Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children Policy Statement—Prevention of Drowning COMMITTEE ON INJURY, VIOLENCE, AND POISON PREVENTION abstract KEY WORDS Drowning is a leading cause of injury-related death in children. In 2006, drowning prevention, pools, swimming lessons fatal drowning claimed the lives of approximately 1100 US children ABBREVIATIONS CPR—cardiopulmonary resuscitation younger than 20 years. A number of strategies are available to prevent AAP—American Academy of Pediatrics these tragedies. As educators and advocates, pediatricians can play an CPSC—Consumer Product Safety Commission important role in the prevention of drowning. Pediatrics 2010;126:178–185 SVRS—safety vacuum-release system PFD—personal flotation device CDC—Centers for Disease Control and Prevention INTRODUCTION This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors Background have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through From 2000 to 2006, drowning was the second leading cause of uninten- a process approved by the Board of Directors. The American tional injury death among US children between 1 and 19 years of age.1 Academy of Pediatrics has neither solicited nor accepted any In 2006, drowning claimed the lives of approximately 1100 US children. commercial involvement in the development of the content of Fortunately, childhood unintentional drowning fatality rates have de- this publication. creased steadily from 2.68 per 100 000 in 1985 to 1.32 per 100 000 in 2006. Rates of drowning death vary with age, gender, and race. Age groups at greatest risk are toddlers and male adolescents. After 1 year of age, male children are at greater risk than are female children. Black and American Indian/Alaska Native children have higher drown- ing fatality rates than do white and Asian American children. From 2000 to 2006, the highest death rates were seen in white boys 0 to 4 years of age (3.53 per 100 000) and black male adolescents 15 to 19 years of age (4.46 per 100 000).1 In 2008, approximately 3800 children younger than 20 years visited a hospital emergency department for a nonfatal www.pediatrics.org/cgi/doi/10.1542/peds.2010-1264 drowning event, and more than 60% of those children were hospital- doi:10.1542/peds.2010-1264 ized.1 Most victims of nonfatal drowning do well, but severe long-term All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, neurologic deficits are seen with extended submersion times, pro- revised, or retired at or before that time. longed resuscitation efforts, and lack of early bystander-initiated car- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). diopulmonary resuscitation (CPR).2–4 Copyright © 2010 by the American Academy of Pediatrics The American Academy of Pediatrics (AAP) has decided to revise this policy statement because of new information and research regarding (1) the World Health Organization’s classification of drowning, (2) drain-entrapment and hair-entanglement injuries, (3) dangers of in- flatable and portable pools, and (4) the possible benefit of swimming lessons for young children. Classification of Drowning The World Congress on Drowning and the World Health Organization have revised the definition of drowning to be “the process of experi- encing respiratory impairment from submersion/immersion in liquid.” Drowning outcomes are now to be classified as “death,” “no morbidity,” or “morbidity” (further categorized as “moderately disabled,” “se- verely disabled,” “vegetative state/coma,” and “brain death”). The new definition and classification are more consistent with other medical 178 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS conditions and injuries and should ment. Prices range from $50 to $750.9 swimming instruction.14 A Chinese help in drowning surveillance and col- From 2004 to 2006, the CPSC reported study of swim instruction revealed lection of more reliable and compre- 47 deaths of children related to inflat- similar drowning-protection statis- hensive epidemiologic information.5 able pools.10 Unfortunately, many par- tics.15 In light of this new research, it is ents do not consider fencing for an in- reasonable for the AAP to relax its pol- Drain Entrapment and Hair flatable or portable pool, and such icy regarding the age at which children Entanglement pools often fall outside of local build- should start learning water-survival From 1990 to 2004, 74 cases (13 ing codes that require pool barriers. skills (see recommendation 6). The ev- deaths) of body entrapment in a pool Because they contain such large idence no longer supports an advisory or spa drain were reported to the Con- amounts of water, these pools are of- against early aquatic experience and sumer Product Safety Commission ten left filled for weeks at a time, which swimming lessons for children of any (CPSC).6 In a separate report, 24 addi- presents a continuous danger. The soft specific age. However, the current evi- tional cases (2 deaths) were reported sides of some models allow children to dence is insufficient to support a rec- in the 3 years from 2005 to 2007.7 The lean over them and easily fall into the ommendation that all 1- to 4-year-old situation often involves a child playing pool headfirst. children receive swimming lessons. It with an open drain, inserting a hand or must be stressed that even advanced foot into the pipe, and then becoming Swimming Lessons for Young swimming skills will not always pre- trapped by increasing suction that Children vent drowning and that swimming les- causes tissue swelling. In the same The position of the AAP has been that sons must be considered only within time period (1990–2004), 43 incidents children are not developmentally the context of multilayered protection (12 deaths) of hair entanglement were ready for swimming lessons until after with effective pool barriers and con- reported.6 These incidents typically in- their fourth birthday.11 This position stant, capable supervision. In addi- volve females who are underwater was based on (1) lack of data needed tion, the possible benefit of early with their long hair near a suction out- to determine if infant and toddler swimming instruction must be let. The water flow into the drain aquatic programs increase or de- weighed against the potential risks sweeps the hair into and around the crease the likelihood of drowning, (2) (eg, hypothermia, hyponatremia, in- drain cover, where it becomes tangled concerns that such programs would fectious illness, and lung damage in the holes and protrusions of the 16–19 cause parents to develop a false sense from pool chemicals). cover. Entrapment and entanglement of security and lead them to provide In recent years, water-survival skills can be prevented by the use of special inadequate supervision around water, programs designed for infants drain covers, safety vacuum-release and (3) evidence that starting swim- younger than 12 months have become systems (SVRSs), filter pumps with ming lessons at a very young age does popular both in the United States and multiple drains, and a variety of other not result in earlier development of internationally. Many movies of tiny in- pressure-venting filter-construction proficient swimming skills.12,13 In addi- fants who have been taught to swim techniques.6 In 2007, Congress passed underwater, float fully clothed on their the Virginia Graeme Baker Pool and tion, there was concern that swim- backs, and even cry out for help have Spa Safety Act (effective December ming programs might reduce a child’s emerged on the Internet. Although 2008), which requires special drain fear of water and unwittingly encour- there are anecdotal reports of infants covers, unblockable drains, and SVRSs age the child to enter the water with- who have “saved themselves,” no sci- for all public pools and spas in the out supervision. entific study has clearly demonstrated United States.8 A recently published case-control the safety and efficacy of training pro- study report from the Eunice Kennedy grams for such young infants. Inflatable, Portable Pools Shriver National Institute of Child Recently there was an increase in Health and Human Development con- Additional details regarding childhood sales of large, inexpensive, inflatable cluded that swimming lessons do not drowning are available in the accom- or portable above-ground pools, which increase the risk of drowning in 1- to panying technical report, available come in various sizes, shapes, and wa- 4-year-olds and may actually provide a online.20 ter depths. The pools are 18 to 48 in reduction in drowning risk in this age deep and can hold less than 200 to group. Drowning victims were less PREVENTION OF DROWNING more than 5000 gallons of water. Some likely than matched controls (3% vs Supervision of young children around models even require filtration equip- 26%, respectively) to have had formal any water is an essential preventive PEDIATRICS Volume 126, Number 1, July 2010 179 Downloaded from www.aappublications.org/news by guest on September 26, 2021 strategy, but inevitable lapses make access to the bathroom should be tiate a discussion about pool supervision alone insufficient.21 Instal- prevented. safety). It is important to ask spe- lation of 4-sided