drowning deaths life jacket and other flotation device typically developing children aged among adolescents and adults, use decreased with increasing age,

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 7 with 50% of children younger than Autism increased risk of drowning related 6 years using a life jacket compared Children with ASD are at increased to increased risk taking and 81 with 3% of adults. risk of drowning. A 2017 study impulsivity. Studies suggest a strong revealed that unintentional injury association between ADHD and risk of all unintentional injuries.91,92 Underlying Medical Conditions deaths were nearly 3 times as likely for all individuals with ASD Studies have demonstrated a Epilepsy compared with the general reduction in unintentional injury Epilepsy is a known risk factor in population.86 This excess risk was risk among those children diagnosed drowning, and drowning is the most particularly high for children with with ADHD who are being treated 92,93 common cause of death from greater degrees of intellectual with medication. disability87 and for those younger unintentional injury for people with Other Neurologic Diagnoses epilepsy, most commonly in than 15 years, who were reportedly bathtubs.82 Children with epilepsy 40 times more likely to die of For children with neuromuscular 86 have a relative risk for fatal and injury. Drowning, specifically, is a junction and muscle diseases or nonfatal drowning 7.5-fold to 10- leading cause of unintentional injury peripheral neuropathies, risk of 86 fold higher than children without deaths among children with ASD. participation in water-based activities may depend on the degree seizures.83,84 Drowning risk is Wandering was the most commonly of fatigability and whether the dependent on such factors as age, reported behavior leading to disease is rapidly degenerative. If severity of illness, degree of drowning, accounting for nearly 74% of fatal drowning incidents engaging in water-based activities, exposure to water, and level of 88 – among children with ASD. It has consultation with the child’s supervision.83 85 been proposed that swimming neurologist and one-to-one adult Despite this drowning risk, water- lessons be provided to children after supervision (ie, constantly attentive 86 and ready to quickly intervene) is based activities such as swimming the diagnosis of ASD is made. A advised. Children with movement can be safe for children with small pilot study of an 8-hour disorders, hemiplegia or diplegia epilepsy, especially for those with aquatic group therapy program demonstrated a statistically (eg, cerebral palsy, stroke), white well-controlled seizures (as defined significant increase in water safety matter diseases (eg, by the child’s neurologist). Many skills among children with ASD.89 adrenoleukodystrophy), and children with epilepsy learn to swim However, swimming instruction neuroimmunological disorders (eg, (and can do so safely), and some alone may not confer the necessary multiple sclerosis), have varied children with epilepsy swim ability to transfer learned skills from effects of the diseases on water competitively. Children with poorly one water setting to another. safety and may have individualized controlled seizures (as defined by Supervision and barriers with capabilities. Therefore, consultation ’ the child s neurologist) might be alarms are critical layers of with a child’s neurologist is advised safest with one-to-one direct protection against drowning for regarding participation in water- supervision (ie, constantly attentive children with ASD and other based activities. Children with and ready to quickly intervene) disabilities. Additionally, removal of implantable devices (eg, during water-based activities. enticing toys from the pool area ventriculoperitoneal shunts, vagus Bathtubs and shallow water can when the pool is not in use is nerve stimulators) are also advised present a hazard for any child with advised. The National Autism to consult their neurosurgeon about epilepsy, and showers are preferred Association’s Big Red Safety Box90 is water safety. over baths when age appropriate.17 a resource that aids in development of a safety plan for public places Cardiac Arrhythmias Parents of children with poorly where there is a handoff of Exertion while swimming can controlled seizure disorders should supervision so that children with trigger arrhythmia among have a discussion with their child’s ASD and other disabilities do not individuals with long QT neurologist or pediatrician before wander off. syndrome.94 Although the condition any swim activity. Whenever is rare and such cases represent a possible, children with epilepsy Attention-Deficit/Hyperactivity Disorder small percentage of drownings, long should also consider swimming only Although it has not been specifically QT syndrome should be considered at locations where there is a examined, children with a diagnosis as a possible cause for unexplained lifeguard to add a layer of protection of attention-deficit/hyperactivity submersion injuries among to their one-to-one supervision. disorder (ADHD) may have an proficient swimmers in low-risk

Downloaded from www.aappublications.org/news by guest on September 30, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS settings. Additionally, Brugada capable of recognizing and in Melbourne, Australia. At syndrome and catecholaminergic responding appropriately to a intervention pools, researchers polymorphic ventricular tachycardia swimmer in distress. Diligent observed improved attention, may also lead to increased risk.95 supervision, along with other proximity, and preparedness among This increased drowning risk measures, may be increasingly parents of children aged 6 to 10 underscores the need to counsel on important among children with years but no significant changes the importance of close supervision conditions that increase drowning among parents of younger or older for any child or adolescent with risks, such as ASD or seizures, as swimmers.98 these conditions when in or around noted above. Additionally, water. supervision is paramount in Appropriate adult supervision for environments where barrier fencing children around water is close, Interventions is not possible. constant, competent, and attentive. In the Haddon matrix of injury In addition, supervisors need to prevention, safety interventions are Unfortunately, parents and know what a distressed swimmer aimed at changing the environment, caregivers may have misperceptions looks like and how to safely the individual at risk, or the agent of about what drowning looks like and intervene if needed. Development how to appropriately supervise and evaluation of effective water injury (in this case, water). For 54,97 drowning prevention, the children. In a survey of 1003 safety education for parents are still environment and the individual are parents of children aged 0 to 12 needed. the prime targets (Table 3). Experts years with access to a pool, researchers found that 48% of Antientrapment and generally recommend multiple parents mistakenly believed they Antientanglement Measures layers of protection be used to would be able to hear splashing or prevent drowning because no single Entrapment and entanglement crying if their child was in trouble in strategy is likely to prevent all prevention measures include use of the water, 56% believed that a submersion deaths and injuries. special drain covers, SVRSs, filter lifeguard, if present, is the primary Such layers might include pumps with multiple drains, and a person responsible for supervising environmental changes, such as variety of other pressure-venting their child, and 32% reported 49 adult supervision, antientrapment filter construction techniques. leaving their child entirely and antientanglement measures, Although such devices are required unsupervised in a pool for 2 pool fencing, pool covers, water in commercial pools, they are often minutes or longer.54 entry alarms, lifeguards, and CPR not required in residential pools.47 Residential pool owners should be training. Additional prevention Because young children who fall layers focused on the individual into water often make no noise and educated to include these effective would include strategies such as can be hard to see below the water safety measures. swimming and survival skills surface, proper care of a young Pool Fencing training and use of life jackets. A nonswimmer or beginning swimmer concise list of recommendations can requires the supervising adult to be Pool fencing is one of the most be found in the AAP policy constantly attentive, in close important prevention strategies to statement “Prevention of proximity (ie, within arm’s reach) decrease the risk of drowning in 96 Drowning.” and prepared to intervene. To stress swimming pools when children are the importance of supervision, as not supposed to have access to the Adult Supervision part of a water safety program, water. Compared with no fencing, Close, attentive, and constant some communities promote “water installation of 4-sided fencing that supervision of young children when watchers,” encouraging a designated isolates the pool from the house and they are in or around any body of adult (identified with a hat or yard has been demonstrated to water is an essential preventive lanyard) to be responsible for decrease the number of pool strategy.18,53 Appropriate constant supervision without immersion injuries among young 99–101 supervision also includes engaging in any distracting children by more than 50%. A examination of any unfamiliar activities.39 However, these Cochrane meta-analysis of available environment for water hazards (eg, programs have not been evaluated. studies found that the odds ratio for unfenced pool or pond) and In an attempt to improve parental a drowning in a fenced versus an prevention measures (eg, doors supervisory behaviors at public unfenced pool was 0.27 (95% locked, gates closed). Adequate pools, an educational program (Keep confidence interval [CI]: 0.16–0.47). supervision should include being Watch @ Public Pools) was piloted In this analysis, 4-sided fencing

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 9 TABLE 3 Haddon Matrix for Drowning Prevention Strategies With Associated Levels of Evidence Personal Equipment Physical Environment Social Environment Pre-event Provide close, constant, Install 4-sided fencing that Swim where there are Mandate 4-sided attentive supervision of completely isolates the lifeguardsa residential pool fencingb children and poor pool from the house and swimmersa yardb Evaluate preexisting health Install self-closing and Attend to warning signagec Mandate life jacket wearb conditionc latching gatesb Develop water competency, Wear life jacketsb Swim at designated swim Adopt the Model Aquatic including swim abilitya sitesc Health Codec Know how to choose and fit Install compliant pool Remove toys from pools Increase availability of a life jacketc drainsa when not in use to lifeguardsa reduce temptation for children to enter the poolc Avoid substance usea Install door locksc Empty water buckets and Increase access to wading poolsc affordable and culturally compatible swim lessonsc Know the water’s hazards Enclosures for natural Lakefront slope gradientd Close high-risk waters and conditionsc bodies of waterc during high-risk timesd Swim at a designated swim Promote life jacket loaner Develop designated natural sited programsc water swim sitesd Learn CPRb Role model life jacket use by Enforce Boating Under the adultsa Influence lawsb Take a boater education Make rescue devices coursec available at swim sitesc — Provide ability to call for helpb — Ensure functional watercraftc Event Water survival skillsc Rescue device availablec Lifeguard or bystander Emergency Medical responseb Systemb Postevent — AEDc Early bystander CPRb Advanced medical carec — Rescue equipmentc EMS responseb a Trials or diagnostic studies with limitations; consistent findings from multiple observational studies. b Well-designed and conducted trials, meta-analyses on applicable populations. c Expert opinion, case reports, reasoning from first principles. d Single or few observational studies or multiple studies with inconsistent findings or major limitations.

(which isolates the pool from the by barriers to entry that will compliance with pool fencing laws house and yard) was superior to 3- effectively prevent small children from approximately 50% to 97%.102 sided fencing (which allows direct from gaining unsupervised and Another study from Australia access to the pool from the house) unfettered access to the pool or revealed that in the 5 years after with an odds ratio of 0.17 (95% CI: spa.”51 Three-sided fencing with enactment of legislation to improve 0.07–0.44).101 In an Australian self-locking or alarming doors the effectiveness of pool fencing, the study, researchers found that the between the house and pool area number of private swimming pool risk of a child drowning in a pool are often considered acceptable, drowning deaths halved.103 with 3-sided fencing was almost and, in some locales, pool covers can twice that seen in pools with 4- substitute for a fence. Often, a fence Children’s ability to climb fences sided fencing (incidence rate ratio, law pertains only to new pool varies with the type of fence. In one 1.78; 95% CI: 1.40–1.79).28 construction or to homes in which a study, chain-link fences were easily young child is actually living at the scaled by children, whereas Unfortunately, laws and ordinances time of the pool installation. ornamental iron bar fences proved regarding pool fencing may have Furthermore, in the United States, more difficult to climb.104 Fences dangerous loopholes. The Virginia pool fences are rarely inspected and should be at least 4 feet high, and Graeme Baker Pool and Spa Safety ordinances are often not enforced. no opening under the fence should Act defined minimum state law In a recent Australian study, be more than 4 inches (some requirements as “the enclosure of all researchers found that government building codes require a 5-foot fence outdoor residential pools and spas inspections raised the rate of and a maximum fence-to-ground

Downloaded from www.aappublications.org/news by guest on September 30, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS distance of only 2 inches). Vertical they cannot be recommended as a feature.42 Effectiveness of door members of the fence should be less substitute for isolation fencing. alarms has not been studied, and than 4 inches apart to keep a child they should only be used as an from squeezing through, and there On the contrary, some types of pool adjunct to other proven layers of should be no foot- or handholds that covers actually present a hazard for protection against drowning. could help a young child climb the children. In 1980, the CPSC issued a Lifeguards fence. The fence should not prevent warning about solar pool covers that a clear view of the pool. Gates are designed to keep the water Although no formal scientific study should be self-closing and self- warm and minimize pool chemical has quantified the value of and water evaporation. When latching, with the placed at lifeguards, anecdotal reports children try to walk on or remove least 54 inches above the bottom of indicate that drowning rates are these thin sheets of plastic, they can the gate. The gate should open away lower when lifeguards are drown when they become entangled 109 from the pool (so that it will not present. The United States in the cover or hidden from view.107 open if leaned on) and should be Lifesaving Association (USLA) Additionally, even weight-bearing checked often to ensure good reports that more than 75% of pool covers can make it difficult to working order. Pool gate alarms drownings at USLA sites occurred at see beneath them, potentially may provide additional protection, times when the beaches were concealing a drowning victim. but no research exists on their unguarded, and the estimate that a efficacy. Detailed guidelines for Alarms person will die by drowning while safety barriers for home pools are protected by USLA-affiliated Pool Alarms 110 42 lifeguards is 1 in 18 million. In available online from the CPSC, addition to rescue efforts, lifeguards but homeowners must also be The CPSC has evaluated the serve to make beaches safer by aware of local laws and building performance of surface, subsurface, and wristband pool alarms. Several monitoring the aquatic environment, codes regarding pool fence of these alarms functioned properly; enforcing rules and regulations, and construction and after installation however, the report concluded that educating beachgoers about safety continue to check the fence and alarms “should not be relied on as a and injury prevention. Lifeguards gate’s integrity. substitute for supervision or a most often perform prevention Pool Covers barrier completely surrounding the activities (54.8%), with rescues pool.” No study has demonstrated representing only 1.9% of lifeguard Retractable pool covers and pool whether pool alarms prevent interventions.111 Studies indicate nets capable of holding the weight drowning.108 Additional research is that lifeguards are cost- of a child have been advertised as needed to evaluate the efficacy of effective112,113 and reduce situations effective barriers for drowning pool alarms, door alarms, and pool likely to end in injury or prevention. Because these covers covers in the prevention of drowning.109 Those choosing to must be removed and replaced each drowning. swim in natural bodies of water or time the pool is used, they are less other sites accessible to the public likely to be effective. Active Door Alarms should swim in designated swim interventions requiring an action Many homes with pools, including areas with lifeguards present. each time they are to be used are private residences and homes used proven to be less effective than as vacation rentals, have doors that Although lifeguards are an passive interventions, which are open directly into the pool area. It is important layer of protection 105,106 always in effect. The CPSC important that all homes with pools against drowning, they are only one states that power safety covers can have security measures in place so part of a multilayered approach. A be installed on pools to serve as a that children cannot enter the pool study examining fatalities in security barrier, especially if the area unsupervised. Door alarms are lifeguarded US swimming pools pool is not completely separated one way to alert that the child has found that, in fatal incidents, from the house and the yard by a gained access to the pool area. The swimmers and pool bystanders 42 fence. However, there is currently CPSC recommends that door alarms were twice as likely to identify the no evidence to support this sound for at least 30 seconds within submersion victim as were recommendation, and pool covers 7 seconds of the door opening, that lifeguards.114 A survey found that may impart a false sense of security. the alarm be loud and distinct from 20% of parents interviewed thought Because there are no studies other sounds in the house, and that that the lifeguard was the main regarding the efficacy of pool covers, the alarm have an automatic reset person responsible for supervising

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 11 their child while in the water, continuum (ie, after a witnessed or Swimming Lessons, Water Survival leading to a false sense of security brief submersion), rescue breathing Training, and Water Competency and a resultant lack of parental to provide effective ventilation of All children should eventually learn 57 supervision. Nevertheless, trained, the victim may be sufficient if to swim. Swim skill and water professional lifeguards provide a circulation remains intact. As the competency may be the most significant layer of protection to drowning victim progresses from important drowning prevention swimmers, especially through respiratory arrest to cardiac arrest (no measures in natural water settings trained rescue and resuscitation in palpable pulse), resuscitation using the because fencing and lifeguarding the event of a significant compressions-airway-breathing may be impractical in these settings. submersion. However, lifeguards do sequence is initiated. “Hands-only” The position of the AAP has focused not take the place of caregiver CPR is not appropriate for drowning on the child being “developmentally supervision. victimsbecausehypoxiaisalmost ready” for formal swimming lessons. exclusively the cause of cardiac arrest Developmental readiness for swim Bystander CPR 118 resulting from drowning. In a lessons is multifaceted; the Immediate resuscitation at the recent study on bystander CPR after determinant of readiness is not the submersion site, even before the drowning, resuscitation of victims aged child’s age but the confluence of arrival of emergency medical 5 to15 years using compression and physical, social, behavioral and services (EMS) personnel, is the ventilation CPR was statistically emotional, and cognitive skills most effective means to improve significantly associated with balanced against the environmental outcomes in the event of a neurologically favorable survival and 2,3 risks of drowning. submersion incident. Prompt survival to hospital discharge initiation of bystander CPR and compared with compression-only It has been demonstrated that activation of prehospital advanced 119 CPR. children aged 2–4 years can acquire cardiac life support for the pediatric the motor skills for swimming and submersion victim have the greatest Automated external defibrillator that most children aged 4.5 years effects on survival and significantly (AED) use may not be beneficial in are developmentally ready to do so; improved neurologic prognosis.4,115 resuscitation of the drowning victim by 5 or 6 years of age, most can as opposed to other etiologies of 121–123 Although the Centers for Disease master the front crawl. cardiac arrest. In a recent study, Control and Prevention recommends Subsequently, Brenner et al revealed application of an AED before the all caregivers and supervisors of the preschool age group experienced arrival of EMS, even for patients children be trained in CPR,32 several a reduction in fatal drowning risk if found to have a shockable rhythm, 124 strategies can increase first response they had had swim lessons, as was associated with decreased skills, including rescue and infant and did Yang et al in a study of Chinese likelihood of favorable neurologic 125 child CPR training for caregivers of at- preschoolers. School-aged outcome.115 Authors postulated that risk drowning populations. A video on children in the Bangladesh SwimSafe lay rescuers may have prioritized drowning risk, pool fencing, and CPR Program were demonstrated to have AED application over ventilation shown to pregnant pool owners significantly decreased drowning provided by CPR or had prolonged 126 increased their likelihood of obtaining rates. resuscitation duration until arrival of CPR instruction compared with those 115 116 EMS. The Heimlich maneuver is Before a case-control study of not shown the video. Another study, 124 the American Heart Association’s not recommended because positive- swimming lessons, concerns “Child CPR Anytime,” a25-minuteCPR pressure ventilation by mouth or about early swim lessons were instruction given to parents while their mask will accomplish adequate based on the fear that swim lessons 127 children were in a community swim oxygenation without the delay caused might increase drowning risk, lesson, led to significant sustained by performing the Heimlich with the premise that parents whose 108 improvement in parental knowledge maneuver. Current American Heart children were in swim programs and confidence in performing CPR.117 Association guidelines recommend would have a false sense of security, that drowning victims who require resulting in inadequate supervision Drowning can be described as a any form of resuscitation (including around water. Several studies have continuum, with an initial phase of only rescue breaths) be transported shown that parents of small children respiratory arrest but intact to the ED for evaluation and enrolled in swimming lessons were circulation that will progress to monitoring, even if they appear alert more likely to endorse the cardiac arrest if persists. In with effective cardiopulmonary statements “swimming lessons are the first stage of the drowning function at the scene.120 the best way to prevent drowning,”

Downloaded from www.aappublications.org/news by guest on September 30, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS “toddlers can learn to save The international drowning deliver water safety classes, and themselves if they fall into water,” prevention community has begun to working with health care clinics and and “it is better to develop expand the concept of water places of worship to refer families to swimming ability rather than rely competency to include needed skills, swim programs.17,132 on adult supervision.”128,129 When knowledge, and behaviors.5 In these parents were given a targeted addition to basic swim skills, water Although early instruction may be educational program to reverse competency should include beneficial, there are currently no misconceptions about water knowledge of local hazards in the data to support a recommendation safety or given feedback about their aquatic environment, risk judgment for infant swim lessons. Aquatic child’s progress or stories of close and self-assessment of abilities, and programs for young children calls, they were more likely to agree recognition and response to a (especially those younger than 1 that their child required more, not person in distress in the water, year) pose some medical concerns, less, supervision and more likely to including safe rescue and CPR.5 and initiation of a swim program disagree that swimming lessons Thus, acquisition of water should be discussed between an ’ were the best way to prevent competency is a protracted process infant s caregiver and pediatrician. drowning.58,128 Thus, swim lessons that involves learning in conjunction These include the risk of , should include parental training to with developmental maturation and dermatitis, and acute respiratory improve the parents’ understanding physical skill sets by the child. illness that result from exposure to of their child’s actual swimming infectious agents and pool abilities and continued risk. Barriers to swim lessons and water competency are more commonly chemicals. Hyponatremia from The American Red Cross Scientific based in cultural norms, economics, ingesting water and hypothermia 133 Advisory Council defines basic swim and access. Black communities have are also health risks to the infant. skills as the following: ability to reported a legacy of reluctance to Fortunately, medical problems from swimming are rare, treatable, and enter the water, surface, turn engage in swimming related to long- 134,135 around, propel oneself for at least standing segregation and exclusion preventable events. The World 129 130 Aquatic Babies and Children 25 yards, and then exit the water. from public pools. Vietnamese Network has published guidelines It is important to recognize that immigrant families reported that for the operation of aquatic performance of these water survival pool environments are alien and programs for children younger than skills, usually learned in a pool, is cold and recreational swimming is 3 years. The guidelines recommend affected by the aquatic environment not valued.131 Clothing that protects (1) required parental involvement, (water temperature, movement, modesty may not be allowed in (2) a fun atmosphere with one-on- depth, clothing, distance), for which some pools, and, for some religious one teaching, (3) qualified teachers, a person may be unprepared. and ethnic groups, single-sex aquatic (4) warm water to prevent Demonstration of skills in one settings are required.17 In addition, hypothermia, (5) maintenance of aquatic environment may not the multiple swim sessions required water purity, and (6) a limited transfer to another. Effective swim to achieve basic water competency number of submersions to prevent lessons should provide repeated and can be costly, and access to water ingestion and progressively more experiential affordable, convenient, and hyponatremia.136 The American Red training, including swimming in culturally appropriate swim lessons Cross has resources for choosing a clothes, swimming in life jackets, may be limited. Moreover, decreased swim program.137 falling in, and self-rescue. municipal funding for swimming Consequently, achieving basic swim pools and lifeguards has worsened Multiple studies have found that skills requires multiple sessions of access to swimming lessons and safe exposure to chlorination byproducts lessons. Thus, parents need to be water recreation in many in swimming pools can damage aware of their child’s progress and communities. These barriers can, respiratory epithelium and can keep their child in lessons until and should, be addressed through result in a child’s predisposition to basic water competency skills are community-based programs asthma and bronchitis and other achieved. More research is needed targeting high-risk groups by allergic conditions.138–142 However, to determine which types of swim providing free or low-cost swim a longitudinal study of children from instruction and water survival skills lessons, developing special birth to age 7 to 10 years revealed training are most effective in programs and changing pool no increased risk of respiratory preventing drowning in children of policies, using language and symptoms, allergy, or asthma among all ages. culturally appropriate instructors to those with chronic but

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 13 noncompetitive swimming pool a male relative, fatally drowns; other proximity to the child, (2) a life exposure. In fact, their function times, both die.144 Because rescuer jacket for the child is onboard in was better.141 safety must be the priority, only case of emergency, and/or (3) the people trained in the advanced skills child has good swimming skills.57 The AAP supports swimming lessons of water rescue should enter the Importantly, many drowning for children older than 1 year. Swim water. Safer rescue techniques incident reports include parents lessons are increasingly available for should be taught to children and who drown while attempting to help children with various disabilities, their parents as a part of their child.143,145 including autism, or other health comprehensive water safety training ’ conditions. A parent s decision about during swim lessons.146 These Life jacket use has expanded when to initiate swimming lessons techniques involve reaching with an beyond boating; they are must be individualized on the basis object or throwing something that increasingly used for children who of a variety of factors, such as floats to avoid water entry (“Reach, are weak swimmers or frequency of exposure to water, throw, or row; don’tgo”). Safe nonswimmers when near or in the health concerns, emotional maturity, rescue of a drowning person water wading or swimming. In one and physical limitations, while requires knowing one’s limitations, recent study, 50% of children considering that toddlers aged 12 to risks, and training to avoid putting younger than 5 years wore one 36 months are at highest risk of oneself at risk. when in the water at designated drowning. It must be stressed that natural water swim sites.81 swimming lessons, in isolation, will Life Jackets Although anecdotal reports remain not drown-proof a child. The goal of Life jackets prevent drowning by the only evidence supporting the swim lessons is to reduce the risk of keeping the airway out of the water effectiveness of life jackets for drowning but also to promote and when the user is immersed. Life preventing drowning when prepare for parent-child activities, jacket requirements for boaters swimming, the means of protection exercise, fun, and enjoyment of the have been promoted by the US would be similar by keeping the long process of acquiring aquatic airway out of the water. Coast Guard and watersports learning and water competency. organizations. Life jackets prevent Swim ability must be considered as Legislation is the most effective way drowning deaths; the use of an only one part of water competency to increase life jacket use, leading to approved life jacket decreased boat- and of a multilayered protection 90% to 95% compliance among related drowning morbidity and plan involving effective pool specific groups, such as children, mortality by 50%.147,148 barriers, constant and capable people on personal watercraft, and Unfortunately, their use remains supervision, life jacket use, and those in activities such as water low; US Coast Guard boating 149 lifeguards. Parents and guardians of skiing. Moreover, local ordinances statistics from 2017 indicate that in children should become an integral requiring life jacket use by those only 15.5% of fatal drownings component of aquatic programs to near or in the water of specific high- among all ages, the victims were facilitate and continue development 78 risk waterways have led to observed of their child’s water competence. wearing a life jacket. However, in increases in life jacket wear.150 the past 10 years, life jacket use Parental modeling148 and Importantly, parental acquisition of among children and teenagers educational campaigns151 can both water competency knowledge and younger than 18 years in boats has increase life jacket use among behaviors are critical to reinforce increased from 56% to 65% children and teenagers in boats. Life and promote the child’s water nationally. Reasons commonly cited jacket loaner programs at swimming competency. Because parents and for not wearing a life jacket include and boating sites increase access to caregivers are usually the most beliefs that drowning risk is low; life jackets, often at no cost, and immediate layer of protection, they that life jackets restrict movement, allow a family to choose to recreate need to learn key physical skill sets, are uncomfortable, or are at a safer site. Some states now too. Untrained rescuers, such as a unattractive; and that wearing a life require camps and other venues to parent or bystander, often die when jacket is a sign of fear or provide life jackets for swimmer 66 they enter the water to attempt the inexperience. Recent changes in use.152 rescue of a drowning victim.143–145 life jacket design address some of Even a small child can drown an these concerns. Parents of children To decrease consumer confusion untrained rescuer. Sometimes the who do not always wear life jackets and increase wear, standardization primary drowning victim survives, report reasons including the of life jacket wear requirements is whereas the intended rescuer, often following: (1) the parent is in close needed. Many states that share

Downloaded from www.aappublications.org/news by guest on September 30, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS bodies of natural water have jacket and require children to wear Boaters’ life jacket wear increases different laws. Few states mandate them. when mandated149,150,155; the life jacket use among boating higher rates observed among teenagers; only Louisiana requires Multiple studies using different teenagers, even when not mandated, use for those younger than 17 methodologies consistently show may be spillover effects from years.153 Using a risk reduction that life jackets decrease boating- pediatric laws. Wear rates also approach, state life jacket laws related injuries and deaths by increase with adult modeling; in 50%.148 In a matched cohort control should include adolescents, the Washington state, if even 1 adult in study of all boating deaths reported highest risk age group, and address the boat wore a life jacket, the to the US Coast Guard, boaters who small vessels, including paddle craft. likelihood of adolescent use rose to wore life jackets had 50% lower 81.4%, compared with only 36.1% death rates compared with those of adolescents accompanied by Newer life jackets address some of 147 who did not in the same boat. In 149 the barriers to their use. Inflatable life adults not wearing a life jacket. Australia, a mandatory life jacket jackets are light and not bulky but are law increased life jacket wear and Drowning Chain of Survival only for those aged $16 years, are also decreased boating drowning costly, and require replacement of the The Drowning Chain of Survival (Fig deaths by 50%.155 inflating carbon dioxide cylinder. US 1) refers to a series of steps that, – when enacted, attempt to reduce Coast Guard approved life jackets In contrast to boating requirements, mortality associated with drowning. now include a model similar to the all states mandate that all people The steps of the chain are the inflatable arm floats popular among wear a life jacket when on a following: Prevent drowning, preschoolers because it facilitates personal watercraft or when being recognize distress, provide flotation, floating (eg, the Puddle Jumper). towed behind a boat, such as water remove from water, and provide Parents need to check that any life skiing or water boarding. Life jacket care as needed. The chain starts jacket fits appropriately and is US wear rates among people of all ages with prevention, the most important Coast Guard approved because there participating in these activities are 156 and effective step to reducing are many similar products that do not greater than 90%. A national law morbidity and mortality from meet safety requirements. It is requires that every boat has drowning.157 The subsequent steps important to recognize that air-filled available an appropriately sized life 153 of the Drowning Chain of Survival swimming aids (such as inflatable jacket for each passenger. Almost differ uniquely from the Cardiac armbands) are toys that can deflate all states require children to wear a Arrest Chain of Survival because of or slip off and should not be used in life jacket when in boats; however, the mandated upper age varies from the water environment; flotation is place of life jackets. Information about ’ 5 to 16 years.153 For states lacking needed to keep the victim s airway infant and child life jackets for a out of the water and to facilitate variety of aquatic situations is life jacket laws, federal law mandates life jackets be worn by getting them to land. The drowning available online from the US Coast children younger than 13 years on a time line (Fig 2) shows the different Guard.154 moving boat.153 These mandates levels of actions and interventions Boating Safety explain why national wear rates chronologically that could interrupt have increased since 1999 only each sequence of the drowning Preventing boating-related injuries 158 among pediatric age groups, process once drowning begins. and deaths requires good boat including teenagers. In 2017, wear These interventions may be used by maintenance and function and safe rates were 94% in children younger the drowning victim who has swim and sober operators and passengers. than 5 years, 87% in those 6 to 12 skills to self-rescue or the parent or Parents can teach boating and water years, and 46.5% in those 13 to 17 lifeguard who needs to recognize safety to their children and prohibit years.156 In contrast, despite the child in trouble, initiate a safe alcohol use during recreational continued efforts and rescue, and provide CPR. The time water activities. They can check that recommendations by multiple line shows that rescue and the boat operator has had boater organizations to promote life jacket resuscitation of a drowning victim education, does not use or allow use while boating, wear rates among must occur within minutes to save drug or alcohol intake while boating, adult motor boaters, the largest lives. It also shows that the lay has appropriately sized US Coast group of boaters, remain stagnant rescuers’ efforts should take place Guard–approved life jackets and low. out of the water to prevent the available for each passenger per rescuer from risk of also federal law, and will both wear a life drowning.143,144 Moreover, it

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 15 FIGURE 1 Drowning chain of survival. Adapted from Szpilman D, Webber J, Quan L, et al. Creating a drowning chain of survival. Resuscitation. 2014;85(9):1151. underscores the critically time- the water.160 Good outcomes time of arrival to the ED.163 Despite sensitive role of the parent or (survival with no neurologic the common belief that young age is supervising adult in preventing a sequelae) are increased with protective, a meta-analysis found drowning and stopping it from submersion durations of less than 6 that young age did not correlate becoming a fatality. minutes and EMS response times of with better outcome.161 less than 10 minutes,161 which can Outcome Predictors be facilitated by early rescue and The strongest predictor of poor The clinical outcome for pediatric initiation of bystander CPR.2,115 The outcome (death or survival with drowning victims can be difficult to Submersion Score, a compilation of moderate or severe neurologic predict and depends on multiple clinical signs, has identified pediatric sequelae) appears to be increased factors.159 Prognosis is ultimately patients at low risk for injury after submersion duration of 6 minutes or dependent on the extent of cerebral significant submersion.162 In longer, with a low likelihood of good hypoxia and resultant cerebral addition, a recent study identified outcome after submersion greater 118,161 damage incurred during the initial that low-risk patients had normal than 10 minutes. In a recent drowning event and retrieval from vital signs and pulse oximetry at the study on childhood swimming pool submersions, poor outcome was associated with submersions 5 minutesorlongerindurationand those occurring on weekdays (possibly because events held at multiresident pools have a higher chance of bystander rescue on weekends).164 The highest risk ratio in a recent systematic review and meta-analysis was submersion of 15 to 25 minutes’ duration, with those longer than 25 minutes being invariably fatal.161

In addition to submersion duration, poor outcome predictors include additional prehospital factors (duration of ), initial ED presentation (fixed and dilated pupils, bradycardia or asystole, hypothermia, Glasgow coma scale score <5, prolonged CPR duration), and other hospital course determinants (intubation and use of inotropes); however, none are absolutely 159,165 FIGURE 2 Drowning time line. Adapted from Szpilman D, Tipton M, Sempsrott J, et al. Drowning time- predictive of outcome. Current line: a new systematic model of the drowning process. Am J Emerg Med. 2016;34(11):2225. evidence has not found a protective

Downloaded from www.aappublications.org/news by guest on September 30, 2021 16 FROM THE AMERICAN ACADEMY OF PEDIATRICS effect of colder water temperatures available in the accompanying policy National Highway Traffic Safety for drowning victims, and statement.96 Administration hypothermia does not improve Richard Stanwick, MD, FAAP – chances of survival.95,161,166 Although LEAD AUTHORS Canadian Pediatric Society acidemia on blood gas analysis (as a Sarah A. Denny, MD, FAAP surrogate for respiratory failure with Linda Quan, MD, FAAP STAFF hypoxia) and hyperkalemia may CAPT Julie Gilchrist, MD, FAAP Bonnie Kozial suggest poor prognosis, there are Tracy McCallin, MD, FAAP insufficient data to adequately predict Rohit Shenoi, MD, FAAP ACKNOWLEDGMENT poor outcome for patients with these Shabana Yusuf, MD, MEd, FAAP laboratory findings.95 In memory of our friend and col- Jeffrey Weiss, MD, FAAP league, Ruth Brenner, MD, FAAP, in Benjamin Hoffman, MD, FAAP The majority of pediatric nonfatal appreciation for her significant con- drowning victims have a good tributions to the field of drowning COUNCIL ON INJURY, VIOLENCE, AND outcome without neurologic prevention and policy and her com- POISON PREVENTION, 2019–2020 sequelae; however, some survivors mitment to the AAP. may have significant long-term Benjamin Hoffman, MD, FAAP, neurologic deficits. Children whose Chairperson submersion duration exceeded 10 Phyllis F. Agran, MD, MPH, FAAP minutes had a significantly poorer Michael Hirsh, MD, FAAP ABBREVIATIONS Brian Johnston, MD, MPH, FAAP health-related quality of life than AAP: American Academy of Sadiqa Kendi, MD, FAAP those who were submerged for Pediatrics 167 Lois K. Lee, MD, MPH, FAAP shorter durations. Patients ADHD: attention-deficit/ Kathy Monroe, MD, FAAP admitted to the hospital who hyperactivity disorder Judy Schaechter, MD, MBA, FAAP demonstrated no neurologic AED: automated external Milton Tenenbein, MD, FAAP improvement at 48 hours had a defibrillator 95 Mark R. Zonfrillo, MD, MSCE, FAAP poor prognosis. Factors AI: American Indian Kyran Quinlan, MD, MPH, FAAP, independently associated with AN: Alaskan native Immediate Past Chairperson higher long-term mortality risk for ASD: autism spectrum disorder survivors of nonfatal drownings BAC: blood alcohol content include age 5 to 15 years and severe LIAISONS CI: confidence interval neurologic impairment at Lynne Janecek Haverkos, MD, MPH, CPR: cardiopulmonary discharge.168 Ultimately, because in- FAAP – National Institute of Child resuscitation hospital treatment has not been Health and Human Development CPSC: Consumer Product Safety demonstrated to improve drowning Jonathan D. Midgett, PhD – Commission outcomes,64 prevention of drowning Consumer Product Safety Commission ED: emergency department incidents is critical. Bethany Miller, MSW, Med – EMS: emergency medical services Health Resources and Services SVRS: safety vacuum release Policy Statement Administration system Advice pediatricians may provide to Judith Qualters, PhD, MPH – Centers USLA: US Lifesaving Association parents and recommendations for for Disease Control and Prevention advocacy at the community level is Alexander W. (Sandy) Sinclair –

FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 30, 2021 23 Prevention of Drowning Sarah A. Denny, Linda Quan, Julie Gilchrist, Tracy McCallin, Rohit Shenoi, Shabana Yusuf, Jeffrey Weiss and Benjamin Hoffman Pediatrics originally published online July 12, 2021;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2021/07/09/peds.2 021-052227 References This article cites 126 articles, 35 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2021/07/09/peds.2 021-052227#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Injury, Violence & Poison Prevention http://www.aappublications.org/cgi/collection/injury_violence_-_poi son_prevention_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 30, 2021 Prevention of Drowning Sarah A. Denny, Linda Quan, Julie Gilchrist, Tracy McCallin, Rohit Shenoi, Shabana Yusuf, Jeffrey Weiss and Benjamin Hoffman Pediatrics originally published online July 12, 2021;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2021/07/09/peds.2021-052227

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