POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Prevention of Drowning 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,e,f Shabana Yusuf, MD, Med, FAAP,e,f Benjamin Hoffman, MD, FAAP,g Jeffrey Weiss, MD, FAAP,h COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION

Drowning is a leading cause of injury-related death in children. In 2017, abstract drowning claimed the lives of almost 1000 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators a and advocates, pediatricians can play an important role in the prevention of College of Medicine, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio; bSchool of Medicine, University of drowning. Washington and Seattle Children’s Hospital, Seattle, Washington; cUS Public Health Service, Rockville, Maryland; dChildren’s Hospital of San Antonio, San Antonio, Texas; eBaylor College of Medicine and fTexas Children’s Hospital, Houston, Texas; gOregon Health and Science University and Doernbecher Children’s Hospital, Portland, Oregon; and hCollege of Medicine, University of Arizona and Phoenix Children’s BACKGROUND Hospital, Phoenix, Arizona

Drowning is the leading cause of injury death in US children 1 to 4 years of Dr Denny led the authorship group; Drs Quan, Gilchrist, McCallin, Yusuf, age and the third leading cause of unintentional injury death among US and Shenoi contributed sections; Dr Hoffman provided significant early 1 review; Dr Weiss authored the previous policy statement that formed children and adolescents 5 to 19 years of age. In 2017, drowning claimed the basis of this document; and all authors approved the final the lives of almost 1000 US children. Fortunately, childhood unintentional manuscript as submitted. drowning fatality rates have decreased steadily from 2.68 per 100 000 in This document is copyrighted and is property of the American 1985 to 1.11 per 100 000 in 2017. Rates of drowning death vary with age, Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of sex, and race and/or ethnicity, with toddlers and male adolescents at highest Pediatrics. Any conflicts have been resolved through a process risk. After 1 year of age, male children of all ages are at greater risk of approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial drowning than female children. Overall, African American children have the involvement in the development of the content of this publication. highest drowning fatality rates, followed in order by American Indian and/or Policy statements from the American Academy of Pediatrics benefit Alaskan native, white, Asian American and/or Pacific Islander, and Hispanic from expertise and resources of liaisons and internal (AAP) and – external reviewers. However, policy statements from the American children. For the period 2013 2017, the highest drowning death rates were Academy of Pediatrics may not reflect the views of the liaisons or the seen in white male children 0 to 4 years of age (3.44 per 100 000), American organizations or government agencies that they represent. Indian and/or Alaskan native children 0 through 4 years (3.58), and African The guidance in this statement does not indicate an exclusive course American male adolescents 15 to 19 years of age (4.06 per 100 000).1 of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Drowning is also a significant source of morbidity for children. In 2017, All policy statements from the American Academy of Pediatrics an estimated 8700 children younger than 20 years of age visited automatically expire 5 years after publication unless reaffirmed, a hospital emergency department for a drowning event, and 25% of revised, or retired at or before that time. 1 those children were hospitalized or transferred for further care. Most DOI: https://doi.org/10.1542/peds.2019-0850 fi victims of nonfatal drowning recover fully with no neurologic de cits, but Address correspondence to Sarah A. Denny, MD, FAAP. E-mail: sarah. severe long-term neurologic deficits are seen with extended submersion [email protected] times (.6 minutes), prolonged resuscitation efforts, and lack of early 2–4 bystander-initiated cardiopulmonary resuscitation (CPR). To cite: Denny SA, Quan L, Gilchrist J, et al. AAP COUNCIL The American Academy of Pediatrics issues this revised policy statement ON INJURY, VIOLENCE, AND POISON PREVENTION. Prevention of Drowning. Pediatrics. 2019;143(5):e20190850 because of new information and research regarding (1) populations at

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 143, number 5, May 2019:e20190850 FROM THE AMERICAN ACADEMY OF PEDIATRICS increased risk, (2) racial and POPULATIONS WITH INCREASED contributing to 30% to 70% of sociodemographic disparities in DROWNING RISK recreational water deaths among US 13 drowning rates, (3) water Certain populations, because of adolescents and adults. competency (water-safety knowledge behavior, skill, environment, or and attitudes, basic swim skills, and underlying medical condition, are at 5,6 UNDERLYING MEDICAL CONDITIONS response to a swimmer in trouble), increased risk of drowning. (4) when children are in and around Epilepsy water (the need for close, constant, Toddlers Drowning is the most common cause attentive, and capable adult – of death from unintentional injury for supervision and life jacket use in For the period 2013 2017, the people with epilepsy,14 and children children and adults), (5) when highest rate of drowning occurred in with epilepsy are at greater risk of children are not expected to be the 0- to 4-year age group (2.19 per drowning, both in bathtubs and in around water (the importance of 100 000 population), with children 12 swimming pools.15 The relative risk physical barriers to prevent to 36 months of age being at highest of fatal and nonfatal drowning in drowning), and (6) the drowning risk (3.31). Most infants drown in patients with epilepsy varies greatly chain of survival and importance of bathtubs and buckets, whereas the but is 7.5- to 10-fold higher than that bystander CPR (Table 1). majority of preschool-aged children drown in swimming pools.8 The in children without seizures15,16 and primary problem for this young age varies with age, severity of illness, CLASSIFICATION OF DROWNING group is lack of barriers to prevent degree of exposure to water, and level – In 2002, the World Congress on unanticipated, unsupervised access to of supervision.15 17 Parents and Drowning and the World Health water, including in swimming pools, caregivers of children with active Organization revised the definition of hot tubs and spas, bathtubs, natural epilepsy should provide direct drowning to “the process of bodies of water, and standing water supervision around water at all times, experiencing respiratory impairment in homes (buckets, tubs, and toilets). including swimming pools and from submersion/immersion in The Consumer Product Safety bathtubs. Whenever possible, liquid.” Drowning outcomes are Commission (CPSC) found that 69% children with epilepsy should shower classified as “death,”“no morbidity,” of children younger than 5 years of instead of bathe17 and swim only at or “morbidity” (further divided into age were not expected to be at or in locations where there is a lifeguard. “moderately disabled,”“severely the pool at the time of a drowning Children with poorly controlled disabled,”“vegetative state/coma,” incident.9 epilepsy should have a discussion and “brain death”). The drowning with their neurologist or pediatrician process is a continuum that can be Adolescents before any swim activity. interrupted by rescue at any point in Adolescents (15–19 years of age) that process, with varying sequelae Autism have the second highest fatal from no symptoms to death. Terms drowning rate. In this age group, just Children with autism spectrum such as wet, dry, secondary, active, less than three-quarters of all disorder (ASD) are also at increased near, passive, and silent drowning 18 drownings occur in natural water risk of drowning, especially those should not be used. The 2002 revised 18 settings, and this age group makes up younger than 15 years of age and definition and classification is more half of childhood drownings in those with greater degrees of consistent with other medical 19 natural water.10 In 2016, Safe Kids intellectual disability. Wandering is conditions and injuries and should Worldwide reported that the natural the most commonly reported help in drowning surveillance and water fatal drowning rate for behavior leading to drowning, collection of more reliable and adolescents 15 to 17 years old was accounting for nearly 74% of fatal comprehensive epidemiological drowning incidents among children 7 more than 3 times higher than that information. 20 for children 5 to 9 years old and twice with autism. TABLE 1 Top Tips for Pediatricians the rate for children younger than 5 years of age.11 The increased risk Cardiac Arrhythmias Assess all children for drowning risk on the basis of risk and age and prioritize for fatal drowning in adolescents can Exertion while swimming can trigger evidence-based strategies: be attributed to multiple factors, arrhythmia among individuals with 21 - barriers; including overestimation of skills, long QT syndrome. Although the - supervision; underestimation of dangerous condition is rare and such cases - swim lessons; situations, engaging in high-risk and represent a small percentage of - life jackets; and impulsive behaviors, and substance drownings, long QT syndrome, as well - CPR. use.12 Alcohol is a leading risk factor, as Brugada syndrome and

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS catecholaminergic polymorphic include water-safety awareness, basic these water-survival skills, usually ventricular tachycardia, should be swim skills, and the ability to learned in a pool, is affected by the considered as a possible cause for recognize and respond to a swimmer aquatic environment (water unexplained submersion injuries in trouble. Swim lessons and swim temperature, water depth, water among proficient swimmers in low- skills alone cannot prevent drowning. movement, clothing, and distance), risk settings.22 Learning to swim needs to be seen as and demonstration of skills in 1 a component of water competency aquatic environment may not transfer that also includes knowledge and to another. There is tremendous SOCIODEMOGRAPHIC FACTORS awareness of local hazards and/or variability among swim lessons, and There continue to be significant racial risks and of one’s own limitations; not every program will be right for and socioeconomic disparities in how to wear a life jacket (previously each child. Parents and caregivers drowning rates among children. For referred to as “wearable personal should investigate options for swim many, cultural beliefs and traditions flotation device”); and ability to lessons in their community before may prevent children from recognize and respond to a swimmer enrollment to make sure that the 23,24 swimming. Furthermore, for in distress, call for help, and perform program meets their needs and the some religious and ethnic groups, safe rescue and CPR.5 needs of the child. High-quality swim single-sex aquatic settings are lessons provide more experiential 25 required, and clothing that protects Evidence reveals that many children training, including swimming in modesty according to religious norms older than 1 year will benefitfrom 28 clothes, in life jackets, falling in, and may not be allowed in some pools. swim lessons. Swim lessons are practicing self-rescue. Achieving basic Socioeconomically, the multiple swim increasingly available for a wide water-competency swim skills lessons required to achieve basic range of children, including those requires multiple lessons, and water competency can be costly or with various health conditions and acquisition of water competency is difficult given limited access and disabilities such as ASD. A parent or a protracted process that involves ’ transportation. Moreover, decreased caregiver s decision about when to learning in conjunction with municipal funding for swimming initiate swim lessons must be developmental maturation. There is pools, for swimming programs, and individualized on the basis of a need for a broad and coordinated for lifeguards has limited access to a variety of factors, including comfort research agenda to address not only swim lessons and safe water with being in water, health status, the efficacy of swim lessons for recreational sites for many emotional maturity, and physical and children age 1 to 4 years but also the communities. cognitive limitations. Although swim many components of water lessons provide 1 layer of protection These barriers may be surmounted competency for the child and parent from drowning, swim lessons do not through community-based programs or caregiver. “drown proof” a child, and parents targeting high-risk groups by must continue to provide barriers to providing free or low-cost swim prevent unintended access when not DROWNING-PREVENTION STRATEGIES lessons, developing special programs in the water and closely supervise to address cultural concerns as well The Haddon Matrix paradigm for children when in and around water. as developing swim lessons for youth injury prevention is used to identify with developmental disabilities, In contrast, infants younger than interventions aimed at changing the changing pool policies to meet the 1 year are developmentally unable to environment, the individual at risk, needs of specific communities, using and/or the agent of injury (in this learn the complex movements, such 31 culturally and linguistically as breathing, necessary to swim. They case, water). Experts generally “ appropriate instructors to deliver may manifest reflexive swimming recommend that multiple layers of ” swim lessons, and working with both movement under the water but protection be used to prevent health care and faith communities to cannot effectively raise their heads to drowning because it is unlikely that refer patients and their families to breathe.29 There is no evidence to any single strategy will prevent – swim programs.25 27 suggest that infant swimming drowning deaths and injuries. The programs for those younger than Haddon Matrix (Table 2) reveals 1 year are beneficial. examples of interventions before the WATER COMPETENCY, SWIM LESSONS, drowning event, during the drowning AND SWIM SKILLS Basic swim skills include ability to event, and after the drowning event Water competency is the ability to enter the water, surface, turn around, at the levels of the individual, anticipate, avoid, and survive propel oneself for at least 25 yards, environment, and policy. Five major common drowning situations.6 The float on or tread water, and exit the interventions are evidence based: 4- components of water competency water.30 Importantly, performance of sided pool fencing, life jackets, swim

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 143, number 5, May 2019 3 lessons, supervision, and lifeguards drowning are discussed in detail in parental supervision is emphasized,39 (with descending levels of evidence). the accompanying technical report and a study in Bangladesh revealed (available online soon). that adult supervision, in addition to Installation of 4-sided fencing (at the physical barrier of playpens, least 4 ft tall) with self-closing and Inadequate supervision is often cited significantly reduced the risk of self-latching gates that completely as a contributing factor for childhood drowning in children ages 1 to isolates the pool from the house and drowning, especially for younger 5 years.27 Supervision should include 11,37,38 yard is the most studied and effective children. Adequate being capable of recognizing and drowning-prevention strategy for the supervision, described as close, responding appropriately to a child in young child, preventing more than constant, and attentive supervision of distress. Supervision is critical for 50% of swimming-pool drownings of young children in or around any safety in children with ASD and other 32,33 young children. Life jackets are water, is a primary and absolutely disabilities. The National Autism 27 now also well proven to prevent essential preventive strategy. For Association’s Big Red Safety Box40 drowning fatalities. Some data reveal beginning swimmers, adequate contains information for parents, that swim lessons may lower supervision is “touch supervision,” in schools, and first responders and 27 drowning rates among children, which the supervising adult is within suggests a safety plan in public places 28 including those 1 to 4 years of age. arm’s reach of the child so he or she where there is a handoff of Lifeguards and CPR training also can pull the child out of the water if supervision so that children with ASD 2,4,34–36 appear to be effective. the child’s head becomes submerged and other disabilities do not However, data regarding the value of under water. Evaluated interventions wander off. other potential preventive strategies, shown to increase the quality of such as pool covers and pool alarms, supervision include swim lessons in Although supervision is an essential are lacking. Interventions to prevent which the need for continued layer of protection when children are

TABLE 2 Haddon Matrix for Drowning-Prevention Strategies Personal Equipment Physical Environment Social Environment Before the event Provide close, constant, and Install 4-sided fencing that Swim where lifeguards are Mandate 4-sided residential attentive supervision of isolates the pool from present pool fencing children and poor the house and yard swimmers Clear handoff supervision Install self-closing and Attend to warning signage Mandate life jacket wear responsibilities latching gates Develop water competency, Wear life jackets Swim at designated swim sites Adopt the Model Aquatic Health including water-safety Code knowledge, basic swim skills, and ability to recognize and respond to a swimmer in trouble Evaluate preexisting health Install compliant pool drains Remove toys from pools when Increase availability of condition not in use to reduce lifeguards temptation for children to enter the pool Know how to choose and fit Install door locks Empty water buckets and Increase access to affordable a life jacket wading pools and culturally compatible swim lessons Avoid substance use Enclosures for open bodies — Close high-risk waters during of water high-risk times Know the water’s hazards, Promote life jacket–loaner — Develop designated open-water conditions programs swim sites Swim at a designated swim site Role model life jacket use by — Enforce boating under the adults influence laws Learn CPR Make rescue devices —— available at swim sites Take a boater education course Phone access to call for help —— — Ensure functional watercraft —— Event Water-survival skills Rescue device available — EMS system After the event Early bystander CPR AED — Advanced medical care Bystander response Rescue equipment —— The Model Aquatic Health Code provides guidelines and standards for equipment, for staffing and training, and for monitoring swimming pools. Bold indicates the most evidence-based interventions. AED, automated external defibrillator.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS expected to be in or around the water, (EMS) personnel, is the most effective 3. Whenever infants and toddlers barriers must be in place to prevent means to improve outcomes in the (or noncompetent swimmers) unintended access of children to event of a drowning incident.2,3 are in or around water, water during nonswim times. Prompt initiation of bystander CPR, a supervising adult with swim Drowning is silent and only takes with a focus on airway and rescue skills should be within an arm’s a minute. Those children with highest breathing before compressions43 and length, providing constant touch drowning risk are 12 to 36 months of activation of prehospital advanced supervision. Even with older age. Developmentally, they are cardiac life support for the pediatric children and better swimmers, curious and lack the judgement or submersion victim, have the greatest the eyes and attention of the awareness of the dangers of water, so impact on survival and prognosis.4,44 supervising adult should still be barriers, such as 4-sided fencing and Current guidelines recommend that constantly focused on the child. door locks, are critical in preventing drowning victims who require any This “water watcher” should not access when the caregiver is form of resuscitation (including only be engaged in other distracting distracted by other children, meal rescue breaths) be transported to the activities that can compromise preparation, etc. emergency department for evaluation this attention, including using the and monitoring, even if they appear The Model Aquatic Health Code,41 telephone (eg, texting), alert with effective cardiopulmonary developed by the Centers for Disease socializing, tending chores, or function at the scene.43 Control and Prevention (CDC), is drinking alcohol, and there needs based on science and best practices to to be a clear handoff of responsibility from one water help guide policy makers and aquatic PREVENTION OF DROWNING watcher to the next. Supervision leaders on pool and spa safety. The RECOMMENDATIONS Model Aquatic Health Code provides must be close, constant, and guidelines and standards for Parents and Caregivers attentive. In case of an fi emergency, the supervising adult equipment, for staf ng and training, 1. Parents and caregivers should must be able to recognize a child and for monitoring swimming pools. never (even for a moment) leave in distress, safely perform Similar attention and effort are young children alone or in the a rescue, initiate CPR, and call for needed for open-water swim sites. care of another child while in or near bathtubs, pools, spas, or help. Parents need to recognize that lifeguards are only 1 layer of DROWNING CHAIN OF SURVIVAL wading pools and when near irrigation ditches, ponds, or other protection, and children in and The drowning chain of survival open standing water. near the water require constant (Fig 1) refers to a series of steps that, caregiver supervision, even if 2. Parents and caregivers must be when enacted, attempt to reduce a lifeguard is present. aware of drowning risks mortality associated with drowning. 4. To prevent unintended access, The steps of the chain are as follows: associated with hazards in the home. families should install a 4-ft, 4- (1) prevent drowning, (2) recognize sided isolation fence that fl • distress, (3) provide otation, (4) Infant bath seats can tip over, separates the pool from the remove from water, and (5) provide and children can slip out of house and the rest of the yard care as needed. The chain starts with them and drown in even a few with a self-closing, self-latching prevention, the most important and inches of water in the bathtub. gate. Detailed guidelines for effective step to reducing morbidity Infants should always be with safety barriers for home pools and mortality from drowning.42 an adult when sitting in a bath 45 are available online from the Rescue and resuscitation of seat in a bathtub. 46 CPSC. Families of children with a drowning victim must occur within • Water should be emptied from ASD or other disabilities who are minutes to save lives and reduce containers, such as pails and at risk for wandering off should morbidity in nonfatal drownings and buckets, immediately after use. identify local hazards and work underscores the critically time- • To prevent drowning in toilets, with the community on pool sensitive role of the parent or young children should not be fencing and mitigation of supervising adult. left alone in the bathroom, and hazards. toilet locks may be helpful. 5. Although data are lacking, IMPORTANCE OF BYSTANDER CPR • Parents and caregivers should families may consider Immediate resuscitation at the prevent unsupervised access to supplemental pool alarms and submersion site, even before the the bathroom, swimming pool, weight-bearing pool covers as arrival of emergency medical services or open water. additional layers of protection;

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 143, number 5, May 2019 5 FIGURE 1 Drowning chain of survival. (Reprinted with permission from Szpilman D, Webber J, Quan L, et al. Creating a drowning chain of survival. Resuscitation. 2014;85[9]:1151.)

however, neither alarms nor pool Parents should be reminded that fences with closed gates in good covers are a substitute for swim lessons will not drown working order, and ensure that adequate fencing and adult proof a child of any age. It is supervision will be consistent supervision. Importantly, some critical that swim instructors with the preceding types of pool covers, such as thin stress this message as well as the recommendations. plastic solar covers, should not need for constant supervision 10. All children and adolescents be used as a means of protection around water. Swim ability must should be required to wear US because they might increase risk be considered as only 1 part of Coast Guard–approved life of drowning. water competence and jackets whenever they are in or 6. Parents, caregivers, and pool a multilayered protection plan on watercraft, and all adults owners should learn CPR and that involves effective pool should wear life jackets when keep a telephone and rescue barriers; close, constant, and boating to model safe behavior equipment approved by the US attentive supervision; life jacket and to facilitate their ability to Coast Guard (eg, life buoys, life use; training in CPR and the use help their child in case of jackets, and a reach tool such as of an automated external emergency. Small children and fi a shepherd’s crook) poolside. de brillator; and lifeguards. nonswimmers should wear life Older children and adolescents Children need to be taught never jackets when they are near water should learn CPR. to swim alone and never to swim and when swimming. Parents without adult supervision. 7. Children and parents should and caregivers should ensure learn to swim and learn water- 8. Parents should monitor their that any life jacket is approved by ’ safety skills. Because children child s progress during swim the US Coast Guard because develop at different rates, not all lessons and continue their many do not meet safety children will be ready to learn to lessons at least until basic water requirements. Information about fi swim at exactly the same age. competence is achieved. Basic tting and choosing US Coast – There is evidence that swim swim skills include ability to Guard approved life jackets is lessons may reduce the risk of enter the water, surface, turn available at the US Coast Guard 47 drowning, including for those 1 around, propel oneself for at least Web site. Parents should not fl fi to 4 years of age. A parent’s 25 yards, oat on or tread water, use air- lled swimming aids fl decision about starting swim and exit the water. (such as in atable arm bands, “fl ” lessons or water-survival skills 9. Any time a young child visits neck rings, or oaties ) in place training at an early age must be a home or business where access of life jackets. These aids can fl individualized on the basis of the to water exists (eg, pool, hot tub, de ate and are not designed to child’s frequency of exposure to open water), parents and/or keep swimmers safe. water, emotional maturity, guardians should carefully assess 11. Jumping or diving into water can physical and cognitive the premises to ensure that basic result in devastating spinal limitations, and health concerns barriers are in place, such as injury. Parents and children related to swimming pools. sliding door locks and pool should know the depth of the

Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS water and the location of poorly controlled seizures should “near drowning”) when speaking underwater hazards before discuss water safety with their to families and the media to avoid jumping or diving or permitting physician before swim activities. confusion and misconceptions fi children to jump or dive. The rst 3. Counseling parents and associated with the other terms entry into any body of water adolescents about water safety previously used. There has been fi should be feet rst. provides an opportunity to stress much misinformation circulated in 12. When selecting an open body of the problems related to alcohol recent years regarding dry water in which their children will and drug use during any activity. drowning and secondary 49 swim, parents should select sites Specifically, the discussion should drowning. Pediatricians should with lifeguards and designated include a warning about the educate caregivers that dry and areas for swimming. Even for the increased drowning risk that secondary drowning are not strongest of swimmers, it is results when alcohol or illicit medically accurate terms. important to consider weather, drugs are used when swimming or Pediatricians can address tides, waves, and water currents boating. Because male adolescents parental concerns by providing in selecting a safe location for have high risk of water-based reassurance that nonfatal or fatal recreational swimming. injuries, they warrant extra drownings do not occur at a later Swimmers should know what to counseling. time in patients with no previous symptoms. do in case of rip currents: swim 4. Pediatricians should help facilitate where there is a lifeguard, and if a conversation between caregivers 3. Pediatricians should partner with caught in a rip current, remain and their children about levels of community groups to increase calm and either swim out of the water competency to decrease the access to life jackets through life – rip current parallel to the shore frequency of children or parents jacket loaner programs at (do not try to swim against the overestimating swimming skills swimming and boating sites. current) or tread water until and equipping older children with 4. Pediatricians should work with safely out of the current and able the ability to make informed community partners to provide to return to shore or signal for decisions when not in the access to programs that develop 48 help. presence of their parent or water-competency swim skills for 13. Parents and children should guardian. all children, especially those from recognize drowning risks in cold 5. Pediatricians should support the low-income and diverse families seasons. Children should refrain inclusion of CPR training in high and those with developmental from walking, skating, or riding school health classes. disabilities. Pediatricians can on weak or thawing ice on any identify and support programs to body of water. increase the access to high-quality, culturally sensitive, and affordable COMMUNITY INTERVENTIONS AND 26 Pediatricians ADVOCACY OPPORTUNITIES programs. 1. Pediatricians should know the Pool Operators leading causes of drowning in Pediatricians their location so they can 1. Pediatricians should work with 1. Community pools should have fi appropriately tailor their legislators and serve as a voice certi ed lifeguards with current fi prevention guidance to caregivers. for children to pass policy that CPR certi cation. Pediatricians can provide specific decreases the risk of drowning, 2. Pool owners and operators should targeted messages by age, sex, including, but not limited to, adopt the Model Aquatic Health high risk of drowning, and policy on fencing, boating, life Code to ensure that best practices geographical location. jackets, safety of aquatic are being used to keep the pool 2. Children with special health care environments, boating under the and spa environment safe. fl needs should have tailored in uence, and EMS systems. 3. Owners of private pools and spas anticipatory guidance related to Pediatricians should partner with and managers of public pools drowning risks. Children with public health and policy leaders to should be made aware of epilepsy, ASD, and cardiac address the issue of childhood entrapment and/or entanglement arrhythmias are at particular risk. drowning by implementing risks and of the laws mandating When swimming or taking a bath, effective evidence-based drain covers and filter pump children of any age with epilepsy interventions. equipment needed to prevent should be supervised closely by an 2. Pediatricians should use the term these injuries that primarily adult at all times.15 Children with “nonfatal drowning” (rather than involve children.50,51

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 143, number 5, May 2019 7 Policy Makers 7. Because we lack a robust evidence other barriers, drain covers, and 1. Policy makers should pass base, a coordinated research CPR. It also includes information legislation or building codes to agenda must be established to about the Virginia Graeme Baker mandate 4-sided isolation pool inform future policy, and federal Pool and Spa Safety Act and a list fencing for new and existing funding should be secured to of manufacturers of approved residential pools at the local and advance this research. drain covers and safety vacuum state level. Local governments release systems. The publications should inspect and strictly section contains safety-barrier APPENDIX: RESOURCES FOR enforce pool fencing requirements guidelines for home pools and PEDIATRICIANS AND FAMILIES because this has been shown to a family education brochure about be effective in reducing 1. The American Academy of preventing childhood drowning. fi drowning.52 Pediatrics Web site (http://www. Speci c information on fencing aap.org) contains educational can be found online.46 2. Policy makers should work with materials for parents from the The recreation and boating agencies to 5. The US Coast Guard Web site Injury Prevention Program about support legislation mandating that (http://www.uscgboating.org/) home water hazards for young life jackets be worn by adolescents contains detailed information and children, life jackets and life and by caregivers of children when tip sheets about life jackets, vessel preservers, pool safety, and water boating.53 When adults model safety checks, approved online safety for school-aged children. It appropriate behavior by wearing boating-safety courses, and beach also has links to water-safety life jackets, children and safety. It also has links to sites information from the CPSC, the adolescents are more likely to do with information about safety and CDC, and Safe Kids Worldwide. so as well.53 boating regulations as well as links 2. The Safe Kids Worldwide Web to statistics, research, and surveys 3. States and communities should site55 contains information about about boating and boating crashes pass legislation and adopt pools and hot tubs, drain covers and injury. Specific information on regulations to establish basic and safety vacuum release systems the right-fit life jacket can be found safety requirements for natural to prevent entrapment, and safety online.47 swimming areas and public and checklists (in English and Spanish) private recreational facilities (eg, 6. The American Heart Association about pools, spas, open-water 57 mandating the presence of Web site contains information swimming and boating, and home certified lifeguards in designated on CPR courses for the community water safety. It also has links to swimming areas).54 and health professionals. a national research study about 7. The National Autism Association 4. States and communities should pool and spa safety. It has some Web site40 contains many enforce laws that prohibit alcohol nice materials for children, resources for families of children and other drug use by all including boating-safety coloring with ASD, including a Family watercraft occupants, not just pages. One can download a color Wandering Emergency Plan, operators. water watcher badge from MedicAlert tools, wireless window 5. State and local EMS personnel, this site. and door alarms, and many other medical examiners, health 3. The CDC Web site (http://www. helpful tools to keep children safe. departments, and child- cdc.gov) contains a water-related death–review teams should use injuries factsheet, CDC research 8. The Water Safety USA Web site consistent systematic reporting of and information on water safety (https://www.watersafetyusa.org/ information on the circumstances and water-related illnesses and ) contains information on water of drowning events. Periodic injuries, and a link to the Web- competency, water watchers, and review of these data is critical in based Injury Statistics Query and water safety. the development of drowning- Report System. The CDC Childhood prevention strategies appropriate Injury Report contains state- LEAD AUTHORS for the geographic area. specific information about 56 Sarah A. Denny, MD, FAAP 6. Local governmental agencies drowning and other injuries. Linda Quan, MD, FAAP should adopt the Model Aquatic 4. The CPSC Web site (https://www. CAPT Julie Gilchrist, MD, FAAP Health Code for swimming pools, poolsafely.gov/) has pool-safely Tracy McCallin, MD, FAAP Rohit Shenoi, MD, FAAP with better inspection and materials for parents, Shabana Yusuf, MD, MEd, FAAP enforcement of swimming-pool grandparents, and caregivers, Benjamin Hoffman, MD, FAAP safety standards.41 including supervision, fencing and Jeffrey Weiss, MD, FAAP

Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS COUNCIL ON INJURY, VIOLENCE, AND Jonathan D. Midgett, PhD – Consumer Product prevention and policy and for her POISON PREVENTION, 2018–2019 Safety Commission commitment to the American Bethany Miller, MSW, Med – Health Resources Benjamin Hoffman, MD, FAAP, Chairperson Academy of Pediatrics. and Services Administration Phyllis F. Agran, MD, MPH, FAAP Alexander W. (Sandy) Sinclair – National Sarah A. Denny, MD, FAAP Highway Traffic Safety Administration Michael Hirsh, MD, FAAP Richard Stanwick, MD, FAAP – Canadian Brian Johnston, MD, MPH, FAAP Pediatric Society Lois K. Lee, MD, MPH, FAAP ABBREVIATIONS Kathy Monroe, MD, FAAP STAFF Judy Schaechter, MD, MBA, FAAP ASD: autism spectrum disorder Milton Tenenbein, MD, FAAP Bonnie Kozial CDC: Centers for Disease Control Mark R. Zonfrillo, MD, MSCE, FAAP and Prevention Kyran Quinlan, MD, MPH, FAAP, Immediate ACKNOWLEDGMENT CPR: cardiopulmonary Past Chairperson We write this article in memory of resuscitation LIAISONS our friend and colleague, Ruth CPSC: Consumer Product Safety Lynne Janecek Haverkos, MD, MPH, FAAP – Brenner, MD, FAAP, and in Commission National Institute of Child Health and Human appreciation for her significant EMS: emergency medical services Development contributions to the field of drowning

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: Dr Quan has provided expert witness testimony in a drowning case in 2018; the other authors have indicated they have no potential conflicts of interest to disclose.

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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